Retention Date: 1/01/2026
A. Purpose
This EM notifies technicians of certain TRICARE beneficiaries eligible for Part B enrollment under the Other Exceptional Conditions (OEC) Special Enrollment Period (SEP).
B. Background
Under Federal law, TRICARE beneficiaries, excluding active-duty service members and their families, who are entitled to Medicare Part A must enroll in Medicare Part B to remain eligible for TRICARE benefits. TRICARE enrollees who become eligible for Medicare Part A based on their spouses’ record must enroll in Medicare Part B to maintain TRICARE eligibility and enrollment. Failure to enroll in Part B results in the loss of TRICARE eligibility.
Due to systems limitations, the Department of Defense (DoD) erroneously maintained TRICARE eligibility for approximately 1,600 beneficiaries who should have been disenrolled for failing to enroll in Part B based on their spouse’s record. DoD has completed systems updates that will disenroll all individuals who should have enrolled in Part B based on their spouse’s record but didn’t. Many will lose TRICARE retroactively.
CMS has determined that the circumstances presented meet the threshold for granting Part B enrollment under the OEC SEP. The DoD will begin notifying TRICARE beneficiaries of their OEC SEP eligibility in June of 2025. The notice will direct them to contact SSA no later than December 31, 2025, to enroll. Eligible individuals may mail-in, fax, call or visit a local field office to request Part B enrollment via form CMS-10797 and must present the DoD notice.
DoD Sample.pdf
C. Processing Instructions
Processing the enrollment request:
· For post-entitlement enrollment requests for Other Exceptional Conditions (OEC) under the SEP
o Obtain a pen-and-ink signed form CMS-10797. Process per HI 00805.277.B.5 and HI 00805.387.
o In the SEP Webpage for the OEC, enter ‘TRICARE SEP per EM-XXXXX.’ No other remarks are required for the TRICARE SEP enrollment.
o Load the completed CMS-10797 into Evidence Portal (EP) along with the DoD notice, that will serve as the required proof per HI 00805.387.C.
o
· For initial claims, including internet claims
· For TRICARE SEP requests postmarked after December 31, 2025:
o If Equitable Relief applies to the request, process according to normal procedures within HI XXX.
o If Equitable Relief does not apply, and no other SEP applies to the beneficiary, inform the beneficiary they can enroll in the General Enrollment Period (2026), with the applicable penalties.
· If the individuals does not have the DoD notice, do not process the enrollment. To get a copy of the notice, advise the individual to contact the Defense Manpower Data Center Support Office at (800) 538-9552 or (866) 363-2883 for the hearing impaired (TTY/TTD).
Direct all program and technical related questions to your management.
References:
HI 00805.277 Processing Special Enrollment Period (SEP) Enrollments
HI 00805.387 Special Enrollment Period (SEP) for Other Exceptional Conditions