1.0 GENERAL
1.1 TRICARE
Plus is a service-directed primary care enrollment program that
is available at selected Military Medical Treatment Facilities (MTFs).
Local MTF Commanders determine whether TRICARE Plus shall be offered based
on their facility’s capacities, capabilities, and mission.
1.2 All TRICARE requirements regarding
TRICARE Plus 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or superseded by the provisions of this section; the TRICARE Policy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, Section 4 for
additional instructions.
3.0 ENROLLMENT
3.1 All beneficiary inquiries regarding
TRICARE Plus enrollment/disenrollment shall be directed to the TOP contractor’s
toll-free number or, based on the Statement of Responsibility (SOR)
with each MTF Commander, to the designated MTF Point of Contact
(POC) for TRICARE Plus. This shall include questions about TRICARE
Plus, general questions about enrollment/disenrollment, providing
enrollment/disenrollment forms, providing information about the
availability of TRICARE Plus at a particular MTF, the extent of
coverage available and not available through TRICARE Plus, the selection
of individual Primary Care Coordinators (PCCs), or confirmation
of enrollment/disenrollment.
3.2 MTFs will
approve or disapprove requests for TRICARE Plus enrollment and for
managing Primary Care Clinic capacity for TRICARE Plus enrollment.
The MTF will ensure that TRICARE Plus enrollment forms are completed with
validated eligibility through the Defense Enrollment Eligibility
Reporting System (DEERS). The MTFs will send all completed and approved
TRICARE Plus enrollment/disenrollment forms to the TOP contractor
no less frequently than weekly.
3.3 The TOP
contractor shall ensure that all TRICARE Plus enrollments are entered
through the Government furnished web-based system/application. The
contractor shall return incomplete forms or any application for
which enrollment/disenrollment cannot be effected, for any reason
other than internal contractor systems or process problems, to the
MTF for completion/correction. The contractor shall make no effort
to correct or complete any TRICARE Plus enrollment/disenrollment
application.
3.4 TOP Prime and TOP Prime Remote
cannot be used in conjunction with TRICARE Plus. Enrollment in TRICARE
Plus will necessitate disenrollment from TOP Prime or TOP Prime
Remote.
3.5 TRICARE Plus enrollment to
an overseas MTF is effective on the date the enrollment application
is approved by the MTF.
5.0 Private
Sector Care Provider Services
5.1 TRICARE Plus is an MTF primary
care access program, not a health plan. TRICARE Plus enrollment
has no impact on care received from civilian providers. Claims for
care rendered to TRICARE Select/TRICARE Plus enrollees by civilian
providers shall be processed according to the TRICARE Reimbursement
Manual (TRM). This includes care rendered by private sector care
providers overseas or civilian providers in the US and the District
of Columbia.
5.2 The TOP contractor shall not
develop private sector care provider networks to support the TRICARE
Plus beneficiary population.
5.3 The TOP
contractor shall not provide Guarantee of Payment to private sector
care providers or institutions for TRICARE Plus enrollees.
5.4 The TOP
contractor shall not make appointments with private sector care
providers for TRICARE Plus enrollees. However, upon beneficiary
request, the contractor shall provide the beneficiary with the name, telephone
number, and address of network or non-network providers of the appropriate
clinical specialty located within the beneficiary’s geographic location.