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specifically changed, waived, or superseded by the provisions of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 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 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.
5.2 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).
8.4 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.
11.4 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
12.2 The TOP contractor shall include
full and complete information about the effects of changes in eligibility and
sponsor rank in beneficiary materials and briefings.