1.0 GENERAL
1.1 The TOP program
provides health care administration and claims processing for individuals with
dual eligibility under both Medicare and TRICARE who receive care
in locations where Medicare is not available. This
includes those beneficiaries eligible for TFL under the Medicare
wraparound coverage option of the TRICARE program made under 10
United States Code (USC) 1086(d).
1.2 The provisions
of
Chapter 20 regarding TFL are applicable to
beneficiaries residing in locations where Medicare is available.
These areas include the 50 United States (U.S.), the District of
Columbia, and the U.S. territories of Puerto Rico, Guam, the U.S.
Virgin Islands, American Samoa, and the Northern Mariana Islands.
2.0 Jurisdiction
2.1 Dual eligible
beneficiaries are covered under TOP, based on their
TRICARE plan if they receive care in a location where
Medicare is not available.
2.2 Dual eligible
beneficiaries residing in Puerto Rico, Guam, the U.S. Virgin Islands,
American Samoa, and the Northern Mariana Islands are not covered
under TOP TFL. These beneficiaries receive TRICARE coverage under
the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
according to the provisions of
Chapter 20.
2.3 Claims
for services rendered on board a commercial ship are the responsibility
of the TDEFIC contractor if the care was rendered in the territorial
waters adjoining the land areas of the U.S. Claims for services
rendered on board ship while outside U.S. territorial waters are
the responsibility of the TOP contractor.
3.0 CONTRACTOR
RESPONSIBILITIES
3.1 The TOP contractor shall provide administration
and claims processing services for the TOP TFL program.
3.2 TOP TFL
has the same cost-shares and deductibles as
any other
TFL claim. Effective January 1, 2018, TFL beneficiaries who are
not enrolled in Prime are covered under TRICARE Standard benefits, cost-shares,
and deductibles as if TRICARE Standard was still being implemented.
See TRM Chapter 2, Sections 1 and 3.
3.3 All TOP TFL
has the same requirements for referrals or prior authorizations
as TOP Standard (through December 31, 2017) or TOP Select (starting
on January 1, 2018). TOP requirements regarding provider
certification apply.
3.4 The TOP contractor shall
not develop purchased care sector provider networks to support the TOP
TFL beneficiary population.
3.5 The TOP contractor shall not
provide health care on a cashless, claimless basis for TOP TFL beneficiaries.
3.6 The TOP
contractor shall not make appointments with purchased care sector
providers for TOP TFL beneficiaries. However, upon beneficiary request,
the contractor shall provide the beneficiary with the name, telephone
number, and address of purchased care sector network or non-network
providers of the appropriate clinical specialty located within the
beneficiary’s geographic region.