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and transfers unless specifically changed, waived, or superseded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 (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
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 US. The TOP contractor shall enroll
TOP Prime enrollees to a Military Medical Treatment Facility (MTF)
Primary Care Manager (PCM), but enrollment to a private sector care
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 TOP
contractor shall enroll TOP Prime Remote enrollees 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) 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 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 The TOP 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
TOP 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:
• Disenroll;
• 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:
• Validation of eligibility,
• Enrollment,
• Re-enrollment,
• Disenrollment,
• Transfers,
• Updating information in DEERS,
• Clearing enrollment discrepancies,
• Assigning or changing PCMs,
• 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 2.5.3.3 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
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 Directors 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/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 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 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 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.
5.1.5 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 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 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 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 to an overseas DMIS with assignment
to an MTF PCM. The TOP 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 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 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 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 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 for a mailing
address. Enrollees may submit a temporary address (e.g., unit address)
until a permanent address is established. The TOP 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.
8.2.3 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. The contractor
shall establish a new TOP enrollment period 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, 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 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.
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 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 requests disenrollment.
11.5.2 When enrollment transfer or disenrollment
has not been requested by the TOP Prime/TPR enrollee by the 91st day,
the TOP contractor shall 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.