Authority for Collection - TRICARE Policy Manual 32 CFR 199.17

TRICARE Policy Manual 6010.57-M, February 1, 2008
Eligibility And Enrollment

Chapter 10

Section 2.1

Prime Enrollment
Issue Date: May 15, 1996
Authority: 32 CFR 199.17
1.0

POLICY

1.1 In order to receive the expanded benefits and special cost-sharing of Prime, all beneficiaries
must take specific action to enroll. For active duty members located in areas where the TRICARE
program is implemented, enrollment in Prime is mandatory. An enrollment action must be
completed and officially documented (enrollment form, Beneficiary Web Enrollment (BWE)
transaction or telephonic request documented in the contractor’s call notes) to ensure Defense
Enrollment Eligibility Reporting System (DEERS) enrollment data is current and claims are
processed expeditiously.
1.1.1

Enrollment Procedures

1.1.1.1 No non-active duty beneficiary shall be enrolled unless he/she is shown as eligible on the
DEERS. All enrollments and re-enrollments shall be recorded on the DEERS.
1.1.1.2 Enrollment may occur at any time; however, the enrollment period shall coincide with the
fiscal year (i.e., the beneficiary’s initial enrollment expires on October 1; all future enrollment
periods will be October 1 to September 30). Enrollment may be on an individual or family basis.
1.1.1.3 The contractor is responsible for collecting enrollment fees from Prime enrollees, as
appropriate, and retains all such fees.
1.1.1.4 Payment of enrollment fees may be made on an annual or quarterly basis by credit card
and for monthly enrollment fee payments, by Electronic Fund Transfers (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 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 (AD)
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 the TRICARE
Operations Manual (TOM), Chapter 6, Section 1, paragraph 7.5.4.
1.1.1.5 TRICARE Prime enrollments for eligible enrollees shall be automatically renewed upon
the expiration of the enrollment unless the enrollee declines renewal, is no longer eligible for Prime
enrollment or fails to pay the enrollment fee on a timely basis.

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Chapter 10, Section 2.1
Prime Enrollment
1.1.1.6 Dependents of Activated Members of Reserve Components (RCs). Dependents of
members of RCs who have been ordered to active duty for a period of 31 days or more may enroll in
TRICARE Prime. RCs include both reservists and members of the National Guard. Members of the
National Guard are included only if ordered to federal duty. All requirements of this and other
services apply to these beneficiaries. Activated members of RCs are treated the same as any other
active duty member.
1.1.2

Enrollment Protocols

1.1.2.1 Beneficiaries enrolling in TRICARE Prime may apply to enroll in a Region other than the
Region servicing their home of residence. See the TOM, Chapter 6, Section 1, paragraph 9.4 and
Chapter 16, Section 1, paragraph 7.0. (Note: This paragraph does not apply to TOP Prime or TOP
Prime Remote beneficiaries.)
1.1.2.2 No eligible beneficiary who resides in the TRICARE region shall be denied enrollment or
re-enrollment in, or be required to disenroll from, the TRICARE Prime program because of a prior or
current medical condition.
1.1.2.3 The contractor shall provide beneficiaries who enroll full and fair disclosure of any
restrictions on freedom of choice that may be applicable to enrollees including the Point of Service
(POS) option.
1.1.2.4 TRICARE for Life (TFL) beneficiaries (retirees and their dependents who are age 65 and
over and are eligible for both Medicare and TRICARE) cannot enroll in TRICARE Prime. However, any
beneficiary who is enrolled in TRICARE Prime at the time they attain their Medicare entitlement
based on age will be permitted to enroll with a Military Treatment Facility (MTF) through TRICARE
Plus, to the extent capability and capacity exists in the MTF. There shall be no TRICARE Plus
affiliation with network providers.
1.1.2.5 Dual eligibles under age 65 (retirees and their dependents who have Medicare Parts A
and B) and dual eligibles who are ADFMs (any age) are eligible to enroll in TRICARE Prime. See the
TOM, Chapter 6, Section 1.
1.1.2.6 TRICARE and the Military Health System (MHS) beneficiaries who are not eligible to enroll
in TRICARE Prime may register for the purpose of accessing space-available care in the MTF and
customer services. This registration is NOT enrollment in TRICARE Prime and no TRICARE Prime
program benefits or services (other than access to customer services and network providers)
applies to this beneficiary group.
1.1.3

Retroactive Enrollment

For emergency cases that should be placed under immediate case management, MTF
Commanders may approve exceptions on a case-by-case basis for retroactive enrollment with an
effective date not earlier than the first day of the month that the application is submitted. Regional
Directors (RDs) may approve exceptions on a case-by-case basis for retroactive enrollment to a
network provider with an effective date not earlier than the first day of the month that the
application is submitted.

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Chapter 10, Section 2.1
Prime Enrollment
1.1.4

Effective Date of Enrollment

1.1.4.1 An initial enrollment period shall begin on the first day of the month following the month
in which the enrollment request (enrollment form, BWE transaction, or telephonic request received
by the contractor) and enrollment fee payment, if applicable, are received by the contractor. If the
request and fee are received after the twentieth (20th) day of the month, enrollment will begin on
the first day of the second month after the month in which they were received by the contractor.
1.1.4.2 Reenrollments for those who were enrolled in Prime immediately prior to a change in
their status:
1.1.4.2.1
When an active duty member’s retirement date is established, a Prime enrollment
request to reenroll (enrollment form, BWE transaction, or telephonic request received by the
contractor) must be completed before or within 30 days following the member’s retirement. The
effective date of reenrollment shall be the date of retirement, which will result in seamless TRICARE
Prime benefits with no break in coverage. Otherwise, the request shall be considered an initial
enrollment in Prime and effective according to the provisions of paragraph 1.1.4.1.
1.1.4.2.2
When an active duty 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) they and any eligible family members shall be allowed to
reenroll in TRICARE Prime with no break in coverage. TAMP eligibles must request enrollment in
Prime (enrollment form, BWE transaction, or telephonic request received by the contractor) prior to
the expiration of their period of TAMP eligibility to reenroll in Prime. Non-TAMP eligibles separating
but who remain eligible for TRICARE must request enrollment in Prime within 30 days of their
change in status. Otherwise, the request shall be considered an initial enrollment in Prime. The
effective date of reenrollment shall be the start date of TAMP eligibility or the date of the separation
which will then result in seamless TRICARE Prime benefits with no break in coverage.
1.1.4.2.3
TAMP eligible family members who were enrolled in Prime immediately prior to their
sponsor’s change in status to active duty may continue their enrollment in TRICARE Prime with no
break in coverage if they request reenrollment in TRICARE Prime (enrollment form, BWE
transaction, or telephonic request received by the contractor) within 30 days of their sponsor’s
return to active duty status. If they request reenrollment within 30 days of the sponsor’s return to
active duty status, the reenrollment will be retroactive to the date of the change in status from
TAMP to active duty. If reenrollment is not accomplished within 30 days of the sponsor’s return to
active duty status, the twentieth of the month rule will apply. For information on the effective dates
of enrollments for Active Duty Service Members (ADSMs), see the TOM, Chapter 6, Section 1.
1.1.5
Beneficiaries shall be disenrolled when they are no longer eligible for TRICARE or when
they do not submit payment for prescribed enrollment fees by the required date.
1.2 Portability. Enrollees may transfer enrollment when they move (within a contract area or
outside a contract area). The transfer request or disenrollment may be submitted using an
enrollment form, BWE transaction or telephonic request received and documented by the
contractor. The losing contractor shall provide continuing coverage until (1) the enrollee requests
enrollment in the new location, (2) the enrollee disenrolls, (3) the enrollee is no longer eligible for
enrollment in TRICARE Prime, or (4) the contractor must disenroll the beneficiary for failure to pay
required enrollment fees, whichever occurs first. The authorization and referral rules of the losing

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Chapter 10, Section 2.1
Prime Enrollment
contractor will continue to apply until enrollment is transferred or the beneficiary is disenrolled
(see the TOM, Chapter 6, Section 2).
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