For purposes of this Chapter,
the word “contractor” refers to the Managed Care Support Contractors
(MCSCs), Uniformed Services Family Health Plan (USFHP)/Designated
Provider (DP), and TRICARE Overseas Program (TOP) contractors unless
otherwise noted.
1.0 ENROLLMENT PROCESSING
1.1 The contractor shall process
enrollments, disenrollments, or Primary Care Manager (PCM) change requests
for beneficiaries by mail using DD Form 2876 (for TRICARE Prime)
or DD Form 3043 (for TRICARE Select), or by fax, telephone, or the
Government-furnished web-based self-service enrollment system/application.
1.2 The contractor shall ensure
the aforementioned form(s) is readily available to potential enrollees.
1.3 The TOP contractor shall also
collect applications and requests as defined above at TRICARE Service Centers
(TSCs).
1.4 The contractor shall process
enrollment requests within the following standards:
1.4.1 The contractor
shall ensure that only eligible beneficiaries are enrolled as shown
in Defense Enrollment and Eligibility Reporting System (DEERS).
1.4.2 The contractor shall update
the residential, mailing, and email addresses and any other fields
that can be updated in DEERS.
1.4.3 The contractor
shall, upon receipt of a Policy Notification Transaction (PNT),
re-enroll beneficiaries when their eligibility is updated in DEERS
by the Uniformed Service.
1.4.4 The contractor
shall reject the enrollment application if the requestor is not
eligible for TRICARE.The contractor shall notify the requestor within
10 business days if the application is rejected.
1.4.6 The contractor shall complete
each enrollment action within three business days of receiving all required
information from the Market Directors/Military Medical Treatment
Facility (MTF) Directors for those enrolled in Direct Care (DC).
1.5 The contractor shall modify
the effective date to be no later than the third business day, or
the date requested by the beneficiary up to 90 calendar days in
the future.
1.6 The contractor shall ensure
that enrollment requests are initiated by the proper person (for
TRICARE Young Adult (TYA) must be the beneficiary themselves) sponsor,
spouse, other legal guardian of the beneficiary, or an eligible
beneficiary age 18 or older. An official enrollment request includes
those with:
• An original signature;
• An electronic signature offered
by and collected by the contractor;
• A verbal consent provided via
telephone and documented in the contractor’s call notes; or
• A self-attestation by the beneficiary
when using the Government-furnished web-based
self-service enrollment system/application.
Note: A signature from an Active
Duty Service Member (ADSM) is never required to complete an ADSM
TRICARE Prime enrollment as enrollment in TRICARE Prime is mandatory
per the TRICARE Policy Manual (TPM),
Chapter 10, Section 2.1.
1.7 The contractor shall educate
beneficiaries regarding their entitlement to enroll in a TRICARE
Health Plan (THP). Education shall include health coverage options
(to include DC and private sector care), enrollment options, timelines
and limitation to space available MTF DC only if the beneficiary
elects not to enroll in a plan.
1.8 The contractor
shall provide beneficiaries who enroll full and fair disclosure
of any restrictions on freedom of choice that apply to enrollees,
including the Point of Service (POS) option for TRICARE Prime enrollees and
the consequences for failure to pay enrollment fees on time, choosing
to not enroll, or disenrolling from either TRICARE Prime or TRICARE
Select.
1.9 The contractor shall follow
the specifications defined and outlined in each Market/MTF Memorandum
of Understanding (MOU)/Statement of Responsibility (SOR) for TRICARE
Prime and TYA Prime enrollments.
1.10 The contractor
shall record all enrollments using the Government
-furnished
web-based enrollment system/application, within 10 business days
of receipt.
1.10.1 The contractor shall resend
TRICARE Prime or TRICARE Plus PCM Information Transfers (PITs) to
Markets/MTFs when requested.
1.10.2 The contractor shall request
DEERS Support Office (DSO) assistance when DEERS will not accept
an enrollment transition for an eligible beneficiary.
1.10.3 The contractor shall pend the
application until the issue is resolved by DSO.
1.10.4 The contractor shall process
or reject the application within three business days, upon response
from DSO.
1.10.5 The contractor shall develop
a residential or mailing address if the enrollment request contains
neither a residential address nor a mailing address.
1.10.5.1 The contractor shall not input
temporary addresses (e.g., Post Office (PO) Box, Unit address) unless provided
by the enrollee or the Government.
1.10.5.2 The contractor shall update
temporary addresses with the permanent address when provided by
the enrollee in accordance with the TRICARE System Manual (TSM),
Chapter 3, Section 4.2.
1.10.5.3 The contractor shall contact
the beneficiary by telephone within five business days if the DEERS record
does not contain an address or if the enrollment request contains
information different from that contained in DEERS in fields for
which the contractor does not have update capability. During the
telephone call, the contractor shall outline the discrepant information
and request the beneficiary contact their military personnel office.
1.10.5.3.1 DMDC will send a notification
to the beneficiary that the TRICARE wallet card is available through MilConnect
1.10.5.3.2 DMDC will also provide notification
of PCM assignments for new TRICARE Prime enrollments, disenrollments,
enrollment transfers, and PCM changes. (See TSM,
Chapter 3, Section 4.2.)
1.10.5.3.3 The return address on any correspondence
mailed by DMDC will be that of the appropriate contractor.
1.10.6 The contractor shall develop
a process to fulfill the delivery if the correspondence is returned
to the contractor by the United States Postal Service (USPS).
2.0 AUTOMATIC
ENROLLMENT MANAGEMENT
2.1 Automatic
Enrollment of ADSMs
DMDC/DEERS
will automatically enroll all new ADSM accessions, to include Reserve
Component (RC) members on active duty for more than 30 calendar
days, into Health Care Delivery Program (HCDP) Plan 001 (TRICARE
Prime for Active Duty Sponsors, No PCM Assigned).
2.2 Automatic Enrollment of Newly
Eligible ADFMs
Note: Requirements
for ADFM automatic enrollment do not apply to USFHP contractors.
2.2.1 The contractor shall adjust
any claims in question to apply TRICARE Prime plan benefits and
waive POS cost-sharing provisions upon request from a beneficiary
or sponsor who was auto-enrolled.
2.2.2 The contractor
shall educate the beneficiary or sponsor of this one-time correction
and provide instruction to the beneficiary regarding their PCM assignment
and the requirement to have referrals for all future specialty care.
2.2.3 The contractor shall document
conversations if received over the telephone.
3.0 DUAL ELIGIBLES (ENTITLEMENT
UNDER BOTH MEDICARE AND TRICARE)
3.1 The contractor shall ensure
that only eligible dual eligible beneficiaries may qualify to enroll
in a private sector plan.
3.1.1 Retirees
and retired family members, under age 65 are eligible to enroll
in TRICARE Prime provided the beneficiary maintains Medicare Part
A and Part B.
3.1.2 Dual eligible
ADFMs, regardless of age, are eligible to enroll in TRICARE Prime
or TRICARE Select.
3.1.3 Dual eligible
retirees and family members age 65 and over are not eligible to
enroll in TRICARE Prime or TRICARE Select.
3.1.3.1 Exception: Those not entitled
to premium free Medicare Part A on their own or the record of their current,
former, deceased spouse may enroll in TRICARE Prime or TRICARE Select.
3.1.3.2 Medicare is primary payer for
all dual eligibles regardless of their sponsor’s status. (See the
TPM,
Chapter 10, Section 2.1 for additional dual
eligible information.)
3.2 TRICARE
Prime-enrolled dual eligibles, to the extent practicable, should
follow all TRICARE Prime requirements for PCM assignment, referrals
and authorizations. However, TRICARE Prime-enrolled dual eligibles
are not subject to POS cost-sharing.
3.3 The contractor
shall ensure enrollment fees are waived for dual eligibles. (See
paragraph 5.0.)
4.0 ASSIGNMENT OF PCM FOR TRICARE
PRIME PLANS ENROLLEES
4.1 The contractor shall assign
all TRICARE Prime enrollees to a PCM by name (PCMBN) on the Government-furnished
web-based enrollment system/application at the time of TRICARE Prime
enrollment. This applies to beneficiaries assigned to the DC and
civilian network PCMs.
4.2 The contractor
shall comply with the Market Director’s/MTF Director’s specifications
as outlined in the Market/MTF MOU/SOR for which enrollees, or categories
of enrollees, be assigned a DC PCM or offered a choice of civilian
network PCMs.
4.2.1 The contractor shall provide
beneficiaries with information about all available PCMs, consistent
with Government Designated Authority (GDA) guidance, including available
outcomes data for private sector care and DC PCMs in the market,
to allow the beneficiary the greatest possible choice of providers.
4.2.2 The contractor shall enroll all
ADSMs who do not meet the requirements for TRICARE Prime Remote (TPR)
to a Market/MTF PCM.
4.2.3 The contractor
shall request the Market/MTF to shift capacity in the Government-furnished
web-based enrollment system/application from another category to
the ADFM beneficiary category if necessary to accommodate an E-1
through E-4 ADFM beneficiary’s PCM assignment request.
4.2.4 The contractor shall assign
the beneficiary to a Market/MTF PCM unless capacity has been reached when
a family member of an active duty E-1 through E-4 sponsor requests
a PCM in a Market/MTF that offers TRICARE Prime for any beneficiary
category other than ADSM.
4.3 The contractor
shall provide guidance to the enrollee in selecting a primary care
location or PCM using the specifications provided in the Market/MTF
MOU.
4.4 The contractor shall refer
the beneficiary to the Market/MTF where the beneficiary is enrolled
upon receipt of an inquiry from a DC enrollee in regards to the
person’s assigned PCM.
4.5 The contractor
shall assign each enrollee a PCMBN at the time of enrollment based
on those PCMs available within the Government
-furnished
web-based enrollment system/application.
4.5.1 The contractor
shall determine the appropriate enrollment Defense Medical Information
System Identification (DMIS-ID) based on the geographical area of
responsibility and Market/MTF MOUs, access standards and other specific
Government guidance at the time of enrollment.
4.5.2 The contractor shall assign
the beneficiary to the PCM requested by the beneficiary (see
paragraph 1.2) if
capacity is available.
4.5.3 The contractor
shall use the default PCM for that DMIS if the preferred PCM is
not available.
4.5.4 The contractor
shall assign an appropriate PCM if the enrollment request (see
paragraph 1.2)
identifies a gender or specialty preference.
4.5.5 The contractor shall enroll
the beneficiary to the default PCM for that DMIS if the gender or
specialty is not available.
4.5.6 The contractor
shall use the default PCM for that DMIS if no PCM preference is
stated on the enrollment application (see
paragraph 1.2).
4.5.7 If there is no DC PCM available
in the appropriate DMIS/Market/MTF, non-active duty beneficiaries
may be enrolled to a civilian PCM by following the procedures specified
in the Market/MTF MOU.
4.5.8 The contractor
shall contact the Market/MTF for instructions if there is no PCM
capacity in the Market/MTF for an ADSM.
4.6 The contractor shall not add,
delete, or modify DC PCMs on the Government repository. The Government-furnished
web-based enrollment system/application reflects only those DC PCMs
that the Market/MTF has loaded onto the DEERS PCM Repository.
4.7 The Government-furnished web-based
enrollment system/application will only display PCMs with available
capacity for the specific beneficiary’s category and age.
4.8 The contractor shall complete
all panel PCM reassignments (batch) using the Government-provided systems
application, PCM Reassignment System (PCMRS).
4.9 A
Market Director/MTF
Director may specify panel reassignments for a variety of reasons,
including the rotation or deployment of DC PCMs. The contractor
should expect at least one-half of DC PCM assignments to change
each year. These moves may be based on various factors of either
the enrollment or the individual beneficiary, including:
• DMIS ID to DMIS ID
• PCM ID to PCM ID
• HCDP
• Sex of beneficiary
• Unit Identification Code (UIC)
(active duty only)
• Age of beneficiary
• Sponsor Social Security Number
(SSN) and DoD Benefits Number (DBN)
• Name of beneficiary
4.9.1 The contractor shall complete
each DC PCM reassignment, both individual and panel reassignment, within
three business days. The Market/MTF may request PCM reassignment,
including panel reassignments, in several ways, including telephone,
email or other electronic submissions. The preferred method for
panel reassignments is the batch staging application within PCMRS.
Regardless of the submission method, the Market/MTF must provide
sufficient information identifying both the PCMs and beneficiaries
involved in a move to allow the contractor to reasonably accomplish
the move.
4.9.2 The contractor shall process
PCM change requests submitted by beneficiaries enrolled to a civilian network
PCM by any means other than the Government-furnished, web-based
self-service enrollment system/application within three business
days of receipt, with an effective date no later than the third
business day.
4.9.3 The contractor
shall modify the effective date to be the date the contractor receives
a PCM change request from the Government-furnished
web-based self-service enrollment system/application and be processed within
six calendar days of receiving the request.
5.0 ENROLLMENT
PERIOD
5.1 The contractor shall support
one annual open enrollment period per calendar year for all Non-Active Duty
Service Member (NADSM) beneficiaries.
5.1.1 Enrollments,
with the appropriate application and any required enrollment fee,
will be effective on January 1 of the following year.
5.1.2 DEERS will automatically re-enroll
beneficiaries each year unless they elect a different option or disenroll
during the open enrollment period. See TPM,
Chapter 10, Section 2.1.
5.2 Effective Date of Enrollment
(On or After January 1, 2018)
5.2.1 TRICARE Prime and TRICARE Select
enrollments will be effective the date of the Qualifying Life Event (QLE)
or on January 1 of the following year for open enrollment period
enrollments (see TPM,
Chapter 10, Section 2.1).
5.2.2 Requests for enrollment based
on a QLE may be received up to 90 calendar days before and no later than
90 calendar days after the date of the QLE.
5.2.2.1 For online requests for an
enrollment period of less than 90 calendar days, or an online request
more than 90 calendar days from the date of the QLE, the Government-furnished
web-based self-service enrollment system/application will display
a message to contact the contractor.
5.3 Enrollment
Transactions with an Effective Date before January 01, 2018
The contractor shall process
retroactive enrollment transactions with an effective date prior
to January 01, 2018, in accordance with guidance provided by the
GDA for the contract.
5.4 Enrollment
Expiration
5.4.1 The contractor shall not send
renewal notices to enrollees.
5.4.1.1 Exception: The contractor shall
send the appropriate individual (e.g., sponsor, custodial parent, retiree,
retiree family member, survivor or eligible former spouse) a written
notification of the pending enrollment expiration that includes
a bill for the re-enrollment fee 30 calendar days before the expiration
date of enrollment for beneficiaries paying enrollment fees quarterly
or annually.
5.4.1.2 The notification shall alert
the beneficiary that he or she will only be eligible for MTF space-available care
only should payment not be received.
5.4.1.3 If appropriate, the notification
shall include any rate change information. The bill shall offer
all available payment options and methods.
5.4.2 The contractor shall issue
a delinquency notice to the appropriate individual 15 calendar days
after the expiration date of the enrollment if a renewal payment
is not received.
5.4.3 The contractor
shall send the appropriate individual (e.g., sponsor, custodial
parent, retiree, retiree family member, survivor or eligible former
spouse) a written notification alerting the beneficiary of any fee
changes at least 30 calendar days prior to the implementation of
any fee changes for beneficiaries that pay enrollment fees or premium
payments on a monthly basis.
5.4.4 The contractor
shall automatically renew enrollments, including those for Service
members, each calendar year unless the enrollee declines renewal,
is no longer eligible for enrollment, or fails to pay any required enrollment
fee on a timely basis.
5.4.5 See TPM,
Chapter 10, Section 2.1 for actions required
if a beneficiary is identified as being ineligible for continued
enrollment.
5.4.6 The contractor shall reinstate
coverage if the request is received with appropriate payment of
fees within 90 calendar days from the last paid-through date.
5.4.7 DMDC will notify the beneficiary
of the disenrollment within five business days of the disenrollment transaction.
5.4.8 ADSMs may not decline reenrollment
nor request disenrollment.
5.5 Disenrollment
5.5.1 The contractor
shall provide a mechanism for voluntary disenrollment.
5.5.1.1 Disenrollment requests must
be initiated by the sponsor, spouse, other legal guardian of the beneficiary,
or an eligible beneficiary 18 or older.
5.5.1.2 An ADSM cannot request disenrollment.
An official disenrollment request includes those with:
• An original signature;
• An electronic signature offered
by and collected by the contractor;
• A verbal consent provided via
telephone and documented in the contractor’s call notes; or
• A self-attestation by the beneficiary
when using the Government-furnished web-based
self-service enrollment system/application.
5.5.2 The contractor shall automatically
disenroll beneficiaries when the appropriate enrollment fee payment
is not received by the 30th calendar day following the last paid-through
date.
5.5.2.1 The contractor shall set the
disenrollment effective date retroactive to the last paid-through
date.
5.5.2.2 An enrollment fee payment includes
the correct premium amount for the period the fee is intended to
cover (i.e., monthly, quarterly, or annually).
5.5.3 The contractor shall reconcile
their fee payment system against the fee totals in DEERS prior to processing
a disenrollment for “non-payment of fees.”
5.5.4 The contractor may, once the
contractor confirms that the payment amounts match, enter the disenrollment
in the Government-furnished web-based enrollment
system/application.
5.5.5 The contractor
shall pend claims received during the grace period to avoid the
need to recoup overpayments. See the TPM,
Chapter 10, Sections 2.1 and
3.1 for additional information on disenrollment.
5.6 Enrollment Lockout
5.6.1 The contractor shall reinstate
(restore) the enrollment if the beneficiary requests reinstatement
within 90 calendar days of their disenrollment date (last paid-through
date) and pays all past due fees, if applicable.
5.6.2 The contractor shall deny requests
for reinstatement due to failure to pay fees and premiums received after
90 calendar days past the last paid-through date.
5.6.3 Exception
5.6.3.1 In the event the “failure to
pay” disenrollment was directly caused by contractor or Government
error (for example, the contractor failed to submit the correct
allotment amount to the Defense Finance and Account Service (DFAS)),
upon request of the beneficiary by the contractor, the GDAs may
direct reinstatement of the coverage greater than 90 calendar days
past the last paid-through date if all past fees are paid if applicable.
5.6.3.2 In no instance shall a new
enrollment period be started in lieu of reinstatement from the last
paid-through date.
6.0 ENROLLMENT FEES
6.1 General
6.1.1 The contractor
shall collect enrollment fee payments from TRICARE Prime and TRICARE
Select enrollees as appropriate and report those fees, including
any overpayments that are not refunded to the enrollee, to DEERS.
6.1.1.1 The contractor shall report
all enrollment fee refunds to DEERS in accordance with
paragraph 8.0.
6.1.1.2 TRICARE Prime and TRICARE Select
enrollees may choose one of the following three payment fee options
(e.g., monthly, quarterly, or annually).
6.1.1.3 Beginning January 1, 2021:
The contractor shall collect enrollment fees for new TRICARE Select policies,
including TRICARE Select Group A enrollees that begin paying enrollment
fees effective January 1, 2021, by monthly allotment only from military
retired/retainer pay, where feasible, as mandated by law (National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2020, Section
702). Lack of feasibility includes instances where this is no retired/retainer
pay (e.g., 100% disabled veterans, certain Unremarried Former Spouses
(URFSs), survivors, etc.) available to cover monthly enrollment
fees; or instances where the beneficiary adamantly refuses to authorize payment
of fees via allotment. If not feasible, the contractor shall allow
payment of monthly TRICARE Select enrollment fees via a monthly
recurring electronic payment in the form of Electronic Funds Transfer
(EFT) (which may include recurring credit and debit charge (RCC)).
6.1.1.4 When enrollment fee or premium
payments are permitted by credit or debit cards, beneficiaries in overseas
locations must use a credit or debit card issued by a US banking
institution or other US financial institution.
6.1.1.5 The contractor may assess the
account holder a fee of up to $20 US dollars in the event that there
are insufficient funds to process an enrollment fee or premium payment.
The contractor retains assessed fees.
6.1.1.6 The contractor shall provide
commercial payment methods for enrollment fees and premiums that best
meet the needs of beneficiaries while conforming to
paragraphs 6.1.2 through
6.7.
6.1.1.7 The contractor shall report
a credit to DEERS to offset outstanding enrollment fees anytime
a retirement date is retroactively changed by the Services as recorded
in DEERS that results in a situation where past prorated enrollment
fees are now due based on the changed date for a retiree who was
previously paid to date in their enrollment fees that occurred before
January, 1, 2018.
6.1.1.8 The contractor shall credit
the retiree’s enrollment fee and report as an offset to the collected enrollments
deposited to the Defense Health Agency’s (DHA’s) account. This shall
occur as long as the retiree’s enrollment fees are otherwise current.
6.1.2 Fiduciary Responsibilities
6.1.2.1 The contractor shall act as
a fiduciary for all funds acquired from TRICARE Prime and TRICARE
Select enrollment fees, which are Government property.
6.1.2.2 The contractor shall develop
strict funds control processes for its collection, retention and
transfer of enrollment fees to the Government.
6.1.2.3 The contractor shall maintain
all enrollment fees in accordance with these procedures.
6.1.2.4 The contractor shall maintain
a separate non-interest bearing account for the collection and disbursement
of enrollment fees.
6.1.2.5 The contractor shall deposit
enrollment fees into the established account within one business
day of receipt.
6.1.2.6 The contractor shall wire transfer
the enrollment fees, minus any refund payments, twice monthly, on the
1st business day and the 15th business day to a specified Government
account as directed by the DHA, Contract Resource Management (CRM)
Office (Section J of the contract).
6.1.2.7 The contractor shall notify
DHA CRM, by email, within one business day of the deposit stating
the date and amount of the deposit.
6.1.2.8 The contractor shall maintain
a clear, auditable record of all enrollment fees received, the date received
and the date transferred to the Government, as well as all refunds
issued, to whom the refund was issued, the amount of the refund,
and the date reported to the Government.
6.1.3 Annual Payment Fee Option
6.1.3.1 The contractor shall collect
all annual payment fee-option fees in one lump sum.
6.1.3.2 The contractor shall prorate
the fee from the enrollment date to December 31 for initial enrollments.
6.1.3.3 The contractor shall accept
payment of the annual enrollment fee only by debit or credit card
(i.e., Visa or MasterCard) refer to
paragraph 5.6 for disenrollment
information if the appropriate enrollment fee payment is not received.
6.1.4 Monthly Payment Fee Option
6.1.4.1 The contractor shall collect
monthly installment fee-options each month. Monthly installment
fee options are equal to one-twelfth (1/12) of the total annual
fee amount, rounded down if not divisible by 12 to the nearest dollar.
Monthly enrollment fees must be paid-through an automated, recurring
electronic payment in the form of an allotment from retirement pay
or through EFT from the enrollee’s designated financial institution
(which may include an RCC. These are the only acceptable payment
methods for the monthly payment option.
6.1.4.2 The contractor shall collect
up to three months of fees for enrollees who elect a monthly fee
payment option contingent on the method and date the request is
submitted to allow time for an allotment, or EFT, or RCC to be established.
6.1.4.3 The contractor shall explain
the deposit amount required and accept payment by personal check, cashier’s
check, traveler’s check, money order, debit, or credit card (e.g.,
Visa or MasterCard) for initial enrollment requests. For continuous
coverage requests, contractors shall accept payment by allotment,
EFT, or RCC.
6.1.4.4 The contractor shall obtain
and verify the information needed to initiate monthly allotments
and EFTs.
6.1.4.5 The contractor shall direct
bill the beneficiary only when a problem occurs.
6.1.4.5.1 The contractor shall grant
the enrollee 30 calendar days from the paid-through date to provide information
for a new automated monthly payment when an administrative issue
arises that stops or prevents an automated monthly payment from
being received by the contractor (e.g., incorrect or transposed
number provided by the beneficiary, credit card expired, bank account
closed).
6.1.4.5.2 The contractor shall provide
the beneficiary with the option to pay quarterly or annually.
6.1.4.5.3 The contractor may accept payment
by check during this 30 calendar day period in order to preserve
the beneficiary’s TRICARE Prime or TRICARE Select enrollment status.
6.1.4.6 The contractor shall coordinate
allotments from retired pay with the Uniformed Service(s) Pay Center(s)
as appropriate (see the TSM,
Chapter 1, Section 1.1 for Payroll Allotment
Interface Requirements).
6.1.4.7 The contractor shall also research
and resolve all requests that have been rejected or not processed by
the Uniformed Service(s) Pay Center(s) and resubmit the allotment
request if the contractor’s research results in the positive application
of the allotment action.
6.1.4.8 The contractor shall notify
the beneficiary within five business days of rejected allotment
requests and issue an invoice to the beneficiary for any outstanding
enrollment fees due.
6.1.4.9 The contractor shall respond
to all beneficiary inquiries regarding allotments in the method
the inquiry is received (e.g., over the telephone, email, letter).
6.2 Member Category
The sponsor’s member category
on the effective date of the initial enrollment, as displayed in
the Government-furnished web-based enrollment
system/application, will determine the requirement for an enrollment
fee.
6.3 URFSs
and Children Residing with Them
6.3.1 URFSs
became sponsors in their own right as of October 1, 2003. As such,
they are enrolled under their own SSN and pay an individual enrollment
fee. URFSs may not “sponsor” other family members and their fees
may not be factored into any family fees associated with the former
spouse or sponsor.
6.3.2 Children
residing with URFS, whose eligibility for benefits is based on the
ex-spouse or former sponsor, are identified and enrolled under the
ex-spouse or former sponsor’s SSN on DEERS, and fees for these children
are combined with other fees paid under the ex-spouse or former
sponsor.
6.3.3 The contractor shall collect
the individual enrollment fee for an URFS’ enrollment under the
URFS’ own SSN.
6.3.4 The contractor
shall also collect a family enrollment fee for any two or more eligible
family members enrolled under the SSN of the ex-spouse or former
sponsor. These enrollees might include the sponsor, any current spouse,
and all eligible children, including those living with the URFS.
6.4 TRICARE Prime Fee Waiver
6.4.1 Each TRICARE Prime enrolled
beneficiary, who is required to pay enrollment fees, regardless
of age, who maintains enrollment in Medicare Part B, is entitled
to a waiver of an amount equivalent to the individual TRICARE Prime
enrollment fee.
6.4.2 Individual
enrollments for such beneficiaries will have the enrollment fee
waived.
6.4.3 A family enrollment in TRICARE
Prime, where one family member maintains enrollment in Medicare Part
B, shall have one-half of the family enrollment fee waived; the
remaining half must be paid.
6.4.4 For a
family enrollment where two or more family members maintain enrollment
in Medicare Part B, the family enrollment fee is waived regardless
of the number of family members who are enrolled in addition to
those entitled to Medicare Part B.
6.4.5 A family
enrollment in TRICARE Plus with Active Duty Select or TRICARE Plus
with Retired Select or TRICARE Prime enrollment, is entitled to
a waiver of an amount equivalent to the individual TRICARE Prime
or TRICARE Select enrollment fee as appropriate (not to exceed two
individual fee payments).
6.5 TRICARE Select Enrollment Fees
Families enrolled in TRICARE
Select plans requiring enrollment fees (any combination of TRICARE
Select or TRICARE Plus with Select plans) do not pay more than the
TRICARE Select family enrollment fee. A fee waiver code will be applied
to any policy that does not require fees to be paid.
6.6 Survivors of Active Duty Deceased
Sponsors and Medically Retired Uniformed Services Members and their
Dependents
6.6.1 Beneficiaries Whose Sponsor
Has An Initial Service Date Before January 1, 2018
6.6.1.1 Effective FY 2012, TRICARE
Prime beneficiaries who are:
6.6.1.1.1 Survivors of active duty deceased
sponsors, or
6.6.1.1.2 Medically retired Uniformed
Services members and their dependents, had their TRICARE Prime enrollment
fees frozen at the rate in effect when classified and enrolled in
a fee paying TRICARE Prime plan. (This does not include TRICARE
TYA plans).
6.6.1.2 Beneficiaries in these two
categories who were enrolled in FY 2011 pay the FY 2011 rate.
6.6.1.3 Beneficiaries who became or
become eligible in either category and enrolled during FY 2012 or
after, shall have their fee frozen at the rate in effect at the
time of enrollment in TRICARE Prime. The fees for these beneficiaries
shall remain frozen as long as at least one family member remains
enrolled in TRICARE Prime.
6.6.1.4 The fee for the dependent(s)
of a medically retired Uniformed Services member shall not change
if the dependent(s) is later re-classified a survivor.
6.6.1.5 These two categories of beneficiaries
who choose to enroll in TRICARE Select do not pay enrollment fees.
6.6.2 Beneficiaries Whose Sponsor
Has An Initial Service Date On Or After January 1, 2018
6.6.2.1 There is no TRICARE Prime enrollment
fee freeze for these retirees and family members; they pay the established
annual TRICARE Prime enrollment fee amount.
6.6.2.2 Medically retired members and
their family members who choose to enroll in TRICARE Select pay
the established annual TRICARE Select enrollment fee.
6.7 Mid-Month
Enrollees
The contractor
shall collect pro-rated fee amounts for enrollees who do not enroll
on the first of a month based on 1/30th of the TRICARE Prime or
TRICARE Select fee, as applicable, calculated from the date of enrollment
(initial eligibility or QLE date) to the end of the month.
6.8 Overpayment Of Enrollment Fees
6.8.1 The contractor shall update
DEERS with the enrollment fee amount collected for any overpayment
of enrollment fees. DEERS will calculate the paid-through date and
notify the contractor. DEERS will only extend the paid-through date
to cover the current enrollment year, plus two future fiscal years
(prior to January 1, 2018) or calendar years (starting January 1,
2018).
6.8.1.1 DEERS will store amounts that
cannot cover one month’s fees or amounts that extend the paid-through
date beyond two years in the future as a credit. Funds applied that
would move the paid-through date beyond the policy end date are
stored as a credit. (The exception is when TRICARE Prime policies,
prior to January 1, 2018, end mid-month; DEERS will set a paid-through
date to the end of that month.)
6.8.1.2 If there is a 100% fee waiver
with an end date that exceeds more than two fiscal years beyond
the current enrollment year, the paid period can extend beyond the
two fiscal years and any fee amounts sent to DEERS will be applied
as a credit.
6.8.1.3 The contractor shall refund
any credit of $1 or more on a current enrollment that extends beyond
two fiscal years (prior to January 1, 2018) or two future calendar
years (starting January 1, 2018).
6.8.1.4 The contractor shall update
DEERS with any fee amount refunded within 30 calendar days.
6.8.1.5 The contractor shall notify
the beneficiaries by letter of the credit, how the credit was applied,
and how a refund can be requested for the 2018 and 2019 enrollment
fees credited to the catastrophic cap.
6.8.1.6 The contractor shall include
an explanation for the premium refund. See also
paragraph 8.0.
6.8.2 The contractor shall resolve
any over or under payments for enrolled beneficiaries.
6.8.2.1 The following reports are provided
to the contractor by DEERS on a monthly basis to assist with identifying
and correcting enrollment fee discrepancies. For split enrollments,
the reports use the billing hierarchy to determine the responsible
contractor.
6.8.2.2 Current policies that are two
months past due (paid period end date more than two months in the past).
6.8.2.3 Any policies where the paid
period end date exceeds the policy end date.
6.8.2.4 Policies where the paid period
end date meets the policy end date but a credit exists.
6.8.2.5 Terminated policies where the
paid period end date does not meet the policy end date.
6.8.3 The contractor shall analyze
and correct all report accounts within 30 calendar days of the report’s availability.
6.8.4 The contractor shall correct
any data inaccuracies in the enrollment fee reporting system, to
include the refunding of enrollment fees in excess of what is due.
6.8.5 The contractor shall update
DEERS with any enrollment fee amounts refunded within 30 calendar
days and notify DHA as specified above.
7.0 ENROLLMENT
OF FAMILY MEMBERS OF E-1 THROUGH E-4
7.1 When family
members of E-1 through E-4 reside within a 30 minute drive time
of a Market/MTF offering TRICARE Prime, the family members the enrolling
entity (contractor or Government) shall encourage them to enroll in
TRICARE Prime
by the enrolling entity (Government
or contractor).
7.1.1 Upon enrollment,
the beneficiary will choose or be assigned a PCM located in the
Market/MTF.
7.1.2 The beneficiary choice to enroll
or to decline enrollment in TRICARE Prime is completely voluntary.
7.1.3 Family members of E-1 through
E-4 who decline enrollment or who enroll in TRICARE Prime and subsequently
disenroll may not re-enroll until the next open period or when a
QLE occurs.
7.2 The contractor
shall reinforce that enrollment in TRICARE Prime is at no cost for
family members of E-1 through E-4 and give them the opportunity
to select or be assigned a Market/MTF PCM, to select a civilian
PCM if permitted by applicable MOU or with USFHP, if available,
or to decline enrollment in TRICARE Prime.
7.3 The contractor
shall process enrollments and allow civilian PCM assignments in
accordance with the MOU between the contractor and the Market/MTF.
7.4 The primary means of identification
and subsequent referral for enrollment shall occur during in-processing
to the installation.
7.4.1 Non-enrolled E-4 and below
families may also be referred to the contractor’s call center by Commanders,
First Sergeants/Sergeants Major, Supervisors, Family Support Centers,
and others.
7.4.2 Beneficiaries at overseas locations
may also be referred to their local TRICARE Service Center (TSC).
7.5 The contractor shall provide
call center representatives and beneficiary education briefings
which provide enrollment information and support the family member
in managing their enrollment options. The education of such potential
enrollees shall specifically address the advantages of TRICARE Prime
enrollment (e.g., guaranteed access, the support of a PCM).
7.6 The contractor shall discuss
the potential effective date of the enrollment.
7.7 Enrollment may be terminated
at any time upon request of the enrollee, sponsor or other party
as appropriate under existing enrollment and disenrollment procedures.
7.8 Prior to January 1, 2018, beneficiaries
may re-enroll at any time without restriction or penalty. See
paragraph 5.2 for
enrollment rules as of January 1, 2018.
7.9 The contractor
shall not screen TRICARE claims to determine whether the claims
may be for treatment of a non-enrolled ADFM of E-1 through E-4 living
in a Prime Service Area (PSA).
7.10 The contractor
shall promptly inform such individuals of their benefits and enroll
them to the appropriate plan when they have been identified by DoD
in the course of such a person’s interaction with the military health care
system or personnel community and have been referred to the contractor
for enrollment.
7.11 DMDC automatically
enrolls newly eligible ADFMs into TRICARE Prime or TRICARE Select,
if overseas into TOP Select. See
paragraph 2.2.
8.0 TRICARE
ELIGIBILITY CHANGES OR REFUNDS OF FEES
8.2 The contractor
shall allow a TRICARE-eligible beneficiary, who has less than 12
months of eligibility remaining, to enroll in TRICARE Prime or TRICARE
Select until such time as the enrollee loses his or her TRICARE eligibility.
8.2.1 The beneficiary will have the
choice of paying the entire enrollment fee or paying the fees on
a more frequent basis (e.g., monthly).
8.2.2 The contractor
shall collect only those installments required to cover the period
of eligibility if the enrollee chooses to pay by installments. DEERS
will calculate the paid-through date based on the enrollment fee amount
collected and entered into DEERS by the contractor, which in this
circumstance, should cover the period of the beneficiary’s eligibility.
8.2.3 The contractor shall refund
any overpayment of $1 or more that DEERS does not use to extend
the paid-through date to the policy end date (or the last day of
the month in which a TRICARE Prime or TRICARE Select policy ends).
8.2.4 The contractor shall include
an explanation to the beneficiary for the fee refund.
8.2.5 The contractor shall update
DEERS with any fee amount refunded within 30 calendar days.
8.3 The contractor shall refund
the unused portion of TRICARE Prime or TRICARE Select enrollment
fees to retired enrollees whose sponsor is recalled to active duty.
8.3.1 The contractor shall include
an explanation to the beneficiary for the fee refund.
8.3.2 The contractor shall calculate
the refund using monthly prorating, and report such refunds to DEERS within
30 calendar days.
8.3.3 Upon activation
of the member, the family members will be automatically enrolled
as ADFMs (see TPM,
Chapter 10, Section 2.1).
8.3.4 If the reactivated member’s family
chooses continued enrollment in TRICARE Prime or TRICARE Select, the
family will begin a new enrollment period and the contractor shall
offer them the opportunity to keep their PCM (TRICARE Prime only),
if possible.
8.4 The contractor
shall apply any catastrophic cap accumulation to the new enrollment
period.
8.5 The contractor shall refund
enrollment fees for deceased enrollees upon receiving a written
request, along with a copy of the death certificate, from the remaining
enrollee or the executor of the decedent’s estate.
8.5.1 The contractor
shall include an explanation for the fee refund to the beneficiary.
8.5.2 The contractor shall prorate
refunds on a monthly basis and apply both to individual plans where
the sole enrollee is deceased and to the conversion of a family
enrollment to an individual plan upon the death of one or more family
members.
8.5.3 The contractor shall refund
remaining enrollment fees to the executor of the estate for individual enrollments.
8.5.4 The contractor shall either
credit the excess fees to the individual plan or refund them either
to the remaining enrollee or to the executor of the decedent’s estate,
as appropriate, for family enrollments that convert to individual
plans.
8.5.5 Enrollment fees for family enrollments
of three or more members are not affected by the death of only one
enrollee and the contractor shall not issue refunds.
8.5.6 The contractor shall update
DEERS with any amount refunded within 30 calendar days.
8.6 The contractor shall refund
the unused portion of TRICARE Prime or TRICARE Select enrollment
fees to enrollees who become eligible for Medicare Part A based
upon disability, End Stage Renal Disease (ESRD) or upon attaining
age 65, provided the beneficiary has Medicare Part B coverage.
8.6.1 The contractor shall issue
refunds to these beneficiaries upon receiving:
• A written request from the
beneficiary (that includes a copy of their Medicare card) and either
confirming their Part B enrollment in DEERS or in a previous Government-furnished
policy notification; or
• Upon receipt of an unsolicited
Government-furnished policy notification
noting a beneficiary’s fee waiver update based on the Part B enrollment.
8.6.1.1 DEERS generates a Government-furnished
policy notification when the Centers for Medicare and Medicaid Services
(CMS) sends DEERS data indicating a Part B enrollment or disenrollment.
8.6.1.2 Refunds are required for all
payments that extend beyond the date the enrollee has Medicare Part
B coverage, as calculated by DEERS.
8.6.1.3 The contractor shall update
DEERS with any amount refunded within 30 calendar days.
8.6.1.4 The contractor shall include
an explanation to the beneficiary for the fee refund.
8.6.1.5 The contractor shall send a
refund to the beneficiary if the fee waiver is a 100% waiver of
the TRICARE Prime enrollment fee.
8.6.1.5.1 If the fee waiver is a 50%
waiver of the TRICARE Prime enrollment fee, DEERS will automatically calculate
the overpayment and extend the paid-through date for the policy.
8.6.1.5.2 A refund may not be required
unless a credit remains when the policy is paid in full.
8.6.2 The contractor shall utilize
the Government-furnished policy notifications received indicating
a fee waiver based on Medicare to substantiate any claim of overpayment.
8.6.3 For TRICARE Prime enrollees
who become Medicare eligible and who maintain Medicare Part B coverage
and TRICARE Select enrollees who become Medicare eligible, refunds
are required for overpayments occurring on and after the start of
health care delivery (SHCD).
8.6.4 The contractor
shall update DEERS with any amount refunded within 30 calendar days
and include an explanation to the beneficiary for the fee refund.
8.6.5 Medicare eligible ADFMs age
65 and over are not required to have Medicare Part B to remain enrolled
in TRICARE Prime or TRICARE Select.
8.6.6 To maintain
TRICARE coverage upon the sponsor’s retirement, they must enroll
in Medicare Part B during Medicare’s Special Enrollment Period prior
to their sponsor’s retirement date.
Note: The Special Enrollment Period
is available anytime the sponsor is on active duty or within the
first eight months of the sponsor’s retirement. If they enroll in
Part B after their sponsor’s retirement date, they will have a break
in TRICARE coverage.
8.6.7 Medicare
eligibles age 65 and over who are not entitled to premium-free Medicare
Part A are not required to have Medicare Part B to remain enrolled
in TRICARE Prime and TRICARE Select. Because they may become eligible
for premium-free Medicare Part A at a later date, under their or
their spouse’s SSN, they should enroll in Medicare Part B when first
eligible at age 65 to avoid the Medicare surcharge for late enrollment.
8.7 The contractor shall draw refunds
from the contractor’s enrollment fee account and report said refunds
to the Government in accordance with the requirements specified
above.
8.8 The contractor shall include
full and complete information about the effects of changes in eligibility
and rank in beneficiary education materials and briefings.
8.9 The contractor shall, pursuant
to criteria and documentation required for the specific TRICARE
eligibility changes as listed in
paragraph 7.0, refund overpaid
fees in the following manner:
8.9.1 The contractor
shall apply overpaid fees to another enrolled family member under
the same Uniformed Service sponsor if within the maximum two calendar
years.
8.9.2 Overpaid fees for URFS can
only be applied to their enrollment records.
8.9.3 The contractor shall automatically
refund prorated enrollment fees in excess of two calendar years.
8.9.4 The contractor shall, upon
request from sponsor or responsible individual, apply overpaid fees
as directed up to the maximum two calendar years and refund overpaid
fees as requested.
8.9.5 The contractor
shall not refund amounts of less than $1.00.
8.9.6 The contractor shall issue
refunds within 30 calendar days to a Uniformed Service sponsor,
eligible spouse, and then oldest child in that order.
8.9.7 Refunds for URFS enrollment
fees shall only be refunded to the URFS.
8.9.8 The contractor
shall update DEERS within 30 calendar days with any refund amount.
9.0 WOUNDED, ILL, AND INJURED (WII)
ENROLLMENT CLASSIFICATION
9.1 The WII
Program provides a continuum of integrated care from the point of
injury to the return to duty or transition to active citizenship
for the Active Component (AC) or the RC Service members who have
been activated for more than 30 calendar days.
9.1.1 These
AC or RC Service members, referred to as Service members, have been
injured or became ill while on active duty and will remain in an
active duty status while receiving medical care or undergoing physical disability
processing.
9.1.2 WII Programs vary in name according
to Uniformed Service.
9.1.3 The Uniformed
Service determines member eligibility for enrollment into a WII
Program, as well as whether or not to utilize these enrollments.
9.2 To better manage this population,
a secondary enrollment classification of HCDP Plan Coverage Codes, WII
415 and WII 416 were developed. These primary rules apply to the
WII HCDP codes:
• Service members must be enrolled
to TRICARE Prime prior to, or at the same time, as being enrolled
into a WII 415 or WII 416 Program.
• A member cannot be enrolled
in WII 415 and WII 416 Programs at the same time.
• WII 415 and WII 416 enrollments
shall terminate at the end of the member’s active duty eligibility,
when members transfer enrollment to another Market/MTF, change of
a plan code, or at the direction of the Uniformed Service-specific
WII entity.
• Any claims processed for WII
415/416 enrollees shall follow the rules associated with the primary
HCDP Plan Coverage Code, such as TRICARE Prime, TPR, TOP Prime,
or TOP Prime Remote. The contractor shall process and pay all claims
under Supplemental Health Care Program (SHCP) rules. DEERS will
not produce specific enrollment cards or letters for WII 415/416
enrollment.
9.3 The contractor
shall code WII 415/416 TRICARE Encounter Data (TED) records with
the WII 415/416 HCDP Plan Coverage Code; however, the Enrollment/Health
Plan Code data element on the TED record shall reflect the appropriate
value for the primary HCDP Plan Coverage Code. For example, a TED
record for a WII 416 enrollee with primary enrollment to TPR would
reflect the HCDP Plan Coverage Code of 416 but the
Enrollment/Health Plan Code would be coded W (TPR Active
Duty Service Member).
9.4 WII
415 - WWI (e.g., Warrior Transition/MEDHOLD Unit (WTU))
9.4.1 The contractor shall enroll
Uniformed Service-defined eligible Service members assigned to a
WII 415 Program such as a MEDHOLD or WTU to TRICARE Prime or TOP
Prime prior to, or at the same time, as being enrolled into the
WII 415.
9.4.1.1 Members cannot be enrolled
to the WII 415 without a concurrent TRICARE Prime or TOP Prime enrollment.
9.4.1.2 Uniformed Service appointed
WII case managers will coordinate with the Market/MTF to facilitate TRICARE
Prime PCM assignments for WII 415 members.
9.4.2 The contractor shall assign
a PCM in accordance with the Market/MTF MOU and in coordination
with the WII case manager.
9.4.3 WII 415
enrollment will not run in conjunction with Transitional Assistance
Management Program (TAMP) and members enrolled in TPR or TOP Prime
Remote are not eligible to enroll in the WII 415.
9.4.4 The contractor shall, upon
receipt of the Government-provided DD Form 2876, the enrollment application
form with WII 415, perform the enrollment in the Government
-furnished
web-based enrollment system/application and include the following
information:
9.4.4.1 WII 415 HCDP Plan Coverage
Code.WII 415 Enrollment Start Date.
9.4.4.2.1 The contractor may change the
Government-furnished web-based enrollment
system/application defaulted start date, which may or may not coincide
with the TRICARE Prime Enrollment Start Date.
9.4.4.2.2 The start date may be changed
up to 289 calendar days in the past or 90 calendar days into the future.)
9.4.5 WII 415 enrollments shall be
in conjunction with a Market/MTF enrollment only, not to civilian
network PCMs under TPR enrollment rules.
9.4.5.1 DEERS ends WII 415 enrollments
upon loss of member’s active duty eligibility.
9.4.5.2 WII 415 Program enrollments
are not portable across programs or geographical area of responsibility.
9.4.6 The TOP contractor shall enter
WII 415 enrollments through the Government-furnished
web-based enrollment system/application for outside the 50 US and
the District of Columbia.
9.4.7 The contractor
shall accomplish the following functions based on receipt of notification
from the Uniformed Service-specific WII Program entities:
• Enrollment
• Disenrollment
• Cancel enrollment
• Cancel disenrollment
• Address update
• The contractor can request unsolicited
Government-furnished policy notifications
resend
• Modify begin date
• Modify end date
9.5 WII 416 - WII - Community Care
Units (CCUs)
9.5.1 The contractor shall assign
a PCM based on the Market/MTF MOU and in coordination with the WII entity
(e.g., CCU).
9.5.1.1 Uniformed Service-defined eligible
Service members may be assigned to a WII 416 Program such as the
Army’s CCU and receive required medical care near the member’s home.
9.5.1.2 The Service member is enrolled
to TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote prior to or
at the same time as being enrolled into WII 416.
9.5.1.3 The contractor shall not enroll
members to the WII 416 program without a concurrent TRICARE Prime, TPR,
TOP Prime, or TOP Prime Remote enrollment.
9.5.1.4 Uniformed Service appointed
case managers will coordinate with the contractor or Market/MTF
to facilitate TRICARE Prime or TPR PCM assignments for eligible
beneficiaries.
9.5.1.5 WII 416 enrollments will not
run in conjunction with TAMP.
9.5.2 The Uniformed
Service-specific WII Program will stamp the front page of the DD
Form 2876, enrollment application form, with WII 416 for all new
enrollments.
9.5.2.1 The begin date will be the
date the contractor receives the signed enrollment form.
9.5.2.2 A signed enrollment application
includes those with an original signature, or an electronic signature offered
by and collected by the contractor.
9.5.3 The contractor shall perform
the enrollment in the Government
-furnished
web-based enrollment system/application and include the following
information:
9.5.3.1 WII 416 HCDP Plan Coverage
Code.
9.5.3.2 WII 416 Enrollment Start Date.
(Date received by the contractor or the date indicated by the Uniformed
Service-specific WII Program which may be up to 289 calendar days
in the past, or 90 calendar days in the future.)
9.5.4 WII 416 enrollments must be
in conjunction with a Market/MTF, TPR, TOP Prime, or TOP Prime Remote enrollment.
9.5.4.1 DEERS will end WII 416 enrollments
upon loss of member’s active duty eligibility.
9.5.4.2 WII 416 program enrollments
are not portable across programs or geographical area of responsibility.
9.5.5 The contractor shall accomplish
the following functions based on receipt of notification from Uniformed
Service-specific WII program entities:
• Enrollment
• Disenrollment
• Cancel enrollment
• Cancel disenrollment
• Address update
• ContractorsThe
contractor can request unsolicited Government-furnished
policy notification resend
• Modify begin date
• Modify end date
10.0 TRICARE
POLICY FOR ACCESS TO CARE (ATC) AND PSA STANDARDS
10.1 Non-active duty beneficiaries
in the Continental United States (CONUS) and Hawaii who reside more
than 30 minutes travel time from their desired PCM but less than
100 miles must waive primary and specialty drive time ATC standards
if they wish to enroll in TRICARE Prime. (Due to the unique HCD
challenges in Alaska, the requirement to request a waiver for the
drive time access standard does not apply to beneficiaries in Alaska.)
10.1.1 The contractor shall, before
effecting an enrollment or portability transfer request, ensure
that a beneficiary has waived travel time ATC standards either by
checking the Drive Time Waiver box in Section V of the DD Form 2876
enrollment application (this includes an electronic signature offered
by and collected by the contractor), by providing verbal consent
via telephone communication (which the contractor shall document
in the contractor call notes), or by requesting enrollment through
the Government-furnished web-based self-service enrollment
system/application (for both civilian and Market/MTF PCMs).
10.1.2 An approved waiver for a beneficiary
residing less than 100 miles but more than 30 minutes from their PCM
will remain in effect until the beneficiary changes residence.
10.2 The contractor shall estimate
the travel time or distance between a beneficiary’s residence to
a PCM (either a civilian PCM or a Market/MTF) using at least one
web-based mapping program.
10.2.1 The choice of the mapping program(s)
is at the discretion of the contractor, but the contractor shall
use a consistent process to determine the driving distance for each
enrollee applicant who may reside more than 30 minutes travel time
from their PCM.
10.2.2 The contractor shall compute
time or distance between the enrollee’s residence and the physical location
of the PCM (including Markets/MTFs).
10.2.3 It is not acceptable to use
a geographic substitute, such as a geographic centroid.
10.3 The contractor shall, in conjunction
with Markets/MTFs for Market/MTF enrollees, provide beneficiary drive
time waiver education and ensure that beneficiaries who choose to
waive these standards have a complete understanding of the rules
associated with their enrollment and the travel time standards they
are forfeiting.
10.4 The contractor
shall educate beneficiaries, who waive their ATC travel standards,
on the following concepts:
10.4.1 They should expect to travel
more than 30 minutes for access to primary care (including urgent
care) and possibly more than one hour for access to specialty care
services.
10.4.2 They will be held responsible
for POS charges for care they seek that has not been referred by
their PCM (or for Market/MTF enrollees, by another Market/MTF provider).
10.4.3 They should consider whether
any delay in accessing their enrollment site might aggravate their
health status or delay receiving timely medical treatment.
10.5 Cross-Geographical Area Of
Responsibility TRICARE Prime Enrollment
10.5.1 The enrolling contractor shall
ensure a beneficiary is not approved for cross-geographical area
of responsibility enrollment if they live within 30 minutes of a
Market/MTF, unless the Market’s/MTF’s servicing contractor approves
the enrollment. Otherwise, the beneficiary will be enrolled to the
Market/MTF if a PCM is available.
10.5.2 The contractor shall enroll beneficiaries
to the geographic area of responsibility where the desired PCM is
located; however, all TRICARE Prime enrollment policies still apply
(i.e., PCM selection and use, referrals, drive times and distance
standards to the desired PCM).
10.5.2.1 An access to care drive time
waiver is required (see
paragraph 10.1).
10.5.2.2 All claims are processed by
the geographic area of responsibility of enrollment.
10.5.2.3 The beneficiary must request
cross-geographical area of responsibility enrollment by either submitting
an enrollment form (DD Form 2876) or by calling the regional contractor
servicing the desired PCM.
10.6 Discrepant
Addresses
10.6.1 The contractor shall inform
the beneficiary at any point during the enrollment period where
the contractor determines or is advised that a beneficiary is no
longer eligible for continued TRICARE Prime enrollment due to an
address discrepancy (e.g., claims filed with a home address listed
which does not match their DEERS record). For example, their residential
address is 100 miles or more from the PCM or Market/MTF (with no
100 mile waiver) to which they are enrolled or their residential
address is 100 miles or more from their assigned network PCM.
10.6.1.1 This notification (letter,
telephone call, or email) shall occur when the discrepant information
is first known by the contractor.
10.6.1.2 If the beneficiary confirms
the DEERS-recorded address is incorrect, and the beneficiary updates DEERS
with correct information (contractor to assist as appropriate),
the beneficiary will remain enrolled in TRICARE Prime if all enrollment
requirements are met.
10.6.2 The contractor shall notify
the beneficiary of any apparent ineligibility for TRICARE Prime
if the contractor confirms the beneficiary is ineligible for enrollment
due to their address.
10.6.3 The contractor shall transfer
the plan enrollment to TRICARE Select if the beneficiary fails to
respond within 90 calendar days to a notification. If the beneficiary
does respond and wishes to remain in TRICARE Prime, the contractor
shall follow the relevant drive time waiver process outlined in
this section.
Note: The contractor, upon beneficiary
request, shall process retroactive enrollment requests from a beneficiary whose
TRICARE Prime coverage was terminated on or after January 1, 2019
due to a discrepant address that resulted in no TRICARE private
sector coverage. Affected beneficiaries may retroactively enroll
in either TRICARE Prime (if qualified) or TRICARE Select. The contractor
shall collect all applicable retroactive TRICARE enrollment fees before
processing an enrollment request. Alternatively, the beneficiary
may elect to restart their TRICARE coverage following QLE or annual
open enrollment season rules and costs.
10.7 Market/MTF
TRICARE Prime Enrollees
10.7.1 Non-active duty beneficiaries
must reside within 30 minutes travel time from a Market/MTF to which they
desire to enroll.
10.7.1.1 If a beneficiary desiring enrollment
resides more than 30 minutes (but less than 100 miles) from the Market/MTF,
they may be enrolled so long as they waive primary and specialty
ATC standards and the Market Director/MTF Director, or designee,
approves the enrollment.
10.7.1.2 If the MOU includes ZIP Codes
or drive time distances for which the Market/MTF is willing to accept enrollments
that are beyond a 30 minute drive, this constitutes approval. See
32
CFR 199.17 for information on access standards.
10.7.1.3 The contractor shall submit
each request not addressed in the MOU to the Market Director/MTF Director,
or designee, in a method that is outlined in the MOU.
10.7.1.4 The GDA may approve waiver
requests from beneficiaries who desire to enroll to a Market/MTF
and who reside 100 miles or more from the Market/MTF. In these cases,
the Market Director/MTF Director must also be agreeable to the enrollment
and have sufficient capacity and capability.
10.7.2 The contractor shall determine
if the beneficiary resides 100 miles or more from the Market/MTF
to which they are enrolled, and, if there is no 100 mile waiver
on file, inform the beneficiary that he or she is no longer eligible
for TRICARE Prime enrollment to the Market/MTF. This notice advises
the beneficiary that he or she is being automatically enrolled in
TRICARE Select, and their option to enroll with a USFHP where available.
10.7.3 The contractor shall inform
a beneficiary choosing not to enroll in TRICARE Select, or USFHP
where available, about his or her military medical benefits limitation
to direct care access to Markets/MTFs on a space available basis
only.
10.7.4 The contractor shall process
all requests for enrollment to a Market/MTF in accordance with the
MOU between the Market/MTF and the contractor. See
paragraph 10.5 regarding
cross-geographical area of responsibility enrollments. Enrollment
guidelines in MOUs may include:
10.7.4.1 ZIP Codes and distances for
which the Market Director/MTF Director is mandating enrollment to
the Market/MTF. These mandatory Market/MTF enrollment areas must
be within access standards (i.e., a 30 minute drive time of the
Market/MTF) and may apply to all eligible beneficiaries or may be
based on beneficiary category priorities for Market/MTF access.
Note: The contractor shall afford non-active
duty TRICARE Prime applicants who reside more than 30 minutes travel
time from a Market/MTF the opportunity to enroll with a civilian
PCM.
10.7.4.2 There may be ZIP Codes and distances
for which the Market Director/MTF Director is willing to accept enrollment.
This can include both areas within a 30 minute or less drive time
and over a 30 minute drive but within 100 miles. Any enrollment
for a beneficiary with a drive of more than 30 minutes requires
a signed waiver of access standards. If an enrollee applicant resides
within a ZIP Code previously determined to lie entirely within 30
minutes travel time from the Market/MTF, the contractor need not
compute the travel time for that applicant.
10.7.4.3 In determining whether or not
the Market Director/MTF Director will consider a request for TRICARE Prime
enrollment beyond 100 miles, the Market Director/MTF Director may
use ZIP Codes to designate those areas where he or she will consider
requests or will not consider requests.
10.7.5 The contractor shall notify
the Market Director/MTF Director (or designee) when a beneficiary
residing 100 miles or more from the Market/MTF, but in the same
geographical area of responsibility, requests a new enrollment or
portability transfer to the Market/MTF. Such notification is not
necessary if the MOU has already established that the Market Director/MTF
Director will not accept enrollment of beneficiaries who reside
100 miles or more from the Market/MTF.
10.7.6 The contractor shall make this
notification by any mutually agreeable method specified in the MOU.
10.7.7 The contractor shall not make
the Market/MTF enrollment effective unless notified by the Market/MTF to
do so.
10.7.7.1 The Market Director/MTF Director
will notify the GDA of their desire to enroll a beneficiary who resides
100 miles or greater from the Market/MTF and request approval for
the TRICARE Prime enrollment. The GDA will make a determination
on whether or not to approve or deny the request and notify the
Market Director/MTF Director of his or her decision by a mutually
agreeable method. The Market Director/MTF Director is responsible
for notifying the contractor of all approved enrollment requests
for beneficiaries who reside 100 miles or greater from the Market/MTF.
10.7.7.2 The contractor shall notify
the beneficiary of the final decision regarding an enrollment request
for TRICARE Prime enrollment where the beneficiary resides more
than 100 miles from a Market/MTF.
10.7.7.3 Approved waivers for beneficiaries
residing 100 miles or more from the Market/MTF remain in effect until
the beneficiary changes residence or unless the Market Director/MTF
Director determines that they will no longer allow these enrollments.
10.7.7.4 Even if a beneficiary has previously
waived travel time standards, any Market Director/MTF Director may
revise the MOU (following the MOU revision process) to state that
enrollment of some or all current enrollees who reside 100 or more
miles from the Market/MTF are not to be renewed at the end of the
enrollment period.
10.7.7.5 The contractor shall inform
such beneficiaries no later than two months prior to expiration
of the current enrollment period that they are no longer qualified
for renewal of enrollment to the Market/MTF.
10.7.7.5.1 The contractor shall, prior
to notification, obtain the rationale for the change from the Market/MTF to
include in the notice to the beneficiary.
10.7.7.5.2 The contractor shall obtain GDA
review and concurrence on the proposed notice prior to sending to
the impacted beneficiaries (the GDA will coordinate notices with
the DHA Communications prior to approval).
10.7.8 The contractor shall, at any
time during the enrollment period the contractor determines there
is no signed travel time waiver on file for a current Market/MTF
enrollee who resides more than 30 minutes from the Market/MTF, require
the beneficiary to waive the primary and specialty care travel standards
to continue their TRICARE Prime enrolled status (This includes monitoring
address changes received by the contractor from all sources).
10.7.8.1 The contractor shall notify the
beneficiary of this waiver requirement within 30 calendar days of determining
a need for waiver. The language for all beneficiary notices is reviewed
and concurred on by the GDA prior to being sent to beneficiaries.
(The GDA will coordinate notices with the DHA Communications prior
to approval.)
10.7.8.2 The contractor shall include
information on any available TRICARE plan option on any notice to
a beneficiary that is requesting they sign a waiver of access standards,
denying their enrollment, or advising them they are not eligible
for re-enrollment to a Market/MTF.
10.7.9 The contractor shall retain
the enrollment request in a searchable electronic file until 24
months after the beneficiary is no longer enrolled to the Market/MTF
for each approved enrollment to a Market/MTF where the beneficiary
has waived access standards.
10.7.10 The contractor shall provide
the retained file to a successor contractor at the end of the final
option period.
10.7.11 When an enrollment request
requires Market Director/MTF Director or GDA approval, any contractual requirements
relating to processing timeliness for enrollment requests will begin
when the contractor has obtained direction from the Market Director/MTF
Director or GDA regarding waiver approval or disapproval.
10.8 Civilian
TRICARE Prime PCMs
10.8.1 The contractor shall provide
the capability and capacity to allow beneficiaries who reside in
a PSA to enroll to a non-MTF civilian PCM within access standards.
10.8.2 The contractor may allow enrollment
if a beneficiary who resides in the PSA requests enrollment to a specific
PCM who is located more than a 30 minute drive from the beneficiary’s
residence and the beneficiary waives travel time access standards.
(Also, see
Chapter 5, Section 1.)
10.8.3 Outside a PSA, for new enrollments
(including portability transfers), the contractor is not required
to establish a network with the capability and capacity to grant
TRICARE Prime enrollment to beneficiaries who reside outside a PSA.
10.8.3.1 The contractor shall grant requests
for new enrollments to the civilian network from beneficiaries residing
outside a PSA, provided there is sufficient unused network capacity
and capability to accommodate the enrollment and that the PSA civilian
network PCM to be assigned is located less than 100 miles from the beneficiary’s
residence.
10.8.3.2 Beneficiaries who reside outside
the PSA and enroll in TRICARE Prime must waive their primary and specialty
care travel time access standards.
10.8.4 ADFMs
(Including ADFM TYA Prime Enrollees) Residing Outside a PSA
The contractor shall manage
grandfathered ADFMs as stated in this Chapter.
10.8.4.1 ADFMs (including ADFM TYA Prime
enrollees) enrolled in TRICARE Prime and who reside outside of a T-3
PSA on September 30, 2013, were grandfathered in TRICARE Prime starting
October 1, 2013.
10.8.4.2 ADFMs will remain enrolled
in TRICARE Prime as long as they reside within 40 miles of the residence where
they were originally granted grandfathered status and maintain eligibility
as ADFMs.
10.8.4.3 The contractor shall continue
to have a PCM available for these beneficiaries and ensure all claims and
benefits are administered as TRICARE Prime. ADFMs shall remain enrolled
in TPRADFM, as appropriate.
10.8.5 Terms
of Grandfathered Prime for Prior PSAs - Status
10.8.5.1 The National Defense Authorization
Act (NDAA) for FY 2014, Section 701, signed into law on December
26, 2013, gave certain beneficiaries a “one-time” election to continue
their TRICARE Prime enrollment. The eligible beneficiaries included
those who:
• Were involuntarily disenrolled
from TRICARE Prime on September 30, 2013, due to the PSA reduction;
and
• Lived within 100 miles of an
Market/MTF.
10.8.5.2 The NDAA for FY 2016, Section
701 signed into law on November 25, 2015, gave certain beneficiaries a
“one-time” election to continue their TRICARE Prime enrollment.
10.8.5.2.1 These eligible beneficiaries
included those who:
• Were involuntarily disenrolled
from TRICARE Prime on September 30, 2013, due to the PSA reduction;
• Resided more than 100 miles
from an MTF/Enhanced Multi-Service Market (eMSM); and
• Were an eligible beneficiary
by reason of service in the Army, Navy, Air Force, or Marine Corps.
10.8.5.2.2 Special enrollment processes
for these particular beneficiaries are outlined below.
10.8.5.3 An Interim Final Rule (IFR)
was published in the
Federal Register on September
29, 2017 (82 FR 45438-45461) that established TRICARE Select and
other TRICARE reforms.
10.8.5.3.1 As noted in the IFR, the Director,
DHA determines the locations where TRICARE Prime will be offered
and announces them prior to the annual open season enrollment period.
10.8.5.3.2 The Final Rule, published February
15, 2019, continues the principle that the purpose of TRICARE Prime
is to support the medical readiness of the armed forces and the
readiness of medical personnel in areas of one or more MTFs.
10.8.5.3.3 The rule preserves the Department’s
discretion with respect to the locations where TRICARE Prime is
offered.
10.8.5.4 The ADFM must maintain a residence
within 40 miles of the residence where they were originally granted
grandfathered status in order to retain grandfathered status.
10.8.5.4.1 Grandfathered ADFMs must be
assigned a PCM.
10.8.5.4.2 Grandfathered ADFMs may add or
terminate enrollment of family members like any other ADFM (e.g.,
marriage, birth, adoption, divorce).
10.8.5.4.3 Family members may live in a
separate residence outside a T-3 PSA and still be grandfathered.
10.8.5.5 Grandfathered ADFMs lose their
grandfathered status when they are:
10.8.5.5.1 No longer TRICARE eligible;
10.8.5.5.2 No longer residing within 40
miles of the residence where they were originally granted grandfathered
status; or
10.8.5.5.3 Change to retired status.
10.8.5.6 The contractor shall not grandfather
retired beneficiaries.
10.8.5.7 The contractor shall grandfather
TAMP beneficiaries enrolled in TRICARE Prime who reside outside
of a PSA similar to other ADFMs.
10.8.5.8 Grandfathered TRICARE Prime
enrollees will continue to be grandfathered if they become TAMP eligible
and enroll in TAMP, as long as they reside within 40 miles of the
residence where they were originally granted grandfathered status.
10.8.6 The contractor shall not enroll
beneficiaries who reside outside the PSA and are 100 miles or greater from
an available civilian network PCM in the PSA in TRICARE Prime.
11.0 REPORTS
The contractor shall provide
monthly ADSM enrollment and beneficiary services reports. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
12.0 Implementation
Of TRICARE Select Group A Enrollment Fees
12.1 The contractor
may collect and process enrollment requests to include processing
of allotment requests prior to Open Season. If the beneficiary arranges
a monthly fee option (allotment, where feasible) by November 20, 2020,
the contractor shall not collect up to three months of enrollment
fees to initialize a monthly fee option. If the beneficiary provides
fee payment arrangements after November 20, 2020, the contractor
shall follow the monthly payment fee option in
paragraph 6.1.4.
12.2 In addition
to the contractor’s existing best business practices regarding “failure
to pay fees” notifications, if not already being done, the contractor
shall:
• Use Health Insurance Portability
and Accountability Act (HIPAA) compliant “robo calls,” text messages,
and emails to notify adult members of each household (sponsor, spouse,
or adult child) that haven’t indicated whether they wish to continue
their coverage and of the opportunity to reinstate their coverage.
• Make and document at least
three phone calls to home, mobile, or work phone numbers of an adult
member of the household.
12.3 The contractor
shall extend the TRICARE reinstatement policy for TRICARE Select
Group A from 90 calendar days (see
paragraph 5.6.1) until 180
days after termination of such coverage for failure to pay fees
on January 1, 2021. Unless otherwise notified, this exception expires
on June 30, 2021.
12.4 The contractor shall include
information on the reinstatement option in claims denial correspondence when
TRICARE Select Group A claims with a date of service after January
1, 2021 through June 30, 2021 are denied due to non-enrollment.
12.5 The contractor
shall provide weekly TRICARE Select Group A reports (not applicable
to those beneficiaries whose enrollment fees are waived by law)
according to DD Form 1423, CDRL, located in Section J of the applicable contract.
Unless otherwise directed, the contractor shall discontinue reports
on June 30, 2021.