1.0 GENERAL
The contractor
shall comply with all TRICARE requirements regarding
eligibility, enrollments, re-enrollments, disenrollments, and transfers
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specifically changed, waived, or superseded by the provisions of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
The contractor
shall verify eligibility for TRICARE via
the Defense Enrollment Eligibility Reporting System (DEERS). The
DEERS record will indicate the dates of eligibility. Except for
newborns, the contractor shall only enroll
and provide benefits to those beneficiaries who are
shown as eligible on DEERS. 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. The contractor shall
enroll TOP Prime enrollees to
a Military Treatment Facility (MTF) Primary Care Manager (PCM), unless enrollment
to a purchased care sector PCM is 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. The contractor
shall enroll TOP Prime Remote enrollees 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 The contractor
shall not enroll non-Command Sponsored ADFMs, retirees,
and retiree family members
to 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. The
contractor shall accomplish enrollment within
five business days after receipt
of a completed 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 Director 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.
The contractor shall not
require a signature
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
TOP Prime
/Prime
Remote enrollment as enrollment in
TOP Prime
/Prime
Remote 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
are 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 TOP 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 See paragraph 6.0 if
the ADFMs are eligible for Transitional Survivor benefits
.
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 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 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 Uniformed Service. This is a Uniformed 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 an MTF PCM.
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. The contractor shall enroll TOP
Prime beneficiaries to an overseas
DMIS with assignment to an MTF PCM. The contractor
shall enroll TOP Prime Remote beneficiaries to
a civilian PCM, the contractor’s call center(s), or a Canadian Forces
Health Facility (in Canada). The contractor shall
provide appointments 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 contractor shall enroll the beneficiary 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 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 The
contractor shall not deny a TRICARE-eligible beneficiary enrollment
or re-enrollment in, or require them 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 MTF
TRICARE
Service Centers (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. 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
contractor shall develop the enrollment
request
for a mailing address. Enrollees
may submit a temporary address (e.g., unit address) until a permanent
address is established.
The contractor shall update
temporary addresses
with
the permanent address when
it is 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
days outlining
the discrepant information and requesting that the beneficiary contact
their military personnel information office for assistance in updating
the DEERS record.
8.2.2 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.
The
contractor shall establish a new TOP enrollment period
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
TOP
contractor shall comply with the provisions of
Chapter 6, Section 1 regarding enrollment
of family members of E-1 through E-4
, 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
TOP
contractor shall comply with the provisions of
Chapter 6, Section 2 regarding enrollment
portability
, except that stateside-enrolled
retirees and retiree family members may not transfer
TRICARE Prime
enrollment to an overseas location.
10.0 Split
Enrollment
The
TOP
contractor shall comply with the provisions of
Chapter 6, Section 3 regarding split enrollment
.11.0 Disenrollment
11.1 The
TOP contractor shall process the disenrollment Policy Notification
Transactions (PNTs) received for these scenarios for ADFMs (see paragraph 11.5):
• 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 The
TOP contractor shall process the disenrollment PNTs when either
of these scenarios occur for Service members (see paragraph 11.4):
• 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
90 days of the end
of the overseas tour when the
ADSM departs
to a new area of assignment.
11.5.1 The TOP contractor shall provide
continuing coverage during the 90 day period until
(1) the enrollment is transferred to
the new location or (2) the enrollee requests disenrollment.
11.5.2 If
the TOP Prime/TOP Prime Remote ADFM enrollee has not disenrolled
or transferred their coverage to the new region by the 91st
day, the contractor shall terminate
the enrollment, effective the 91st day. For these beneficiaries,
any care received outside the direct care system is not covered.
11.5.3 The
contractor, upon beneficiary request, shall process retroactive
enrollment requests for 90 days after the disenrollment date from
a beneficiary whose TOP Prime/TOP Prime Remote ADFM coverage was
terminated due to a discrepant address that resulted in no TRICARE
private sector coverage. Affected beneficiaries may retroactively
enroll in TOP Prime/TOP Prime Remote ADFM or TOP Select (if qualified)
or any available stateside TRICARE health plan for which they are
eligible.
Note: The contractor
may reprocess impacted claims upon request from the beneficiary
once retro-active enrollment is completed.
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.