2.5.2 Enrollment
will
be done occur during
an the
TRICARE open season enrollment period prior to the beginning
of each plan year, which operates with the calendar year for TRICARE
Prime and TRICARE Select. TRICARE Retired Reserve (TRR), TRICARE
Reserve Select (TRS) and TRICARE Young Adult (TYA) have open enrollment
(see
Chapter 1, Section 1.1). An enrollment choice
will be effective for the plan year. Beneficiaries may choose to
enroll, change, or terminate TRICARE Prime or TRICARE Select coverage
from the Monday of the second full week in November to the Monday
of the second full week in December of each calendar year. See TOM,
Chapter 6, Section 1.
Note: In any given year,
if the date range detailed in paragraph 2.5.2 for
the open season enrollment period amounts to less than 30 days as
required in 32 CFR 199.17(o)(1)(i), the Defense Health
Agency (DHA) will add days to the end of the date range detailed
above in order for the open season enrollment period to total 30
days. The DHA will communicate the resulting final date range for
the open season enrollment period to the contractor for the years
where such added days are required.
2.5.2.1 If a beneficiary elects to change
their TRICARE coverage during the TRICARE open
season enrollment period, the newly elected
coverage will begin on January 1 of the following year and will
continue in effect until they lose eligibility or request to change
their coverage when authorized.
2.5.2.2 If a beneficiary chooses to
not elect to change their TRICARE coverage during the open enrollment period,
the coverage will be continued until the end of the next calendar
year unless otherwise terminated.
2.5.3 Qualifying Life Events (QLEs)
As an exception to the open enrollment
period rule, enrollment changes can be made during the plan year
for certain QLEs,
including to
include:
• Marriage, divorce, or annulment;
• Birth or adoption of a child;
• Placement of a child by a court
in a member’s home;
• Change in sponsor status that
results in ineligibility to continue existing TRICARE coverage;
• Gain or loss of command sponsorship
(overseas only);
• Loss of sponsor or family member
eligibility (age, Medicare, etc.);
• Relocation to a new country,
and/or city (OCONUS), region or ZIP
+4 code (date received or date specified by the beneficiary in the
future) (self-attestation);
• Gain or loss of Other Health
Insurance (OHI) (self-attestation);
• Gain or loss of Medicaid entitlement;
• Gain or loss of Medicare entitlement
(not applicable for loss of Medicare coverage for failing to sign
up on time for Medicare coverage or failing to pay Medicare premiums);
• Death of a sponsor, spouse
or child;
• Change in eligibility status
of any single family member in another family (e.g., joint service
member);
• Upon
reflection of delayed gain or loss of retroactive eligibility in
DEERS (see paragraph 2.5.3.1.3 for exception);
• Change in family composition
(gaining family only): Beneficiaries with multiple sponsors whose
eligibility to enroll is established from one sponsor to another
in DEERS without evidence of any other QLE. However, this QLE cannot
be used in the Government furnished web-based self-service enrollment
system/application. Beneficiaries must contact the contractor to
use this QLE.
• Government directed PCM changes:
If a Market/MTF requires a TRICARE Prime enrollee to move from a
network PCM to a Market/MTF/PCM or vice versa, the enrollee may
choose to agree with the PCM change or may enroll in TRICARE Select.
• Government directed plan change:
If the Government no longer offers a TRICARE enrolled health plan
in one or more areas, affected beneficiaries may elect to enroll
in another qualified TRICARE plan Health
Plan (THP).
2.5.3.1 Enrollment must be within 90
calendar days
of the date of the QLE. Coverage starts as of the date of the QLE.
Applicable enrollment fees must be paid for that period. For QLEs
resulting from address changes, the effective date will be the address
effective date on DEERS. Whenever DEERS supports entry of a future
effective date for a QLE event, DEERS will allow a QLE enrollment
action up to 90 calendar days prior to that date. The enrollment
action will be effective the date of the QLE. This includes self-attest
QLEs with a future effective date.
2.5.3.1.1 EXCEPTION: The
contractor shall, upon request, enroll retired service members and
their family members into TRICARE Prime (if qualified) or TRICARE
Select coverage retroactive to the date of retirement if the enrollment
request is received within 12 calendar months of the retirement
date and as long as enrollment fees (if applicable) are paid back
to the retirement date for Uniformed Services retirements that occur
on or after January 1, 2018. The effective start date of coverage
must be the member’s retirement date.
2.5.3.1.2 The contractor shall apply
open season and QLE rules for requests for a retroactive enrollment
date greater than 12 months in the past or request a start of coverage
date other than the date of retirement, unless directed otherwise
by the GDA.
2.5.3.1.3 EXCEPTION: The
contractor shall enroll, upon request, Unremarried Former Spouses
(URFS) who become eligible for TRICARE as their own sponsor on or
after January 1, 2018, into TRICARE Prime (if qualified) or TRICARE
Select coverage retroactive to the date of eligibility as an URFS
if the enrollment request is received within 12 calendar months
of the initial eligibility date as an URFS and as long as all enrollment
fees (if applicable) back to the initial URFS eligibility date are
paid. The effective start date of coverage must be initial URFS
eligibility date.
2.5.3.1.4 EXCEPTION: The
contractor shall, upon request, in the case of retroactive eligibility
determinations that occur on or after January 1, 2018, enroll Service
members and their family members into TRICARE Prime (if qualified)
or TRICARE Select coverage retroactive to the date of eligibility
as assigned in the Uniformed Services personnel systems regardless
of the date of receipt of the request and as long as all enrollment
fees (if applicable) back to the retroactive eligibility date are
paid. The effective start date of coverage must be the date reflected
in DEERS as adjusted by the Uniformed Service. Without a retroactive
eligibility date reflected in Uniformed Services personnel systems
and DEERS, Open Season and QLE rules apply for retroactive enrollment
requests received after January 1, 2018.
2.5.3.1.5 The contractor shall apply
open season and QLE rules for a retroactive enrollment date greater
than 12 months in the past or request a start of coverage date other
than the date of eligibility as an URFS, unless directed otherwise
by the GDA.
2.5.3.2 A QLE for one beneficiary in
a sponsor’s family permits a change in the sponsor’s enrollment
or other family member’s enrollment status during the QLE period.
A specific QLE may only be used once to make a change in enrollment
status.
2.5.3.3 Overlapping QLEs. If the beneficiary
has more than one QLE that have overlapping 90 calendar day periods,
the beneficiary will be allowed to pick which QLE to use. If the
beneficiary chooses a later QLE, the previous QLEs will no longer
be available to use. For example: A beneficiary loses OHI on January
1st and has a child on upon February
1st. Within 90 calendar days for either QLE, the beneficiary may
change their enrollment status based on the loss of OHI or for the
birth of a child, whichever QLE they decide to use. If the beneficiary
chooses to use the latter QLE to make an enrollment change, they
may no longer use the earlier QLE (loss of OHI in this example).
If the beneficiary makes a QLE enrollment status change but then
changes their mind, they must contact the contractor to make the
change if they are within the 90 calendar day period of a valid
QLE. The beneficiary will be unable to take this action in the Government
furnished web-based self-service enrollment system/application.
2.5.3.4 Enrollment choices made during
open season can be changed if there is a QLE that happens between that
choice and December 31st of that year.
2.5.3.5 The GDA reserves the right
to direct the contractors to change an enrollment regardless of
the QLE rules.
2.5.3.6 Canceling a QLE event invalidates
the QLE. If a projected QLE does not happen, the beneficiary can request
the previous coverage to be reinstated as long as they are within
90 calendar days of the projected QLE. In the Government furnished
self-service web-based enrollment system/application, once a QLE
is selected (or declined) no more actions may be made based on that
QLE. This includes future QLEs.
2.5.3.7 A reinstatement of eligibility
is not a QLE. Extending the previous eligibility is not a QLE.
2.5.3.8 Enrollment portability and
PCM changes are not limited to the open enrollment period and do
not require a QLE.
2.5.3.8.1 A PCM change within a geographic
area of responsibility can occur at any time even if address does not
change.
2.5.3.8.2 The contractor shall verify that
PCM assignment complies with Market/MTF Memorandum of Understanding/Statement
of Understanding (MOU/SOU).
2.5.3.8.3 The TRICARE overseas contractor
shall treat in-country moves as PCM changes. This will be enforced
when the TRICARE Overseas contractor receives the Policy Notification
Transaction (PNT).
2.5.3.8.4 TRICARE Prime Uniformed Services
Family Health Plan (USFHP) enrollees who are not otherwise TRICARE-eligible
(i.e., grandfathered Medicare eligible beneficiaries who only have
Part A) may only transfer enrollment from one USFHP to another USFHP;
they may not transfer to a Managed Care Support Contractor (MCSC).
2.5.5 Payment of enrollment fees
may be made on an annual or quarterly basis by credit card and for monthly
enrollment fee payments, by EFTs or an allotment from retirement
pay. No administrative fees are charged to enrollees who choose
to pay monthly or quarterly.
Note: Effective March 26, 1998, the
TRICARE Prime enrollment fee is waived for those enrollees who have Medicare
Part B, regardless of age. Dual eligibles age 65 and older, who
have an active duty sponsor or who are not entitled to premium-free
Medicare Part A on their own record, or the record of their current,
former, or deceased spouse, may enroll in TRICARE Prime. See TOM,
Chapter 6, Section 1.