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shall apply to the TOP unless specifically changed, waived, or superseded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