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shall apply to the TOP unless specifically changed, waived, or superseded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.