1.0 POLICY (Before January 1, 2018)
1.1 Generally, when the TRICARE eligibility
status changes, eligibility for TRICARE Prime benefits also changes.
The time frames for TRICARE Prime eligibility
parallel TRICARE eligibility.
1.2 In all
cases, when TRICARE eligibility ends, eligibility for TRICARE Prime
ceases. This includes retirees, their family members and survivors
who turn age 65 and are entitled to Medicare but are not eligible
for TRICARE for Life (TFL), dependent children who lose TRICARE
eligibility due to age, remarriage of former spouses, etc.
1.3 To have continuous TRICARE
Prime coverage, the enrollee will submit an enrollment form, or
use the Government furnished web-based self-service enrollment system/application
transaction, or make a telephonic request to the contractor before,
or within 30 calendar days following, their retirement date, and
pay the appropriate enrollment fees, calculated based on the effective
date of enrollment, within the required time frames (see
Section 2.1). Active duty personnel who retire
may enroll at the same time as the remaining family members.
1.3.1 The contractor shall apply
an effective date according to the provisions of
Section 2.1 if
this is not done before or within 30 calendar days following the
member’s retirement or separation.
1.3.2 If the
enrollee is receiving ongoing care at the time of retirement or
separation, he or she must comply with all of the care authorization
requirements of the enrollee’s new status including getting a new
authorization from the contractor.
1.4 The contractor shall offer TRICARE
Prime enrollees an opportunity to continue enrollment in TRICARE Prime,
if available, but at the retiree cost-sharing rates when status
changes from Active Duty Family Member (ADFM) to retiree family
member. These enrollees must pay the applicable enrollment fees. Beneficiaries
shall be permitted The contractor shall
permit beneficiaries to keep their Primary Care Manager
(PCM), if possible. Market Directors/Military Medical Treatment
Facility (MTF) Directors will determine if retiring beneficiaries
who enroll in TRICARE Prime could can keep
their Market/MTF PCMs, given the Market’s/MTF’s enrollment plan
and Market/MTF capacity.
1.5 TRICARE
Prime Enrollment for Transitional Survivors. Those in Transitional
Survivor Status, are not distinguished from other ADFMs for TRICARE
Prime eligibility. See the Transitional Survivor Status policy in
Section 7.1.
1.6 When an
active duty member retires other than the first of the month or
a member separates other than the first of the month but continues
to be eligible (e.g., is the spouse of an active duty member; or
is eligible for Transitional Assistance Management Program (TAMP)),
TRICARE Prime enrollment may continue as of the date of retirement
or separation so long as all enrollment requirements have been met
as stated in
Section 2.1.
1.7 When TRICARE
Prime enrollment changes from an individual to a family enrollment
status prior to annual renewal for beneficiary categories required
to pay an enrollment fee, the
contractor shall apply
the unused portion (prorated on a monthly basis) of
the fee
will be applied toward a new
enrollment period or refund
ed it in accordance
with the TRICARE Operations Manual (TOM),
Chapter 6, Section 1.
1.7.1 For ADFMs,
single enrollment can be changed to family at any time during the
enrollment period. A new enrollment period shall be established
for the family.
1.7.2 The contractor
shall process claims with the TRICARE Prime copayment even in the
absence of referrals or authorizations for newborns or adoptees
as described in this paragraph.
A The
contractor shall deem a newborn or adoptee
will
be deemed to be enrolled in TRICARE Prime as of the
day of birth or adoption if one family member is already enrolled
in TRICARE Prime. A responsible representative has 60 calendar days
to officially enroll the child to the TRICARE Prime option. If the
newborn or adoptee is formally enrolled in TRICARE Prime within
the 60 calendar day period, the effective date of enrollment will
be the first of the month following the date of birth or adoption.
(The 20th of the month enrollment rule is waived, if necessary.)
If the newborn or adoptee is not formally enrolled during the 60
calendar day period, the newborn or adoptee will revert to a non-enrolled
beneficiary effective the 61st calendar day. If the decision is
made to continue TRICARE Prime coverage,
a responsible
family member must complete an official enrollment request
(enrollment form, Government furnished web-based self-service enrollment
system/application transaction, or telephonic request)
must
be completed on behalf of the child. For retirees
or their family members or survivors who decide to continue enrollment
for the child, the
contractor shall apply the unused
portion (pro-rated on a monthly basis) of the single enrollment
fee
they the beneficiary paid
will
be applied toward a new family enrollment period.
For newborns and newly adopted children enrolled under this provision,
the
contractor shall not apply Point of Service (POS) cost-sharing
does
not apply through the 60th calendar day or the effective
date of enrollment, whichever is earlier. The Government Designated
Authority (GDA)
is granted has the
authority to extend the deemed period up to 120 calendar days, on a
case-by-case or a geographical area basis.
Note: In the case of a reservist
who has been called to active duty for a period of 30 calendar days
or less, a new family member is not considered enrolled in TRICARE
Prime, since the family members of the reservist are not eligible
to enroll in TRICARE Prime.
1.7.3 The contractor
shall process claims as civilian TRICARE Prime for this period for
those newborns and adoptees who are covered under the 60 calendar
day “deemed enrollment” benefit.
1.7.4 The contractor
shall process claims using enrollment status if the newborn or adoptee
is formally enrolled during this period.
1.7.5 The contractor
shall process all claims as a non-enrolled beneficiary if the newborn
or adoptee is not formally enrolled during the 60 day calendar day
period, at the end of the 60th calendar day period applying the appropriate
TRICARE cost-shares and deductibles. See the TOM,
Chapter 8, Section 1, for claims processing procedures.
1.8 When
a family enrollment status changes to single,
there
is no the contractor shall not refund
of the
paid enrollment fee, unless the family enrollment becomes an individual
enrollment due to death of one or more family members or a retired
TRICARE Prime enrollee becomes dual eligible (see the TOM,
Chapter 6, Section 1). The remaining single
enrollee continues to have TRICARE Prime coverage until the enrollee
takes action to disenroll, the enrollee is no longer eligible for
TRICARE Prime, or the enrollee fails to pay a required enrollment
fee.
1.9 TRICARE eligible beneficiaries
who have less than 12 months of eligibility remaining (for example,
retirees who are 64 years of age, TAMP beneficiaries) are allowed
to enroll in TRICARE Prime, however, these enrollees will be disenrolled
from TRICARE Prime when they lose their TRICARE eligibility. The
beneficiary has the choice of paying all of the enrollment fee or
paying the fees on a monthly or quarterly basis. If paid on a monthly
or quarterly basis, the beneficiary will be required to pay the
installments that would cover the period of their eligibility only. See
paragraph 1.8 for
those who pay in full at the beginning of the enrollment period.
1.11 Enrollees may disenroll from
TRICARE Prime according to the requirements of
Section 2.1.
2.0 Policy (On Or After January
1, 2018)
2.1 Generally, when the TRICARE
eligibility status changes, eligibility for TRICARE Prime or TRICARE
Select benefits also changes.
2.2 In all
cases, when TRICARE eligibility ends, eligibility for TRICARE Prime
or TRICARE Select ceases. This includes retirees, their family members
and survivors who turn age 65 and are entitled to Medicare but are
not eligible for TFL if they don’t elect Medicare Part B, for example,
dependent children who lose TRICARE eligibility due to age, remarriage
of former spouses.
2.3 A change
in status that results in a change in TRICARE coverage is considered
a Qualifying Life Event (QLE). Eligible beneficiaries may elect
to enroll in TRICARE Prime or TRICARE Select within 90 calendar
days of a QLE. See
Section 2.1.
2.4 Active duty personnel who retire
may enroll at the same time as the remaining family members.
2.5 If a TRICARE Prime enrollee
is receiving ongoing care at the time of retirement or separation,
he or she must comply with all of the care authorization requirements
of the enrollee’s new status including getting a new authorization
from the contractor.
2.6 When status
changes from ADFM to retiree family member,
the contractor
shall offer TRICARE Prime enrollees
shall
be offered an opportunity to continue enrollment
in TRICARE Prime, if available, but at the retiree cost-sharing
rates. These enrollees must pay the applicable enrollment fees.
Beneficiaries shall be permitted to keep their PCM, if possible.
Market Directors/MTF Directors will determine if retiring beneficiaries
who enroll in TRICARE Prime could keep their Market/MTF PCMs, given
the Market/MTF’s enrollment plan and Market/MTF capacity. Alternatively,
they may elect to enroll in TRICARE Select. See
Section 2.1,
for QLE information.
2.7 TRICARE
Prime Enrollment for Transitional Survivors. Those in Transitional
Survivor Status, are not distinguished from other ADFMs for TRICARE
Prime eligibility. See the Transitional Survivor Status policy in
Section 7.1.
2.8 Claims For Newborns and Adoptees
2.8.1 ClaimsThe
contractor shall cost-share claims for newborns and
adoptees
will be cost-shared for up
to the first 90 calendar days of life as TRICARE Prime if one or
more family members (including
Active Duty Service Members
(ADSMs
)) are enrolled in TRICARE
Prime. Otherwise, the
contractor shall cost-share claims
will
be cost-shared as TRICARE Select for up to the first
90 calendar days of life.
The contractor shall include
the following alert note on Explanation Of Benefits (EOBs) for claims
processed during this deemed enrolled period: “TWO ACTIONS are required
within 90 days of birth or adoption to ensure continued TRICARE
private sector coverage: (1) register the child into Defense Enrollment
Eligibility Reporting System (DEERS) at a Department of Defense
(DoD) ID card office; AND (2) choose a TRICARE health plan and enroll
your child if necessary. How best to enroll your new child depends
on who you are (ADSM or retiree) and your location. For more information,
please visit https://www.tricare.mil/LifeEvents/Baby/GettingTRICAREforChild.
Claims will be denied if received after 90 days of life if the newborn
is not enrolled in TRICARE Prime or TRICARE Select coverage.” Claims
will be denied The contractor shall deny
claims if received after 90 calendar days of life if
the newborn is not enrolled in TRICARE Prime or TRICARE Select coverage.
2.8.2 The contractor shall only reprocess
claims paid during the first 90 calendar days of life when requested by
a responsible member of the family once the newborn or adoptee is
enrolled in TRICARE coverage.
EXCEPTION: If overseas, the time
frame is above for newborn
claims is extended up to the first 120 calendar days
of life or from the date of adoption.
The sponsor shall register the child in DEERS within 120 days from
the child’s birth date or the date of adoption. Once registered
in DEERS, newly eligible ADFMs residing in an overseas area are automatically
enrolled into TRICARE Overseas Program (TOP) Select and have 90
days after the auto enrollment to change their enrollment to TOP
Prime/TOP Prime Remote if desired and if command sponsored.
2.8.3 Once a
newborn or adoptee is shown as enrolled in a TRICARE plan in Defense
Enrollment Eligibility Reporting System (DEERS), the TRICARE Prime
or TRICARE Select “deemed status” for cost sharing of claims no longer
applies and claims received after the date of enrollment shall be
processed according to the cost sharing provisions of their enrolled
plan.
2.8.4 See the
TOM,
Chapter 22, Section 1, for policy with processing
newborn and adoptee claims under TRICARE Reserve Select (TRS) and
TRICARE Retired Reserve (TRR) coverage.
2.9 The contractor shall
allow TRICARE eligible beneficiaries who have less than
12 months of eligibility remaining (for example, retirees who are
64 years of age, TAMP beneficiaries)
are allowed to
enroll in TRICARE Prime or TRICARE Select; however, these enrollees
will be disenrolled when they lose their TRICARE eligibility. The
contractor
shall allow the beneficiary
has the
choice of paying all of the enrollment fee or paying the fees on
a monthly or quarterly basis. Once the enrollment is terminated,
the
contractor shall apply the remaining enrollment fees
may
be applied to the enrollment fees of another family
member, or at the request of the beneficiary,
may
be refunded refund the remaining enrollment
fees. See the TOM,
Chapter 6, Section 1.
2.10 Reserve
Component (RC) beneficiaries that move between a TRICARE Premium
Plan (TRS, TRR, TRICARE Young Adult (TYA), or Continued Health Care
Benefit Plan (CHCBP) and a non-premium plan. See
Section 2.1 for how
these status changes affect the beneficiaries’ cost-share, deductible
and catastrophic cap. When a RC member is activated and is treated
as any other active duty member, the member’s
dependents family
members qualify as ADFMs. See
Section 2.1 for
how this status change affects the
dependent’s family
member’s cost-shares, deductibles, and catastrophic
cap.
2.11 Enrollees
may disenroll from TRICARE Prime or TRICARE Select according to
the requirements of
Section 2.1.