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
DMDC
will automatically enroll newly eligible ADFMs in TRICARE Prime
or TRICARE Select. If the beneficiary is overseas, they will be
enrolled in TOP Select. See Chapter 24, Section 5 for
TOP enrollment guidance.
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.
They are automatically
covered by TRICARE For Life (TFL), provided they have Medicare Part
A and Part B.3.1.3.1 Exception: Those not entitled
to premium free Medicare Part A on their own or the record of their current,
former, or 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 must follow
all TRICARE Prime requirements for PCM assignment, referrals and
authorizations. However, TRICARE Prime-enrolled dual eligibles are not
subject to POS cost-sharing. DMDC waives enrollment fees
for dual eligible enrollees who have Medicare Part B.
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 assigning enrollees,
or categories of enrollees,
be assigned to a
DC PCM or
offered offering 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 upon 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 upon the
geographical area of responsibility and Market/MTF MOUs/SOR,
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 preference 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 private
sector 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 are based
on upon 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 Department of Defense (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 The contractor shall process
the request within six calendar business days
of receiving the request.
Note: Prior to January 1,
2018, the contractor was to modify the effective date to be no later
than the third business day, or the date requested by the beneficiary
up to 90 days in the future.
5.0 ENROLLMENT
PERIOD
5.1 The contractor shall support
one annual open enrollment period per
calendar year Calendar
Year (CY) for all Non-Active Duty Service Member (NADSM)
beneficiaries.
5.1.1 Enrollments, with the appropriate
application and any required enrollment fee, will
be are 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.
The
Government will establish and communicate the specified fee payment
amount to the contractor.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 there 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 United
States (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 first 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 the 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 Government will
establish and communicate the specified fee payment to the contractor.
6.1.3.4 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
Quarterly
Payment Fee Option6.1.4.1 Quarterly installments
are equal to one-fourth (1/4) of the total annual fee amount.
6.1.4.2 The Government will
establish and communicate the specified fee payment amount to the contractor.
6.1.4.3 The contractor shall
prorate the quarterly fee to cover the period until the next quarter
for initial enrollments. Quarters begin on January 1, April 1, July
1, and October 1. The contractor shall collect quarterly fees thereafter.
6.1.4.4 The contractor shall
accept payment of the quarterly enrollment fee by debit/credit card
(e.g., Visa/MasterCard) and optionally may elect to receive quarterly
payments via RCC or EFT transactions. See paragraph 5.6 for
disenrollment information if the appropriate enrollment fee payment
is not received.
6.1.5 Monthly Payment Fee Option
6.1.5.1 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.
6.1.5.2 The Government will
establish and communicate the specified fee payment amount to the contractor.
6.1.5.3 MonthlyBeneficiaries
shall pay 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.
6.1.5.4 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.
6.1.5.5 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.
6.1.5.6 The contractor shall obtain
and verify the information needed to initiate monthly allotments
and EFTs.
6.1.5.7 The contractor shall direct
bill the beneficiary only when a problem occurs.
6.1.5.7.1 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).
6.1.5.7.2 The contractor shall provide
the beneficiary with the option to pay quarterly or annually.
6.1.5.7.3 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.
6.1.5.8 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).
6.1.5.9 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.
6.1.5.10 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.
6.1.5.11 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 contractor shall
use 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 to 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 ChildrenThe
contractor shall identify and enroll 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 in 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 may 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, and 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.
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 shall 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 and enroll
in TRICARE Select.
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
s 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 upon the
enrollment fee amount collected and entered into DEERS by the contractor,
which in this circumstance, should shall 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 are 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 entitled
to Medicare Part A
based upon disability,
End Stage Renal Disease (ESRD) or upon attaining age 65 regardless
of reason or age, 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 upon 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 is not be required
unless a credit remains when the policy is paid in full.
8.6.2 The contractor shall utilize use 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 and
TRICARE Select enrollees who become entitled
to Medicare eligible and
who maintain Medicare Part B coverage and TRICARE
Select enrollees who become Medicare eligible, the
contractor shall issue 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 ADFMs must
enroll in Medicare Part B during
Medicare’s their Special
Enrollment Period
prior to their sponsor’s retirement
date.
To avoid a break in TRICARE coverage,
ADFMs should sign up for Medicare Part B the month before their
sponsor retires and pay applicable Medicare Part B premiums.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
eligiblesTRICARE beneficiaries 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 or 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. The contractor shall
advise enrollees who are not eligible for Medicare Part A that they
may be eligible for Medicare on a spouse’s record. If there is the
possibility to be eligible for Medicare Part A on a spouse’s record,
then the contractor shall advise 65 year old TRICARE beneficiary
to sign up for Medicare Part B in order to avoid the Medicare Part
B late enrollment premium penalty. Everyone is eligible for Medicare
Part B at age 65, even if not eligible for Part A. To be eligible
for Medicare Part A on a spouse’s record, the following criteria
must be met:
• For those currently
married: Need to be married for at least a year.
• For those currently
divorced: Must be single, after being married for at least ten years,
to a spouse eligible for Medicare. If remarried, and still TRICARE
eligible, see above for those currently married.
• For those widowed: Must
be single after at least nine months of marriage to a spouse eligible
for Medicare. If remarried, and still TRICARE eligible, see above
for those currently married.
Those
not eligible for Medicare Part A must sign up for Medicare Part
A on their spouse’s record two to three months before the spouse
turns 62 years of age. Otherwise, sign up must occur at the time
the 65 year old is denied Medicare on their own record.
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 CYs.
8.9.2 Overpaid fees for URFS can only
be applied to their enrollment records the
URFS.
8.9.3 The contractor
shall automatically refund prorated enrollment fees in excess of
two calendar years CYs.
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 CYs 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 Services sponsor,
eligible spouse, and then oldest child in that order.
8.9.7 Refunds for URFS enrollment fees shall are 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 Services.
9.1.3 The Uniformed Services 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:
9.2.1 The contractor shall
enroll 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.
9.2.2 AThe
contractor shall not enroll a Service member cannot
be enrolled in WII 415 and WII 416 Programs at the
same time.
9.2.3 The contractor shall
terminate 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 Services-specific
WII entity.
9.2.4 Any claims processed
for WII 415/416 enrolleesThe contractor shall follow
the rules associated with the primary HCDP Plan Coverage Code, such
as TRICARE Prime, TPR, TOP Prime, or TOP Prime Remote for
any claims processed for WII 415/416 enrollees.
9.2.5 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)
/MEDHOLD)
9.4.1 The contractor
shall enroll Uniformed Service
s-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 Services 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 the Transitional
Assistance Management Program (TAMP) and Service 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 will ends WII
415 enrollments upon loss of the Service 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 upon receipt
of notification from the Uniformed Service-specific WII Program
entities:
• Enrollment
• Disenrollment
• Cancel enrollment
• Cancel disenrollment
• Address update
• The contractor
canMay 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 Services-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 Service 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 Service members
to the WII 416 program without a concurrent TRICARE Prime, TPR,
TOP Prime, or TOP Prime Remote enrollment.
9.5.1.4 Uniformed Services-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
s-specific WII Program
will stamp
s 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
Services-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 are 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 the Service 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 upon receipt
of notification from Uniformed Service
s-specific
WII program entities:
• Enrollment
• Disenrollment
• Cancel enrollment
• Cancel disenrollment
• Address update
• The contractor
canMay 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 remains 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 travelTravel may be 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 beBeneficiaries
are 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 TheyBeneficiaries should
consider whether any delay in accessing their enrollment site might may 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 is 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 beneficiaryBeneficiaries 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 remains enrolled
in TRICARE Prime if all enrollment requirements are met.
10.6.2 For the Continental
US, Hawaii, and the District of Columbia: The contractor
shall notify the beneficiary of any apparent ineligibility for TRICARE
Prime
/Prime Remote if the contractor confirms
the beneficiary is ineligible for enrollment due to their
residential address.
The
notification must be within five business days of confirmation of the
discrepant address and must indicate that the beneficiary will be
disenrolled unless further action is taken within 90 days. Notification
shall include information about TRICARE Standard and Extra, prior
to January 1, 2018, or TRICARE Select, starting January 1, 2018.
See paragraph 1.0 for notification
processes for discrepant DEERS records. The contractor shall continue
to process all claims until the enrollment is changed.
10.6.3 The contractor
shall transfer the plan enrollment to TRICARE Select if the beneficiary
fails to respond beneficiary must take
action to enroll in TRICARE Select of USFHP (where available) within
90 calendar days to a of this 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. The contractor
may reprocess impacted claims upon request from the beneficiary
once retro-active enrollment is completed.
10.6.4 If the beneficiary takes
no action within the 90-day window, the contractor shall terminate
the TRICARE Prime/Prime Remote enrollment, effective the 91st day.
Once enrollment is terminated, any care received outside the direct
care system is not covered.
10.6.5 TRICARE Select JurisdictionIf at any point during
the enrollment period the contractor determines or is advised that
a TRICARE Select enrollee’s residential address does not match the
region of enrollment, the contractor shall not disenroll the beneficiary.
If the contractor is aware of a TRICARE Select beneficiary requesting
enrollment with an out-of-region address in DEERS, the contractor
shall advise the beneficiary of the necessity to enroll in the region
of their address in DEERS and inform the beneficiary to contact
their correct Regional contractor to enroll in TRICARE Select.
10.7 Market/MTF
TRICARE Prime Enrollees
- Continental US, Hawaii, and
the District of Columbia10.7.1 Non-active duty beneficiaries
must shall reside
within 30 minutes travel time from a Market/MTF to which they desire
to enroll.
10.7.1.1 If aA beneficiary
desiring enrollment who resides more than
30 minutes (but less than 100 miles) from the Market/MTF, they may
be enrolled so as long
as they the beneficiary waives 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 the beneficiary 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 See paragraph 10.6.
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 The
following enrollment guidelines
may be included 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 upon 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 or distances
for which the Market Director/MTF Director is willing to accept
enrollment. This can may include
both areas within a 30 minute or less drive time and or 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 theThe Market
Director/MTF Director will consider a request for TRICARE
Prime enrollment may use ZIP codes to
designate distances beyond 100 miles, the
Market Director/MTF Director may use ZIP Codes to designate those
areas where he or she for which they will
consider requests or will not consider requests for
enrollment.
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 ofhis or her the decision
by a mutually agreeable method. The Market Director/MTF Directoris
responsible for notifying will notify 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 will 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 will 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.
10.7.8.3 If the beneficiary chooses
to not enroll in TRICARE Select, or USFHP (where available) within
90 days of notification, the contractor shall terminate the TRICARE
Prime enrollment. DMDC will send the disenrollment notice. 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.)
10.7.9 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
- Continental US, Hawaii, and the
District of Columbia10.8.1 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,
forFor 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
TRICARE 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 6.1.5.
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
toDetails for reporting are identified
in DD Form 1423, CDRL, located in Section J of the applicable
contract. Unless otherwise directed, the contractor shall discontinue
reports on June 30, 2021.