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specifically changed, waived, or superseded by the provisions of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.