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changed, waived, or superseded by the provisions of this section;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 Medical 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) Executive 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
Executive 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
Executive 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 Executive 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
Executive 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
Executive 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.