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TRICARE Operations Manual 6010.62-M, April 2021
TRICARE Overseas Program (TOP)
Chapter 24
Section 5
TOP Eligibility And Enrollment
Revision:  C-14, September 13, 2024
1.0  General
AllThe contractor shall comply with all TRICARE requirements regarding eligibility, enrollments, re-enrollments, disenrollments, and transfers shall apply to the TOP unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United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; the TPM, Chapter 10; and the TRICARE Systems Manual (TSM) for additional instructions.
2.0  Eligibility
EligibilityThe contractor shall verify eligibility for TRICAREis verified 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 will be enrolled or receive benefits under the TOP. 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 US. The TOP contractor shall enroll TOP Prime enrollees shall normally be enrolled to a Military Medical Treatment Facility (MTF) Primary Care Manager (PCM), but enrollment to a private sector care PCM may be 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 TOP contractor shall enroll TOP Prime Remote enrollees shall be enrolled to a remote Defense Medical Information System (DMIS) code with assignment to a private sector care 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 or 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 calendar days, and their Command Sponsored ADFMs who accompany the RC member on his or her overseas tour or are on orders in an overseas location. See paragraph 5.0 for additional details on family member eligibility.
3.3  NonThe TOP contractor shall not enroll non-Command Sponsored ADFMs, retirees, and retiree family members are not eligible for 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 Active Duty Service Members (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 the 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:
•  They disenrollDisenroll;
•  Transfer enrollment to another TRICARE region/program;
•  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:
•  validationValidation of eligibility,
•  enrollmentEnrollment,
•  reRe-enrollment,
•  disenrollmentDisenrollment,
•  transfersTransfers,
•  updatingUpdating information in DEERS,
•  clearingClearing enrollment discrepancies,
•  assigningAssigning or changing PCMs,
•  collectingOther Health Insurance (OHI) information, and
•  relatedRelated enrollment functions.
The contractor shall use the approved TRICARE enrollment request options for enrollment activities.Enrollment The contractor shall accomplish enrollment shall be accomplished within five business days of 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 2.5.3.3 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 Directors 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. A The contractor shall not require a signature is not required 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/TOP Prime Remote enrollment as enrollment in TOP Prime/TOP 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 US 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 TRICARE 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 must be 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 calendar 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 ADFMs
5.1  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 Federal Travel Regulation (JFTR), Volume I, Appendix A (available at https://secureapp2/hqda.pentagon.mil/perdiem/) unless one of the following exceptions exists:
5.1.1  If the Service member and his or 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 JFTR 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  IfSee paragraph 6.0 if the ADFMs are eligible for Transitional Survivor benefits (see paragraph 6.0).
5.2  ADFMs who choose to reside overseas but are not Command Sponsored as defined in the JFTR, 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 calendar 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 in this section.
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 US 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 US and the District of Columbia.
7.0  ASSIGNMENT OF PCM
7.1  Unless the Government has approved enrollment to a private sector care PCM, TOP Prime enrollees will be assigned toa an MTF PCM MTF.
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 SORs. 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 TOP contractor shall enroll TOP Prime beneficiaries must enroll to an overseas DMIS with assignment to an MTF PCM. The TOP contractor shall enroll TOP Prime Remote beneficiaries must enroll to a civilian PCM, the contractor’s call center(s), or a Canadian Forces Health Facility (in Canada).Appointments will be provided The TOP contractor shall provide appointments within the TRICARE Prime access standards on a best effort basis.
7.4  MTF Commanders 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 TOP contractor shall enroll the beneficiary shall be enrolled 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 will also perform PCM reassignment, as necessary, in response to Service member reassignments or turnover in private sector care 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 private sector care PCM, as appropriate.
8.0  ENROLLMENT PROCEDURES
8.1  NoThe contractor shall not deny a TRICARE-eligible beneficiary shall be denied enrollment or re-enrollment in, or be required 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 MTFs TRICARE Service Centers (TSCs), or other sites mutually agreed to by the contractor, TAO Director, and the MTF Commander, 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.
8.2.2  At the time of enrollment processing, the TOP 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 TOP contractor shall develop the enrollment request shall be developed for a mailing address. Enrollees may submit a temporary address (e.g., unit address) until a permanent address is established. TemporaryThe TOP contractor shall update temporary addresses must be updated 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 calendar days outlining the discrepant information and requesting that the beneficiary contact their military personnel information office for assistance in updating the DEERS record.
8.2.3  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).
8.3  See Chapter 6, Section 1, for enrollment periods and effective coverage dates.
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. A The contractor shall establish a new TOP enrollment period shall be established for the family. See Chapter 6, Section 1, for enrollment time-frames.
8.5  Enrollment fees are not required for TOP Prime or TOP Prime Remote. 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 shall apply to the TOP, 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 shall apply to the TOP, 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 shall apply to TOP Prime and TOP Select.
11.0  DISENROLLMENT
11.1  ADFMs shall be disenrolled from TOP Prime/TOP Prime Remote whenThe 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. ; or
•  The enrollee has not requested enrollment transfer/disenrollment within 60 calendar days following the end of the overseas tour.
11.2  Service members shall be disenrolled from TOP Prime/TOP Prime Remote whenThe TOP contractor shall process the disenrollment PNTs received for these scenarios for Service members (see paragraph 11.4):
•  The enrollee transfers enrollment to a new TRICARE region; or
•  The enrollee loses TRICARE eligibility in DEERS. ; or
•  The enrollee has not requested enrollment transfer/disenrollment within 60 calendar days following the end of the overseas tour.
11.3  See Chapter 6, Section 1 for guidance regarding enrollment lock-outs. See TPM, Chapter 10, Section 2.1, for QLE information and Chapter 6, Sections 1 and 2, for enrollment eligibility and time frames.
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 enrollees must either transfer enrollment or disenroll within 60 calendar 90 days of the end of the overseas tour when the Service member departs to a new area of assignment.
11.5.1  The TOP contractor shall provide continuing coverage during the 90 day period until:
•  The enrollment has been transferred to the new location; or
•  The enrollee disenrolls; or requests disenrollment.
11.5.2  When enrollment transfer or disenrollment has not been requested by the TOP Prime/TPR enrollee by the 60th 91st day, the TOP contractor shall automatically disenroll the beneficiary on the 61st calendar day following the end date of the overseas tour from TOP Prime/TPR. Effective January 1, 2018, ADFMs disenrolled from TOP Prime or TOP TPR will be only eligible for space available care at MTFs terminate the enrollment, effective the 91st day. For these beneficiaries, any care received outside the direct care system in 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 retroactive enrollment is completed.
12.0  TRICARE ELIGIBILITY CHANGES
12.1  Refer to the TPM, Chapter 10, Section 3.1 for information on changes in eligibility.
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.
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