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shall apply to the TOP unless specifically changed, waived, or superseded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 (US) 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 US. TOP Prime enrollees shall normally
be enrolled to a Military Medical Treatment Facility (MTF) Primary
Care Manager (PCM), but enrollment to a private sector care 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 private sector care 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 or 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 calendar days, and their Command Sponsored ADFMs who
accompany the RC member on his or 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 the 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;
• 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 business 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 Directors 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 US 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
See TPM, Chapter
10, Section 3.1.
3.9 The
provisions of Chapter 6, Section 1 and the
TPM, Chapter 10, Section 2.1 regarding TRICARE
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 calendar 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 Federal Travel Regulation (JFTR), Volume I, Appendix
A (available at
https://secureapp2/hqda.pentagon.mil/perdiem/)
unless one of the following exceptions exists:
5.1.1 If the
Service member and his or 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 JFTR 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 JFTR, 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
TRICARE 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 calendar 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 in this section.
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 US 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 US and
the District of Columbia.
7.0 ASSIGNMENT
OF PCM
7.1 Unless the Government has approved
enrollment to a private sector care 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 SORs.
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
Commanders 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 business days of the effective date of the PCM’s
reassignment. The contractor will also perform PCM reassignment,
as necessary, in response to Service member reassignments or turnover
in private sector care 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 private sector care 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 Commander, 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).
8.3 See Chapter
6, Section 1, for enrollment periods and effective coverage
dates.
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. See Chapter
6, Section 1, for enrollment time-frames.
8.5 Enrollment
fees are not required for TOP Prime or TOP Prime Remote. 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;
• The enrollee loses TRICARE
eligibility in DEERS; or
• The enrollee has not requested
enrollment transfer/disenrollment within 60 calendar days following
the end of the overseas tour.
11.2 Service
members shall be disenrolled from TOP Prime/TOP Prime Remote when:
• The enrollee transfers enrollment
to a new TRICARE region;
• The enrollee loses TRICARE
eligibility in DEERS; or
• The enrollee has not requested
enrollment transfer/disenrollment within 60 calendar days following
the end of the overseas tour.
11.3 See Chapter
6, Section 1 for guidance regarding enrollment lock-outs.
See TPM, Chapter 10, Section 2.1, for QLE
information and Chapter 6, Sections 1 and 2,
for enrollment eligibility and time frames.
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 enrollees 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:
• The enrollment has been transferred
to the new location;
• The enrollee disenrolls; or
• When
enrollment transfer or disenrollment has not been requested by the
TOP Prime/TPR enrollee by the 60th day, the TOP contractor shall
automatically disenroll the beneficiary on the 61st calendar day
following the end date of the overseas tour from TOP Prime/TPR.
Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP
TPR will be only eligible for space available care at MTFs.
12.0 TRICARE
ELIGIBILITY CHANGES
12.1 Refer to the TPM, Chapter
10, Section 3.1 for information on changes in eligibility.
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.