1.0 General
1.1 The TOP
program provides health care administration and claims processing
for individuals with dual eligibility under both Medicare and TRICARE
who receive care in locations where Medicare is not available. This includes
those beneficiaries eligible for TFL under the Medicare wraparound
coverage option of the TRICARE program made under 10 United States
Code (USC) 1086(d).
1.2 The provisions
of
Chapter 20 regarding
TFL are applicable to beneficiaries residing in locations where Medicare
is available. These areas include the 50 United States (US), the
District of Columbia, and the US territories of Puerto Rico, Guam,
the US Virgin Islands, American Samoa, and the Northern Mariana
Islands.
2.0 JURISDICTION
2.1 Dual eligible
beneficiaries are covered under TOP, based on their TRICARE plan
if they receive care in a location where Medicare is not available.
2.2 Dual eligible
beneficiaries residing in Puerto Rico, Guam, the US Virgin Islands,
American Samoa, and the Northern Mariana Islands are not covered
under TOP TFL. These beneficiaries receive TRICARE coverage under
the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
according to the provisions of
Chapter
20.
2.3 Claims for services rendered
on board a commercial ship are the responsibility of the TDEFIC
contractor if the care was rendered in the territorial waters adjoining
the land areas of the US claims for services rendered on board ship
while outside US territorial waters are the responsibility of the
TOP contractor.
3.0 CONTRACTOR
RESPONSIBILITIES
3.1 The TOP contractor shall provide
administration and claims processing services for the TOP TFL program.
3.2 TOP TFL
has the same cost-shares and deductibles as any other TFL claim.
TFL beneficiaries who are not enrolled in Prime are covered under
TRICARE Standard benefits, cost-shares, and deductibles as if TRICARE Standard
was still being implemented. See TRM
Chapter 2, Sections 1 and
3.
3.3 All TOP TFL has the same requirements
for referrals or prior authorizations as TOP Select requirements regarding
provider certification apply.
3.4 The TOP
contractor shall not develop private sector care provider networks
to support the TOP TFL beneficiary population.
3.5 The TOP
contractor shall not provide health care on a cashless, claimless
basis for TOP TFL beneficiaries.
3.6 The TOP
contractor shall not make appointments with private sector care
providers for TOP TFL beneficiaries. However, upon beneficiary request,
the contractor shall provide the beneficiary with the name, telephone
number, and address of private sector care network or non-network
providers of the appropriate clinical specialty located within the
beneficiary’s geographic region.