1.0 GENERAL
All TRICARE requirements regarding eligibility,
enrollments, re-enrollments, disenrollments, and transfers shall
apply to the TOP unless specifically changed, waived, or superseded
by the provisions of this section; the TRICARE Policy Manual (TPM),
Chapter 12; or the TRICARE contract for health
care support services outside the 50 United States (U.S.) and the
District of Columbia (hereinafter referred to as the “TOP contract”).
See
Chapter 6; the TPM,
Chapter 10;
and the TRICARE Systems Manual (TSM) for additional instructions.
2.0 Eligibility
Eligibility for TRICARE is verified via the
Defense Enrollment Eligibility Reporting System (DEERS). The DEERS
record will indicate the dates of eligibility. Except for newborns,
only those beneficiaries who are shown as eligible on DEERS will
be enrolled or receive benefits under the TOP. In addition to DEERS
eligibility, TOP Active Duty Family Members (ADFMs) shall demonstrate
Command Sponsorship to be eligible for TOP Prime and TOP Prime Remote
enrollment unless a specific exception exists. The TOP contractor
shall verify DEERS eligibility (and Command Sponsorship, where required) prior
to enrolling beneficiaries into TOP.
Note: Family members of the Armed Forces of foreign
North Atlantic Treaty Organization (NATO) or Partnership For Peace
(PFP) nations are not eligible for the TOP.
3.0 Enrollment
Processing
3.1 TOP Prime and TOP Prime Remote are available
to Service members and certain ADFMs in overseas locations as described
below. These programs are similar, but not identical, to TRICARE
Prime and TRICARE Prime Remote (TPR)/TRICARE Prime Remote for ADFMs
(TPRADFMs) in the U.S. TOP Prime enrollees shall normally be enrolled
to a Military Treatment Facility (MTF) Primary Care Manager (PCM), but
enrollment to a purchased care sector PCM may be authorized when
MTF capacity is reached. TOP Prime enrollment procedures shall be
established in the Statements of Responsibilities (SORs) between the
TOP contractor and the MTF Director. TOP Prime Remote enrollees
shall be enrolled to a remote Defense Medical Information System
(DMIS) code with assignment to a purchased care sector PCM or to
the TOP contractor, according to the specific regional enrollment
procedures established in the SORs between the contractor and the
TRICARE Area Office (TAO) Directors.
3.2 Unless a specific exception
exists, enrollment to TOP Prime or TOP Prime Remote is available only
to Service members who are permanently assigned overseas, and to
ADFMs who are Command Sponsored and accompanying their sponsor on
his/her overseas tour, or on orders in an overseas location (see
paragraph 5.1 for
additional information regarding Command Sponsorship). This includes activated
Reserve Component (RC) Service members who are on orders to an overseas
location for more than 30 days, and their Command Sponsored ADFMs
who accompany the RC member on his/her overseas tour or are on orders
in an overseas location. See
paragraph 5.0 for additional details on family member
eligibility.
3.3 Non-Command Sponsored ADFMs, retirees, and
retiree family members are not eligible for TOP Prime or TOP Prime
Remote enrollment in any overseas location. This long standing limitation
derives from the limited number and capacity of MTFs and staff in
overseas locations, coupled with their mission critical requirement
to provide Prime coverage for ADSMs as their first priority, and
to command sponsored ADFMs as their second priority. ADFMs who are
not Command Sponsored or on military orders as described in this
section are eligible to enroll in TRICARE Select. Because TRICARE
for Life (TFL) beneficiaries are not eligible to enroll in TRICARE Select, they
are covered as if TRICARE Standard was still implemented (see TRICARE
Reimbursement Manual (TRM),
Chapter 2).
3.4 Enrollment
may occur at any time after TOP eligibility has been established,
and normally remains effective during the overseas tour of the sponsor.
Annual re-enrollment is not required for TOP Prime or TOP Prime
Remote. Once enrolled, beneficiaries remain enrolled in these programs
until:
• They
disenroll;
• Transfer
enrollment to another TRICARE region/program; or
• Lose eligibility
for TRICARE, TOP Prime, or TPR.
3.5 The
TOP contractor shall perform all enrollment-related activities for
TOP Prime, TOP Prime Remote, TRICARE Plus, TRICARE Young Adult (TYA),
TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR) and TOP
Select in overseas locations. These activities may include validation
of eligibility, enrollment, re-enrollment, disenrollment, transfers,
updating information in DEERS, clearing enrollment discrepancies,
assigning or changing PCMs, collecting Other Health Insurance (OHI) information,
and related enrollment functions. The contractor shall use the approved
TRICARE enrollment request options for enrollment activities. Enrollment
shall be accomplished within five work
days
of receipt of a complete TRICARE enrollment request.
Note: Overseas insurance plans such as German Statutory
Health Insurance, Japanese National Insurance (JNI), Philippines
Phil Health, and Australian Medicare, etc., are considered OHI.
3.6 For
enrollment requests received outside of the annual open enrollment
season, the TOP contractor shall follow the requirements in TPM,
Chapter 10, Section 2.1, paragraph 2.3.3 to
process the enrollment in accordance with a Qualifying Life Event
(QLE). The effective date of enrollment shall be the date of the
QLE unless a retroactive enrollment has been authorized by the TAO
Director or designee. For telephonic enrollments, the TOP contractor shall collect
the Military Sponsor’s Order Number and date on the orders and document
in the contractor’s call notes. By providing the Order Number and
date on the orders, the Sponsor and/or ADFM attests to command sponsorship.
For TOP emergency cases that should be placed under immediate case
management, TOP MTF Directo
r and/or the
TAO Directors may approve exceptions on a case-by-case basis for
retroactive TOP enrollment. Except for administrative errors, the
effective date for retroactive enrollments shall not be earlier
than the first day of the month that the application is submitted
(see the TPM,
Chapter 10, Section 2.1).
• An officially signed
enrollment request includes those with (1) an original signature,
(2) an electronic signature offered by and collected by the contractor,
or (3) a verbal consent provided via telephone and documented in
the contractor’s call notes. A signature is not required to make
enrollment changes by phone as long as the verbal request is documented.
A signature from a Service member is never required to complete
Prime enrollment as enrollment in Prime is mandatory per TPM,
Chapter 10, Section 2.1, paragraph 1.1.
3.7 The contractor
shall follow guidance from the TAO Directors and the MTFs regarding
PCM assignment when enrolling beneficiaries into TOP Prime. The
MTF enrollment area encompasses a 40-mile radius or a one-hour drive
time from the MTF. TOP Prime Remote beneficiaries will be enrolled
to the appropriate DMIS code for the beneficiary’s remote overseas
location. TOP Prime Remote enrollees in Canada will follow guidance
applicable to the U.S. and Canada Reciprocal Health Care Agreement, and
may be assigned to a Canadian Forces Health Facility for their primary
care.
3.8 Newborn/Adoptee
Claims
3.9 The provisions
of
Chapter 6, Section 1 and the TPM,
Chapter 10, Section 2.1 regarding Prime enrollment
fees shall not apply to TOP Prime or TOP Prime Remote. There are
no enrollment fees associated with TOP Prime or TOP Prime Remote.
4.0 Enrollment
Policy For Service MEMBERS
4.1 Except as described in
paragraph 4.2,
all Service members who are permanently assigned to an overseas
duty location must be enrolled into the TOP program that is available
in their area. This includes RC Service members who are called to
active duty for more than 30 consecutive days with a final assignment
to an overseas duty station.
4.2 Service
members assigned to operational forces with assigned organic medical
assets may be enrolled to an operational forces’ DMIS ID affiliated
with its “Parent” DMIS. This includes activated RC members on duty
in combatant theaters of operation with existing or embedded organic
medical treatment and support capabilities for health care. Enrollment
to a Service or Region-specific operational forces’ DMIS for all
Service members should occur prior to deployment.
4.3 Since a
signature from an ADSM is never required to complete Prime enrollment,
the TOP contractor shall accept enrollment spreadsheets (with all
applicable information) as a valid process for enrolling Service
members into TOP Prime or TOP Prime Remote.
5.0
Enrollment
Policy For ADFM
s5.1 ADFMs
who have Permanent Change of Station (PCS) orders to accompany the
sponsor overseas or service-funded orders to relocate overseas without
the sponsor are eligible for TOP Prime or TOP Prime Remote enrollment.
In order to enroll in these programs, ADFMs must meet the definition of
Command Sponsorship in the Joint Travel Regulation (JTR), Volume
I, Appendix A (available at
https://www.defensetravel.dod.mil/Docs/perdiem/JTR.pdf)
unless one of the following exceptions exists:
5.1.1 If the Service member and
his/her Command Sponsored ADFM(s) are enrolled in TOP Prime or TOP
Prime Remote, and the sponsor is reassigned on unaccompanied PCS
orders to a location that does not permit Command Sponsored family
members, the family member(s) may retain their TOP enrollment for
a period based on the length of the sponsor’s unaccompanied orders
(but not to exceed two years). In order to retain TOP enrollment
in this situation, the family member(s) must continue to be Command
Sponsored and may not relocate elsewhere during the sponsor’s PCS
move.
5.1.2 If the ADFM(s) are authorized to relocate to
an overseas location per the sponsor’s PCS orders in accordance
with JTR U5222, or per Noncombatant Evacuation Orders without the
sponsor, then the ADFM(s) are eligible for enrollment in the appropriate
TOP program consistent with their orders.
5.1.3 If the ADFM(s) resided in
an overseas location prior to the activation/mobilization of a RC sponsor,
then the ADFM(s) are eligible for enrollment in the appropriate
TOP program based on the residential mailing address of the sponsor
prior to activation/mobilization. The ADFM(s) must have had the
same overseas residential address as the sponsor at the time of
activation/mobilization.
5.1.4 If the ADFM(s) are currently
enrolled in TOP Prime, TOP Prime Remote, or TRICARE Select and the
family has a newborn or adopts a child, then the new family member
is eligible to enroll in the same TOP program.
5.1.5 If the
ADFMs are eligible for Transitional Survivor benefits (see
paragraph 6.0).
5.2 ADFMs who
choose to reside overseas but are not Command Sponsored as defined
in the JTR, and who do not meet any of the exceptions listed above,
are not eligible for enrollment in TOP Prime or TOP Prime Remote.
These ADFMs are eligible for TRICARE Select, TRICARE Plus (where
available), or MTF care on a space-available basis only. ADFMs may
not retain Prime enrollment to a stateside Managed Care Support
Contract (MCSC) while residing overseas.
5.3 Once registered in DEERS,
newly eligible ADFMs residing in an overseas area are automatically enrolled
into 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.
5.4 Eligibility for TOP enrollment normally requires
the family to be accompanied by the sponsor; therefore, a family
member cannot relocate within the overseas region, relocate to another
overseas region, or relocate from an overseas location to an overseas
location and transfer enrollment except as specified under the exceptions
in this section.
5.5 The TOP contractor shall verify
that all of the above requirements are met (including DEERS eligibility
check and validation of Command Sponsorship/military orders, if
required) prior to enrolling an ADFM into TOP Prime or TOP Prime
Remote.
5.6 The process for identifying
ADFMs who are Command Sponsored may vary by Service. This is a Service
personnel decision and as such, these processes may change over
the life of the contract. The TOP contractor shall accept any current,
valid method of identifying Command Sponsorship to meet the TOP
enrollment requirements (e.g., Navy ADFMs who are not listed on
the sponsor’s orders, but who are in receipt of a letter from the
Navy Personnel Services Division (PSD)).
5.7 ADFMs may request enrollment to an MTF that
is not located at the sponsor’s assigned installation; however,
only requests for enrollment within the same TAO region as the sponsor’s assigned
location will be considered. All ADFM enrollments are subject to
the MTF’s enrollment/empanelment guidelines.
6.0
Enrollment
Policy For Transitional Survivors
The general
provisions of TPM,
Chapter 10, Section 7.1 regarding Transitional
Survivors shall apply to the TOP. Specific guidelines for Overseas
Transitional Survivor benefits are listed below.
6.1 TOP Prime/TOP
Prime Remote enrollment policy provisions which require command sponsorship
shall not apply to Transitional Survivors whose sponsors died on
or after October 7, 2001.
6.2 Transitional Survivors whose
sponsors died on or after October 7, 2001 and who choose to remain
in an overseas location are eligible for TOP Prime/TOP Prime Remote
enrollment during the Transitional Survivor period, regardless of
whether they remain at their original residence or relocate to another
overseas location. These Transitional Survivors are also eligible
for health care benefits and may elect to enroll in TOP Select.
6.3 Transitional
Survivors whose sponsors died on or after October 7, 2001 and who
choose to return to the U.S. from an overseas location are eligible
for TRICARE Prime (in TRICARE Prime service areas) or TPRADFMs (in
remote locations) during the Transitional Survivor benefit period.
These Transitional Survivors are also eligible for health care benefits if
they elect to enroll in TOP Select.
6.4 Transitional Survivors whose
sponsors died on or after October 7, 2001 and who choose to move
from a stateside location to an overseas location are eligible for
TOP Prime or TOP Prime Remote enrollment during the Transitional
Survivor benefit period.
6.5 Transitional Survivors whose
sponsors died on or after October 7, 2001 are eligible for enrollment
and claims reprocessing per TPM,
Chapter 10, Section 7.1. Transitional Survivors
are also eligible for enrollment fee refunds (if applicable) per
TPM,
Chapter 10, Section 7.1.
6.6 If the
Transitional Survivors are not enrolled in TOP Prime, the Transitional
Survivor’s priority for appointments at overseas MTFs will be the
same as that of ADFMs who are not enrolled in TOP Prime.
6.7 At the
end of the Transitional Survivor period, survivors lose their eligibility
for enrollment in TOP Prime/TOP Prime Remote (in overseas locations)
and TRICARE Prime/TPRADFM (in remote locations) in the 50 U.S. and
the District of Columbia.
7.0 Assignment Of PCM
7.1 Unless the Government has approved enrollment
to a purchased care sector PCM, TOP Prime enrollees will be assigned
to a PCM MTF.
7.2 The MTFs will maintain current
PCM lists and will make these lists available to the TOP contractor
on a regular basis as determined in the SOR. MTF PCM lists will
contain sufficient detail to facilitate new enrollments or PCM reassignments
until capacity is optimized per MTF guidance.
7.3 The TOP contractor shall assign TOP enrollees
to a PCM at the time of enrollment via the Government furnished
web-based enrollment system/application per the SOR, access standards,
and/or other specific Government guidance. The Government furnished
web-based enrollment system/application will only display PCMs with
available capacity. TOP Prime beneficiaries must enroll to an overseas
DMIS with assignment to an MTF PCM. TOP Prime Remote beneficiaries
must enroll to a civilian PCM, the contractor’s call center(s),
or a Canadian Forces Health Facility (in Canada). Appointments will
be provided within the TRICARE Prime access standards on a best
effort basis.
7.4 MTF Directors may
establish specific MTF enrollment/empanelment guidelines for their facilities.
The TOP contractor shall enroll TOP Prime beneficiaries and assign
PCMs according to these MTF guidelines. Upon receipt of a completed
TRICARE enrollment request, the contractor shall attempt to enroll
the beneficiary according to the identified preferences (e.g., specific
provider, gender or specialty preference). If the beneficiary’s
PCM preferences are incompatible with MTF enrollment/empanelment
guidelines, the beneficiary shall be enrolled according to MTF guidelines.
If the preferred PCM is not available (no capacity), the contractor shall use
the default PCM for that MTF. If there is no PCM capacity in the
MTF, the contractor shall contact the MTF for instructions.
7.5 A significant number of MTF PCMs rotate or
move each year. This will require the TOP contractor to move the
enrollment panels associated with those PCMs. Through a Government-provided
application, the contractor shall perform batch PCM reassignments
based on the parameters established by the MTF. Those parameters
include DMIS ID to DMIS ID, PCM ID to PCM ID, Health Care Delivery
Plan (HCDP), sex of beneficiary, Unit Identification Code (UIC)
(active duty only), age of beneficiary, sponsor Social Security
Number (SSN) (for family moves) and name of beneficiary. The contractor shall perform
MTF PCM reassignment moves within three working days of the effective
date of the PCM’s reassignment. The contractor shall also
perform PCM reassignment, as necessary, in response to Service member
reassignments or turnover in purchased care sector PCMs.
7.6 The TOP contractor shall enroll TOP Prime Remote
beneficiaries to the appropriate enrollment DMIS ID based on beneficiary
location. The contractor shall list the name/city/country of the
assigned remote location/site or the purchased care sector PCM,
as appropriate.
8.0 Enrollment Procedures
8.1 No TRICARE-eligible beneficiary shall be denied
enrollment or re-enrollment in, or be required to disenroll from,
the TOP Prime/TOP Prime Remote program because of a prior or current
medical condition.
8.2 The TOP contractor shall be responsible for
enrollment processing and for coordinating enrollment processing
with the MTF, the appropriate TAO Director, and DEERS. The contractor
shall enter enrollments into DEERS through the Government furnished
web-based enrollment system/application according to the provisions
of the TSM,
Chapter 3. The contractor shall perform the following
specific functions related to enrollment processing:
8.2.1 The contractor shall collect TOP Prime enrollment
requests at the MTFs TSCs, or other sites mutually agreed to by
the contractor, TAO Director, and the MTF Director,
or by mail, telephone, Government furnished web-based self-service
enrollment system/application, or other secure means determined
by the contractor. The contractor shall collect TOP Prime Remote
service area enrollment requests by mail, telephone, or other secure
means determined by the contractor.
8.2.2 At the time of enrollment processing, the contractor
shall access DEERS to verify eligibility of applicants and shall
update the residential mailing address and any other fields for
which they have update capability on DEERS. If the enrollment request
does not contain a mailing address, the enrollment request shall
be developed for a mailing address. Enrollees may submit a temporary address
(e.g., unit address) until a permanent address is established. Temporary
addresses must be updated with the permanent address when provided
to the contractor by the enrollee in accordance with the TSM,
Chapter 3, Section 4.2. The contractor shall
not input temporary addresses not provided by the enrollee. If the
DEERS record does not contain an address, or if the enrollment request
contains information different from that contained on DEERS in fields
for which the contractor does not have update capability, the contractor
shall contact the beneficiary within five calendar days outlining
the discrepant information and requesting that the beneficiary contact
their military personnel information office for assistance in updating
the DEERS record.
8.2.3 Unless the Government has
waived the signature requirement, enrollment requests must be submitted
by the sponsor, spouse, or other legal guardian of the beneficiary
via one of the official enrollment request options (see
paragraph 3.6).
8.4 TOP Prime/TOP Prime Remote enrollment may be
on an individual or family basis. Single enrollment may be changed
to family due to marriage or birth of a child at any time during
the TOP enrollment period. A new TOP enrollment period shall be
established for the family. Effective January 1, 2018, see
Chapter 6, Section 1, for enrollment time-frames.
8.5 Enrollment fees are not required for TOP Prime
or TOP Prime Remote. Effective January 1, 2018, see TRM,
Chapter 2, for enrollment fee information.
8.6 Service members and ADFMs on PCS assignment
in Canada (not at the request of the Canadian Government) may enroll
in TOP, but must pay up front for all health care and file a claim
with the TOP contractor for reimbursement.
9.0 Enrollment
of Family Members Of E-1 Through E-4
9.1 The provisions of
Chapter 6, Section 1 regarding enrollment
of family members of E-1 through E-4 shall apply to the TOP, except
that TOP Prime/TOP Prime Remote shall be effective the date that
the enrollment is requested as long as it coincides with dates of
eligibility. See
Chapter 6, Section 2,
for effective enrollment dates. See TPM,
Chapter 10, Section 2.1, for QLE information.
9.2 The provisions of
Chapter 6, Section 2 regarding
enrollment portability shall apply to the TOP, except that stateside-enrolled
retirees and retiree family members may not transfer Prime enrollment to
an overseas location.
10.0 Split Enrollment
The provisions of
Chapter 6, Section 3 regarding
split enrollment shall apply to TOP Prime and TOP Select.
11.0 Disenrollment
11.1 ADFMs shall be disenrolled from TOP Prime/TOP
Prime Remote when:
• The enrollee requests
disenrollment;
• The
enrollee transfers enrollment to a new TRICARE region;
• The enrollee loses
eligibility for TOP Prime or TOP Prime Remote; or
• The enrollee loses
TRICARE eligibility in DEERS.
11.2 Service members shall be disenrolled from TOP
Prime/TOP Prime Remote when:
• The enrollee transfers
enrollment to a new TRICARE region; or
• The enrollee loses
TRICARE eligibility in DEERS.
11.4 Service members cannot voluntarily disenroll
from TOP Prime or TOP Prime Remote if they remain on permanent assignment
in an overseas location where these programs are offered. Service member
enrollment in TOP Prime or TOP Prime Remote continues until they
transfer enrollment to another TRICARE region/program or lose eligibility
for TOP/TRICARE.
11.5 TOP
Prime/TOP Prime Remote ADFMs must either transfer enrollment or
disenroll within 60 calendar days of the end of the overseas tour
when the Service member departs to a new area of assignment. The
TOP contractor shall provide continuing coverage until (1) the enrollment
has been transferred to the new location or (2) the enrollee disenrolls.
If the TOP Prime/TOP Prime
Remote ADFM enrollee has not disenrolled
or transferred their coverage to the new region by the 61st day,
the TOP contractor shall disenroll them from TOP Prime/TOP Prime Remote
and enroll the ADFM to TRICARE Select.
12.0 TRICARE Eligibility Changes
12.2 The TOP contractor shall include full and complete
information about the effects of changes in eligibility and sponsor
rank in beneficiary materials and briefings.