[Federal Register Volume 60, Number 211 (Wednesday, November 1, 1995)]
[Rules and Regulations]
[Pages 55448-55456]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-27116]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
RIN 0720-AA19
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Expanded Active Duty Dependents Dental Benefit Plan
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: The rule establishes an expanded dental program for dependents
of active duty members of the Uniformed Services. The amendment
specifically describes: the legislative authority for expansion of
dental benefits outside the United States; the continuation of dental
benefits for active duty survivors; eligibility for pre-adoptive wards;
the enhanced benefit structure; enrollment and eligibility
requirements; premium cost-sharing; and benefit payment levels. The
provisions of this rule will provide military families with the high
quality of care they desire at an affordable price.
EFFECTIVE DATE: This final rule is effective December 1, 1995.
FOR FURTHER INFORMATION CONTACT:
David E. Bennett, Program Development Branch, OCHAMPUS, Aurora,
Colorado 80045-6900, telephone (303) 361-1094.
SUPPLEMENTARY INFORMATION: In the Federal Register of September 16,
1993 (58 FR 48473), The Office of the Secretary of Defense published
for public comment a proposed rule establishing an expanded dental
program for dependents of active duty members of the Uniformed
Services.
Background
The Basic Active Duty Dependents Dental Benefit Plan, was
implemented on August 1, 1987, allowing military personnel to
voluntarily enroll their dependents in a dental health care program
that included diagnostic and preventative benefits, as well as simple
restorative services. Under this program, DoD shared the cost of the
premium with the military sponsor. Although the program was viewed as a
major step in benefit enhancement for military families, with
enrollment levels reaching as high as 60 percent, there were still
complaints that the enabling legislation was too restrictive in scope
and that there should be expansion of services to better meet the
dental needs of the military family.
[[Page 55449]]
Congress responded to these concerns by authorizing the Secretary
of Defense to develop and implement an Expanded Active Duty Dependents
Dental Benefit Plan (The Defense Authorization Act for Fiscal Year
1993, Public Law 102-484, section 701, Revisions to Dependents Dental
Program Under CHAMPUS). The provisions of this Act specified the
expanded benefit structure, as well as maximum monthly premiums for
members and their families, the application of which was not allowed
until April 1, 1993. Cost-sharing levels for the expanded benefits were
left up to the discretion of the Secretary of Defense after
consultation with the other Administering Secretaries.
The provisions of section 701 of The Defense Authorization Act for
Fiscal Year 1993, were implemented on April 1, 1993, while the
Department proceeded with the rulemaking process required for
regulations which have a substantial and direct impact on the CHAMPUS
population. This interim Expanded Active Duty Dependents Dental Benefit
Plan was initiated based on Congressional direction that improvements
take effect April 1, 1993. Revisions were to be made as a result of the
rulemaking process in establishment/implementation of a permanent
Expanded Active Duty Dependents Dental Benefit Plan.
Coverage/Benefits
Under the Basic Dependents Dental Program which was in effect prior
to April 1, 1993, coverage was limited to two categories of dental
benefits: diagnostic, oral examination, preventive services and
palliative emergency care paid at the lower of the actual charge or 100
percent of the insurer's determined allowable charge; and basic
restorative services of amalgam and composite restorations and
stainless steel crowns for primary teeth, and dental appliance repairs
paid at 80 percent of the allowable charge. Payment to a participating
provider was considered payment in full, less the 20 percent cost-share
of the allowable charge for restorative services. Nonparticipating
providers were paid the same amounts; however, the beneficiary was
responsible for the amount of the charge for all services above the
allowable charge, except when the dental plan was unable to identify a
participating provider of care within 35 miles of the dependent's place
of residence with appointment availability within 21 calendar days.
Under the Expanded Active Duty Dependents Dental Benefit Plan,
Congress authorizes a broad range of dental services, the payment
levels of which are based on actuarial projections and budgeted program
costs. The enhanced plan includes those services which were offered
under the Basic Active Duty Dependents Dental Plan (examinations, x-
rays, cleanings, sealants, fillings) along with the following expanded
benefit categories and payment levels:
------------------------------------------------------------------------
Payment
Covered benefits levels
(percent)
------------------------------------------------------------------------
Sealants............................................ 80
Endodontics (root canal treatment).................. 60
Periodontics (treatment of gum disease)............. 60
Oral surgery (extractions).......................... 60
Prosthodontics (bridges and dentures)............... 50
Orthodontics (braces)............................... 50
Crowns and Casts.................................... 50
------------------------------------------------------------------------
Preventive and diagnostic services will continue to be paid at 100
percent of the insurer's allowable charge, with the exception of
sealants which will now be paid at the 80 percent level. Basic
restorative services will also remain at the current level (80 percent
of the allowable).
``By-report'' professional services (i.e., those services for which
a dentist must explain on the claim the unusual circumstances about the
case that make them necessary) will be paid at the following payment
levels:
------------------------------------------------------------------------
Payment
By report professional services levels
(percent)
------------------------------------------------------------------------
Miscellaneous Emergency............................. 100
Professional Consultation........................... 80
Professional Visits................................. 80
Drugs............................................... 50
Post-Surgical....................................... 80
------------------------------------------------------------------------
The beneficiary or sponsor will be responsible for the difference
between the insurer's allowable charge and the established payment
level for each category of benefit. This cost-share amount will
represent the beneficiary's or sponsor's total liability when dealing
with participating providers. If the dentist is non-participating, the
beneficiary will have to pay any difference between the insurer's
allowed amount and the amount charged by the non-participating dentist.
The new benefit program will also be limited by an annual maximum
amount of not less than $1000 per beneficiary for non-orthodontic
dental care and not less than a $1200 lifetime limit per beneficiary
for orthodontics.
Enrollment
The Basic Active Duty Dependents Dental Plan was terminated upon
implementation of the interim Expanded Dependents Dental Plan. The
effective date of this change was April 1, 1993. Enrollment in this
interim plan was automatic for all active duty families in the United
States, the District of Columbia, the Commonwealth of Puerto Rico, Guam
and the U.S. Virgin Islands, whose military sponsors were known to have
at least 24 months remaining in service, and for those dependents
enrolled in the Basic Active Duty Dependents Dental Plan regardless of
their sponsors' remaining time in service. Enrollment criteria for
sponsors outside the continental United States remained unchanged.
Those who intended to remain in the service for 24 or more months
and whose families were not automatically enrolled in the new plan,
could have enrolled them at their military personnel office by
completing DD Form 2494, Uniformed Services Active Duty Dependent
Dental Plan (DDP) Enrollment Election Form. DD Form 2494-1,
Supplemental Uniformed Services Active Duty Dependent Dental Plan (DDP)
Enrollment Election Form, would have been used if dependents had
resided in two or more physically separate locations and only the
family members in one location were to be enrolled.
Service members who wanted to remove their families from the new
interim Expanded Active duty Dependents Dental Benefit Plan were
allowed to do so during the one-month period before the date on which
the expanded plan went into effect, and for 4 months after the
beginning date. They received a full refund of all premiums deducted,
so long as the program had not been used following the implementation
date. Use of the new plan during the disenrollment period constituted
acceptance of the plan by the military sponsor and his or her family.
Once the new plan was used, the family could not be disenrolled, and
the premiums could not be refunded.
Premium Payments
Monthly premiums for the interim Expanded Active Duty Dependents
Dental Benefit Plan were $9.65 for a single member, and $19.30 for two
or more family members. Payroll deductions for the new premiums began a
month prior to the starting date of the interim plan. These premium
rates were
[[Page 55450]]
selected to maximize benefits while at the same time maintaining an
approximate 60 percent government/40 percent sponsor cost-share
specified in congressional reports and meet appropriated budget levels.
There were no reductions in premiums for enlisted members in pay grades
E-4 and below.
Monthly premiums were increased effective August 1, 1994. The
increases were assessed beginning with the September 1994 payroll
deduction for active-duty military sponsors. The new premiums are $10
for one enrolled active-duty family member, and $20 for active-duty
sponsors with two or more enrolled family members.
Legislative Changes
The Defense Authorization Act (Pub. L. 103-337, October 5, 1994)
established: authority for the Secretary of Defense to expand dental
benefits outside the United States and to provide continued dental
coverage for eligible dependents of service members who die on or after
October 1, 1993, while on active duty for up to one year from the date
of the member's death; and CHAMPUS eligibility for children placed in
the custody of a service member by a court or recognized adoption
agency on or after October 5, 1994, in anticipation of a legal
adoption. These provisions have been codified in 10 U.S.C. Chapter 55,
sections 1072(6) and 1076a--Dependent's Dental Program--and are
reflected in the regulatory provisions of this rule.
Review of Comments
As a result of the publication of the proposed rule, the following
comments were received from interested associations and agencies.
Comment 1. One commentor felt that all references to
``orthodontia'' should be changed to ``orthodontics'' since it was a
more contemporary term and preferred by the specialty.
All references to ``orthodontia'' have been changed to
``orthodontics'' in the final rule.
Comment 2. The same commentor provided a definition which was felt
to more accurately describe the scope of orthodontic practice. The
commentor felt that the definition contained in the proposed rule
failed to adequately address the dentofacial orthopedic aspects of
orthodontic practice.
The definition of ``orthodontics'' has been changed to: ``The
supervision, guidance, and correction of the growing or mature
dentofacial structures, including those conditions that require
movement of teeth or correction of malrelationships and malformations
of their related structures and the adjustment of relationships between
and among teeth and facial bones by the application of forces and/or
the stimulation and redirection of functional forces within the
craniofacial complex.''
Comment 3. Several commentors expressed concern over specific
reference to American Dental Association (ADA) codes in the Regulation
since they would become outdated and require continual revision. They
pointed out that the ADA's Code on Dental Procedures and Nomenclature
was currently under revision and that it would likely result in
deletion of several existing codes and the addition of new codes. It
was recommended that a general reference be made to the use of codes
contained in the current edition of the ADA's Code on Dental Procedures
and Nomenclature, without reference to specific codes.
Specific ADA codes have been deleted from the final rule and
replaced with a general reference to the use of the American Dental
Association's Code on Dental Procedures and Nomenclature as listed in
the Current Dental Terminology (CDT) manual.
Comment 4. One commentor felt that ADA code 08999--Unspecified
orthodontic procedures--should be included under ``Orthodontics''
[paragraph (e)(2)(vi)] if specific codes continued to be referenced in
the final rule.
This is no longer an issue since specific ADA codes have been
deleted from the final rule.
Comment 5. One commentor felt that the statement ``subject to the
dental plan's exclusions, limitations, and benefit determination rules
as adopted by OCHAMPUS'' should be deleted from the final rule since it
could be used by the insurance carrier to reduce the actual benefits
which would be contrary to the intent of the 1993 law.
All benefit programs must have exclusions and limitations, the
intent of which are to define what is and what is not covered and the
conditions under which the procedures are benefits. These limitations
and exclusions are taken into consideration when determining the cost
(premiums). The policies, limitations and exclusions are approved by
OCHAMPUS and agreed to by contract.
Comment 6. Another commentor wanted to know how providers will be
able to tell who is covered under the old plan (Basic Dependents Dental
Plan) and distinguish them from those who are covered under the new
plan (Expanded Dependents Dental Plan).
The Basic Active Duty Dependents Dental Benefit Plan was terminated
upon implementation of the interim Expanded Active Duty Dependents
Dental Benefit Plan on April 1, 1993. Enrollment in this interim plan
was automatic for all active duty families in the United States, the
District of Columbia, the Commonwealth of Puerto Rico, Guam and the
U.S. Virgin Islands, whose military sponsors were known to have at
least 24 months remaining in service, and for those dependents that
were already enrolled in the Basic Active Duty Dependents Dental
Benefits Plan regardless of their sponsors' remaining time in service.
Implementation of the interim Expanded Active Duty Dependents Dental
Benefit Plan has been addressed in the Supplementary Information
section of this rule.
Comment 7. One commentor recommended that the definition of
sealants be changed to remove the word ``resinous''.
The word ``resinous'' has been removed from the definition of
sealants.
Comment 8. The same commentor felt that the definition of sealants
should be further revised by substituting ``on tooth surface'' for ``on
the occlusal surfaces.''
The suggestion was not adopted since the existing definition/
specification only allows sealants on the unrestored occlusal surface.
This applies even when the facial and/or lingual surfaces require a
restoration. This was instituted because the previous definition
resulted in denial of sealants when any surface of the tooth was
carious or restored.
Comment 9. Another commentor recommended that coverage of resin
restorations be extended to one to four or more surfaces.
CHAMPUS coverage of resin restorations is extended to one to four
or more surfaces under the Expanded Active Duty Dependents Dental
Benefit Plan. Specific ADA codes and nomenclature have been deleted
from the final rule and replaced with general categories of coverage
along with a reference to the use of American Dental Association's Code
on Dental Procedures and Nomenclature as listed in the current Dental
Terminology manual.
Comment 10. One commentor felt that an appropriate inlay code
should be reported along with the onlay code under restorative services
since onlays cannot be done without an inlay.
The current procedure code nomenclature and fees define the inlay
in addition to the onlay. However, this is to only pay benefits for
onlays if the tooth qualified on the basis of breakdown. Simple inlays
(not covering cusps) are converted to a comparable
[[Page 55451]]
amalgam restoration. Inlays, per se, are not benefits.
Comment 11. One commentor pointed out that 03350 and 04265 were no
longer valid ADA codes and should be removed.
Specific ADA codes have been deleted from the final rule and
replaced with general categories of coverage along with a reference to
the use of the American Dental Association's Code on Dental Procedure
and Nomenclature as listed in the current Dental Terminology manual.
Comment 12. Another commentor felt that ``periodontal root
planing'' should be expanded to read ``periodontal scaling and root
planing.''
Although it is agreed that ``periodontal root planing'' should be
expanded to read ``periodontal scaling and root planing,'' specific ADA
codes and nomenclature have been deleted from the final rule and
replaced with general coverage categories, along with a reference to
the use of the American Dental Association's Code on Dental Procedure
and Nomenclature as listed in the current Dental Terminology manual.
Comment 13. One commentor felt that ``Periodontal prophylaxis''
should be changed to read ``Periodontal maintenance procedures.''
The terminology of ``periodontal prophylaxis'' clarifies that it is
considered a prophylaxis and counts toward the limitations.
Comment 14. One commentor felt that an appropriate inlay code
should accompany the onlay code under prosthodontic services.
The current procedure code nomenclature and fees define the inlay
in addition to the onlay. However, this is to only pay benefits for
onlays if the tooth qualified on the basis of breakdown. Simple inlays
(not covering cusps) are converted to a comparable amalgam restoration.
Inlays are not benefits.
Comment 15. Another commentor expressed concern over the fact that
active duty members could no longer disenroll because of permanent
changes in duty station if dental care was available to the members'
dependents under a program other than the Dependents Dental Plan. The
commentor felt that the proposed regulation did not reflect the
statutory right established by 10 U.S.C. Section 1076a(f) to disenroll
from the program and subsequently reenroll.
The option to disenroll as a result of a change in active duty
station has been reinstated with removal of the mileage restriction.
Summary of Regulatory Modifications
The following revisions were made as a result of legislative
mandates, contract modifications, and suggestions received during the
public comment period: established authority for expansion of dental
benefits outside the United States; provided coverage for eligible
dependents of services members who died on active duty for up to one
year from date of member's death; established CHAMPUS eligibility for
pre-adoptive wards of service members; raised the cost-share from 50 to
60 percent of the insurer's determined allowed charges for endodontics,
periodontics and oral surgery; raised the lifetime orthodontic limits
from $1000 to $1200; provided payment levels for ``by-report''
professional services; provided new monthly premiums which went into
effect on October 1, 1994; reinstated the option to disenroll as a
result of a change in active duty station; established a new definition
for orthodontics; and removed specific ADA codes/nomenclature and
replaced them with general coverage categories and a reference to the
use of the American Dental Association's Code on Dental Procedures and
Nomenclature as listed in the current Dental Terminology manual.
Regulatory Procedures
Executive Order 12866 requires that a regulatory impact analysis be
performed on any significant regulatory action, defined as one which
would result in an annual effect on the national economy of $100
million or more, or which would have other substantial impacts.
The Regulatory Flexibility Act (RFA) requires that each federal
agency prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation which would
have a significant impact on a substantial number of small entities.
This final rule is not a significant regulatory action under
Executive Order 12866. The changes set forth in this final rule are
minor revisions to existing regulation. In addition, this rule will
have very minor impact and will not significantly affect a substantial
number of small entities. In light of the above, no regulatory impact
analysis is required.
This final rule does not impose information collection
requirements. Therefore, it does not need to be reviewed by the
Executive Office of Management and Budget under authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520).
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, and Military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
PART 199--[AMENDED]
1. The authority citation for Part 199 continues to read as
follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
2. Section 199.13 is amended as follows:
a. By removing paragraph (c)(5)(vi).
b. By redesignating paragraphs (c)(2)(ii)(G) as (c)(2)(ii)(H) and
(c)(5)(vii) as (c)(5)(vi).
c. By adding paragraph (a)(3)(i)(C), (c)(2)(ii)(G) and (c)(8).
d. Paragraph (b) by adding definitions ``endodontics,'' ``oral
surgery,'' ``orthodontics,'' ``periodontics,'' ``Prosthodontics,'' and
``sealants'' and placing them in alphabetical order.
e. Paragraph (b) by revising the definitions for ``beneficiary
liability'' and ``participating provider.''
f. By revising paragraphs (c)(1), (c)(3) and (c)(4); (c)(5)(iv) and
(c)(5)(v); (e)(1)(i); (e)(2) and (e)(3); (f)(1)(ii); (f)(1)(vi) and
(f)(1)(vii); (f)(6)(i) and (f)(6)(ii); (g)(2) and (g)(3) introductory
text.
Sec. 199.13 Active duty dependents dental plan.
* * * * *
(a) * * *
(3) * * *
(i) * * *
(C) Care outside the United States. 10 U.S.C. 1076a authorizes the
Secretary of Defense to establish basic dental benefit plans for
eligible dependents of members of the uniform services accompanying the
member on permanent assignments of duty outside the United States.
* * * * *
(b) * * *
Beneficiary liability. The legal obligation of a beneficiary, his
or her estate, or responsible family member to pay for the costs of
dental care or treatment received. Specifically, for the purposes of
services and supplies covered by the Active Duty Dependents Dental
Benefit Plan, beneficiary liability includes cost-sharing amounts and
any amount above the prevailing fee determination by the insurer where
the provider selected by the beneficiary is not a participating
provider or a provider within an approved alternative delivery system.
Beneficiary liability also includes any expenses for services and
supplies not covered by the Active
[[Page 55452]]
Duty Dependents Dental Benefit Plan, less any discount provided as a
part of the insurer's agreement with an approved alternative delivery
system.
* * * * *
Endodontics. The etiology, prevention, diagnosis, and treatment of
diseases and injuries affecting the dental pulp, tooth root, and
periapical tissue as further defined in paragraph (e) of this section.
* * * * *
Oral surgery. Surgical procedures performed in the oral cavity as
further defined in paragraph (e) of this section.
* * * * *
Orthodontics. The supervision, guidance, and correction of the
growing or mature dentofacial structures, including those conditions
that require movement of teeth or correction or malrelationships and
malformations of their related structures and adjustment of
relationships between and among teeth and facial bones by the
application of forces and/or the stimulation and redirection of
functional forces within the craniofacial complex.
* * * * *
Participating provider. A dentist or dental hygienist who has
agreed to accept the insurer's reasonable fee allowances or other fee
arrangements as the total charge (even though less than the actual
billed amount), including provision for payment to the provider by the
beneficiary (or sponsor) of any cost-share for services.
* * * * *
Periodontics. The examination, diagnosis, and treatment of diseases
affecting the supporting structures of the teeth as further defined in
paragraph (e) of this section.
* * * * *
Prosthodontics. The diagnosis, planning, making, insertion,
adjustment, relinement, and repair of artificial devices intended for
the replacement of missing teeth and associated tissues as further
defined in paragraph (e) of this section.
* * * * *
Sealants. A material designed for application on the occlusal
surfaces of specified teeth to seal the surface irregularities to
prevent ingress of oral fluids, food, and debris in order to prevent
tooth decay.
* * * * *
(c) * * *
(1) General. 10 U.S.C. 1076a, 1072(2)(A), (D) or (I) and 1072(6)
set forth those persons who are eligible for voluntary enrollment in
the Active Duty Dependents Dental Benefit Plan. A determination that a
person is eligible for voluntary enrollment does not automatically
entitle that person to benefit payments. The person must be enrolled in
accordance with the provisions set forth in this section and meet any
additional eligibility requirements in other sections of this part in
order for dental benefits to be extended.
* * * * *
(2) * * *
(ii) * * *
(G) A child placed in the custody of a service member by a court or
recognized adoption agency on or after October 5, 1994, in anticipation
of a legal adoption.
* * * * *
(3) Enrollment.
(i) Basic active duty dependents dental benefit plan. The dependent
dental plan is effective from August 1, 1987, up to the date of
implementation of the Expanded Active Duty Dependents Dental Benefit
Plan.
(A) Initial enrollment. Eligible dependents of members on active
duty status as of August 1, 1987 are automatically enrolled in the
Active Duty Dependents Dental Plan, except where any of the following
conditions apply:
(1) Remaining period of active duty at the time of contemplated
enrollment is expected by the active duty member or the Uniformed
Service to be less than two years, except that such members' dependents
may be enrolled during the initial enrollment period for benefits
beginning August 1, 1987 provided that the member had at least six
months remaining in the initial enlistment term. Enrollment of
dependents is for a period of 24 months, subject to the exceptions
provided in paragraph (c)(5) of this section.
(2) Active duty member had completed an election to disenroll his
or her dependents from the Basic Active Duty Dependents Dental Benefit
Plan.
(3) Active duty member had only one dependent who is under four
years of age as of August 1, 1987, and the member did not complete an
election form to enroll the child.
(B) Subsequent enrollment. Eligible active duty members may elect
to enroll their dependents for a period of not less than 24 months,
provided there is an intent to remain on active duty for a period of
not less than two years by the member and the Uniformed Service.
(C) Inclusive family enrollment. All eligible dependents of the
active duty member must be enrolled if any were enrolled, except that a
member may elect to enroll only those dependents who are remotely
located from the member (e.g., a child living with a divorced spouse or
a child in college).
(ii) Expanded active duty dependents dental benefit plan. The
expanded dependents dental plan is effective on August 1, 1993. The
Basic Active Duty Dependents Dental Benefit Plan terminated upon
implementation of the expanded plan.
(A) Initial enrollment. Enrollment in the Expanded Active Duty
Dependents Dental Benefit Plan is automatic for all eligible dependents
of active duty members known to have at least 24 months remaining in
service, and for those dependents enrolled in the Basic Dependents
Dental Benefit Plan regardless of the military member's remaining time
in service unless the active duty member elects to disenroll his or her
dependents during the one-time disenrollment option period (one-month
period before the date on which the expanded plan went into effect, and
for 4 months after the beginning date). Those active duty members who
intend to remain in the service for 24 months or more, whose dependents
were not automatically enrolled, may enroll them at their military
personnel office by completing the appropriate Uniformed Services
Active Duty Dependents Dental Plan Enrollment Election Form. Use of the
new plan during the one-time disenrollment option period by a dependent
enrolled in the Basic Active Duty Dependents Dental Benefit Plan,
constitutes acceptance of the plan by the military sponsor and his or
her family. Once the new plan is used, the family cannot be
disenrolled, and the premiums will not be refunded.
(B) Subsequent enrollment. Eligible active duty members may elect
to enroll their dependents for a period of not less than 24 months,
provided there is an intent to remain on active duty for a period of
not less than two years by the member and the Uniformed Service.
(C) Inclusive family enrollment. All eligible dependents of the
active duty member must be enrolled if any are enrolled, except as
defined in paragraphs (c)(3)(ii)(C) (1) and (2) of this section.
(1) Enrollment will be by either single or family premium as
defined herein:
(i) Single premium.
(A) Sponsors with only one family member age four (4) or older who
elect to enroll that family member; or
(B) Sponsors who have more than one family member under age four
(4) may elect to enroll one (1) family member under age four (4); or
(C) Sponsors who elect to enroll one (1) family member age four or
older but may have any number of family members under age four (4) who
are not
[[Page 55453]]
elected to be covered. At such time when the sponsor elects to enroll
more than one (1) eligible family member, regardless of age, the
sponsor must then enroll under a family premium which covers all
eligible family members.
(ii) Family premium.
(A) Sponsors with two (2) or more eligible family members age four
(4) or older must enroll under the family premium.
(B) Sponsors with one (1) eligible family member age four (4) or
older and one (1) or more eligible family members under the age of four
may elect to enroll under a family premium.
(C) Under the family premium, all eligible family members of the
sponsor are enrolled.
(2) Exceptions.
(i) A sponsor may elect to enroll only those eligible family
members residing in one location when the sponsor has other eligible
family members residing in two or more physically separate locations
(e.g., children living with a divorced spouse; children attending
college).
(ii) Instances where a family member requires hospital or special
treatment environment (due to a medical, physical handicap, or mental
condition) for dental care otherwise covered by the dental plan, the
family member may be excluded from the dental plan enrollment and may
continue to receive care from a military treatment facility.
(D) Enrollment period. Enrollment of dependents is for a period of
24 months except when:
(1) The dependent's enrollment is based on his or her enrollment in
the Basic Active Duty Dependents Dental Benefit; or
(2) One of the conditions for disenrollment in paragraph (c)(5) of
this section is met.
(4) Beginning dates of eligibility.
(i) Basic active duty dependents dental benefit plan.
(A) Initial enrollment. The beginning date of eligibility for
benefits is August 1, 1987.
(B) Subsequent enrollment. The beginning date of eligibility for
benefits is the first day of the month following the month in which the
election of enrollment is completed, signed, and received by the active
duty member's Service representative, except that the date of
eligibility shall not be earlier than September 1, 1987.
(ii) Expanded active duty dependents dental benefit plan.
(A) Initial enrollment. The beginning date of eligibility for
benefits is April 1, 1993.
(B) Subsequent enrollment. The beginning date of eligibility for
benefits is the first day of the month following the month in which the
election of enrollment is completed, signed, and received by the active
duty member's Service representative, except that the date of
eligibility shall not be earlier than the first of the month following
the month of implementation of the expanded benefit.
* * * * *
(5) * * *
(iv) Disenrollment because of no eligible dependents. When an
active duty member ceases to have any eligible dependents, the member
must disenroll.
(v) Option to disenroll as a result of a change in active duty
station. When an active duty member transfers with enrolled family
members to a duty station where space-available dental care is readily
available at the local military clinic, the member may elect within 90
days of the transfer to disenroll from the plan. If the member is later
transferred to a duty station where dental care is not available in the
local military clinic, the member may re-enroll his or her dependents
in the plan.
* * * * *
(8) Continuation of eligibility for dependents of service members
who die on active duty. Eligible dependents of service members who die
on or after October 1, 1993, while on active duty for a period of more
than 30 days and who are enrolled in the dental benefits plan on the
date of the death of the member shall be eligible for continued
enrollment in the dental benefits plan for up to one year from the date
of the service member's death.
* * * * *
(e) * * *
(1) * * *
(i) Scope of benefits. The Active Duty Dependents Dental Benefit
Plan provides coverage for diagnostic and preventive services,
sealants, restorative services, endodontics, periodontics,
prosthodontics, orthodontics and oral surgery to eligible, enrolled
dependents of active duty members as set forth in paragraph (c) of this
section.
* * * * *
(2) Benefits.
(i) Diagnostic and preventive services. Benefits may be extended
for those dental services described as oral examination, diagnostic,
and preventive services defined as traditional prophylaxis (i.e.,
scaling deposits from teeth, polishing teeth, and topical application
of fluoride to teeth) when performed directly by dentists or dental
hygienists as authorized under paragraph (f) of this section. These
services are defined (subject to the dental plan's exclusions,
limitations, and benefit determination rules approved by OCHAMPUS)
using the American Dental Association's Code on Dental Procedures and
Nomenclature as listed in the Current Dental Terminology manual to
include the following categories of services:
(A) Diagnostic services.
(1) Clinical Oral examinations.
(2) Radiographs.
(3) Tests and laboratory examinations.
(B) Preventive services.
(1) Dental prophylaxis.
(2) Topical fluoride treatment (office procedure).
(3) Sealants.
(4) Space maintenance (passive appliances).
(ii) Adjunctive general services (services ``by report''). The
following categories of services are authorized when performed directly
by dentists or dental hygienists only in unusual circumstances
requiring justification of exceptional conditions directly related to
otherwise authorized procedures. Use of the procedures may not result
in the fragmentation of services normally included in a single
procedure. These services are defined (subject to the dental plan's
exclusions, limitations, and benefit determination rules as adopted by
OCHAMPUS) using the American Dental Association's Code on Dental
Procedures and Nomenclature as listed in the Current Dental Terminology
manual to include the following categories of service:
(A) Emergency oral examinations.
(B) Palliative emergency treatment of dental pain.
(C) Professional consultation.
(D) Professional visits.
(E) Drugs.
(F) Post-surgical complications.
(iii) Restorative. Benefits may be extended for basic restorative
services when performed directly by dentists or dental hygienists, or
under orders and supervision by dentists, as authorized under paragraph
(f) of this section. These services are defined (subject to the dental
plan's exclusions, limitations, and benefit determination rules as
adopted by OCHAMPUS) using the American Dental Association's Code on
Dental Procedures and Nomenclature as listed in the Current Dental
Terminology manual to include the following categories of services:
(A) Restorative services.
(1) Amalgam restorations.
(2) Silicate restorations.
(3) Resin restorations.
(4) Prefabricated crowns.
(5) Pin retention.
(B) Other restorative services.
(1) Diagnostic casts.
[[Page 55454]]
(2) Onlay restoration--metallic.
(3) Crowns.
(iv) Endodontic services. Benefits may be extended for those dental
services involved in treatment of diseases and injuries affecting the
dental pulp, tooth root, and periapical tissue when performed directly
by dentists as authorized under paragraph (f) of this section. These
services are defined (subject to the dental plan's exclusions,
limitations, and benefit determination rules as adopted by OCHAMPUS)
using the American Dental Association's Code on Dental Procedures and
Nomenclature as listed in the Current Dental Terminology manual to
include the following categories of services:
(A) Pulp capping--indirect.
(B) Pulpotomy.
(C) Root canal therapy.
(D) Periapical services.
(E) Hemisection.
(v) Periodontic services. Benefits may be extended for those dental
services involved in prevention and treatment of diseases affecting the
supporting structures of the teeth to include periodontal prophylaxis,
gingivectomy or gingivoplasty, gingival curettage, etc., when performed
directly by dentists as authorized under paragraph (f) of this section.
These services are defined (subject to the dental plan's exclusions,
limitations, and benefit determination rules as adopted by OCHAMPUS)
using the American Dental Association's Code on Dental Procedures and
Nomenclature as listed in the Current Dental Terminology manual to
include the following categories of services:
(A) Surgical services.
(B) Periodontal scaling and root planing.
(C) Unscheduled dressing change.
(vi) Prosthodontic services. Benefits may be extended for those
dental services involved in fabrication, insertion, adjustment,
relinement, and repair of artificial teeth and associated tissues to
include removable complete and partial dentures, fixed crowns and
bridges when performed directly by dentists as authorized under
paragraph (f) of this section. These services are defined (subject to
the dental plan's exclusions, limitations, and benefit determination
rules as adopted by OCHAMPUS) using the American Dental Association's
Code on Dental Procedures and Nomenclature as listed in the Current
Dental Terminology manual to include the following categories of
services:
(A) Prosthodontics (removable).
(1) Complete/partial dentures.
(2) Adjustments to removable prosthesis.
(3) Repairs to complete/partial dentures.
(4) Denture rebase procedures.
(5) Denture reline procedures.
(6) Interim complete/partial dentures.
(7) Tissue conditioning.
(B) Prosthodontics (fixed).
(1) Bridge pontics.
(2) Retainers (by report).
(3) Bridge retainers-crowns.
(4) Other fixed prosthetic services.
(vii) Orthodontic services. Benefits may be extended for the
supervision, guidance, and correction of growing or mature dentofacial
structures, including those conditions that require movement of teeth
or correction of malrelationships and malformations through the use of
orthodontic procedures and devices when performed directly by dentists
as authorized under paragraph (f) of this section to include in-process
orthodontics. Coverage of in-process orthodontics is limited to
services rendered on or after the date of enrollment in the expanded
dependents dental play. These services are defined (subject to the
dental plan's exclusions, limitations, and benefit determination rules
as adopted by OCHAMPUS) using the American Dental Association's Code on
Dental Procedures and Nomenclature as listed in the Current Dental
Terminology manual to include the following categories of services:
(A) Minor treatment for tooth guidance.
(B) Minor treatment to control harmful habits.
(C) Interceptive orthodontic treatment.
(D) Comprehensive orthodontic treatment--transitional dentition.
(E) Comprehensive orthodontic treatment--permanent dentition.
(F) Treatment of the atypical or extended skeletal case.
(G) Post-treatment stabilization.
(viii) Oral surgery services. Benefits may be extended for basic
surgical procedure of the extraction, reimplantation, stabilization and
repositioning of teeth, alveoloplasties, incision and drainage of
abscesses, suturing of wounds, biopsies, etc., when performed directly
by dentists as authorized under paragraph (f) of this section. These
services are defined (subject to the dental plan's exclusions,
limitations, and benefit determination rules as adopted by OCHAMPUS)
using the American Dental Association's Code on Dental Procedures and
Nomenclature as listed in the Current Dental Terminology manual to
include the following categories of services:
(A) Extractions.
(B) Surgical extractions.
(C) Other surgical procedures.
(D) Alveoloplasty--surgical preparation of ridge for denture.
(E) Surgical incision and drainage of abscess--intraoral soft
tissue.
(F) Repair of traumatic wounds.
(G) Complicated suturing.
(H) Excision of pericoronal gingiva.
(ix) Exclusion of adjunctive dental care. Under limited
circumstances, benefits are available for dental services and supplies
under CHAMPUS when the dental care is medically necessary in the
treatment of an otherwise covered medical (not dental) condition, is an
integral part of the treatment of such medical condition, and is
essential to the control of the primary medical condition; or is
required in preparation for, or as the result of, dental trauma which
may be or is caused by medically necessary treatment of an injury or
disease (iatrogenic). These benefits are excluded under the Active Duty
Dependents Dental Plan. For further information on adjunctive dental
care benefits under CHAMPUS, see Sec. 199.4(e)(10).
(x) Exclusion of benefit services performed in military dental care
facilities. Except for emergency treatment, dental care provided
outside the United States, and services incidental to noncovered
services, dependents enrolled in the Active Duty Dependents Dental Plan
may not obtain those services which are benefits of the Plan in
military dental care facilities. Enrolled dependents may continue to
obtain noncovered services from military dental care facilities subject
to the provisions for space available care.
(xi) Benefit limitations and exclusions. The Director, OCHAMPUS or
designee may establish such exclusions and limitations as are
consistent with those established by dental insurance and prepayment
plans to control utilization and quality of care for the services and
items covered by this dental plan.
(3) Beneficiary and sponsor liability.
(i) Diagnostic and preventive services. Enrolled dependents of
active duty members or their sponsors are responsible for the payment
of only those amounts which are for services rendered by
nonparticipating providers of care which exceed the equivalent of the
statewide or regional prevailing fee levels as established by the
insurer, except in the case of sealants where the dependents or their
sponsors will also be responsible for payment of 20 percent of the
insurer's determined allowable amount. Where the dental plan is unable
to identify a participating provider of care within 35 miles of the
dependent's place of residence with appointment availability within 21
calendar days, the dental plan will reimburse the dependent, or
sponsor, or
[[Page 55455]]
the nonparticipating provider selected by the dependent within 35 miles
of the dependent's place of residence at the level of the provider's
usual fees less 20 percent of the insurer's allowable amount for
sealants.
(ii) Restorative services. Enrolled dependents of active duty
members or their sponsors are responsible for payment of 20 percent of
the amounts determined by the insurer for services rendered by
participating providers of care, or 20 percent of these amounts plus
any remainder of the charges made by nonparticipating providers of
care, except in the case of crowns and casts where the dependents or
their sponsors will be responsible for payment of 50 percent of the
insurer's determined allowable amount. Where the dental plan is unable
to identify a participating provider of care within 35 miles of the
dependent's place of residence with appointment availability within 21
calendar days, dependents or their sponsors are responsible for payment
of 20 percent (50 percent in the case of crowns and casts) of the
charges made by nonparticipating providers located within 35 miles of
the dependent's place of residence.
(iii) Endodontic, periodontic, and oral surgery services. Enrolled
dependents of active duty members or their sponsors are responsible for
payment of 40 percent of the amounts determined by the insurer for
services rendered by participating providers of care, or 40 percent of
these amounts plus any remainder of the charges made by
nonparticipating providers of care. Where the dental plan is unable to
identify a participating provider of care within 35 miles of the
dependent's place of residence with appointment availability within 21
calendar days, dependents or their sponsors are responsible for payment
of 40 percent of the charges made by nonparticipating providers located
within 35 miles of the dependent's place of residence.
(iv) Prosthodontic and orthodontic services. Enrolled dependents of
active duty members or their sponsors are responsible for payment of 50
percent of the amounts determined by the insurer for services rendered
by participating providers of care, or 50 percent of these amounts plus
any remainder of the charges made by nonparticipating providers of
care. Where the dental plan is unable to identify a participating
provider of care within 35 miles of the dependent's place of residence
with appointment availability within 21 calendar days, dependents or
their sponsors are responsible for payment of 50 percent of the charges
made by nonparticipating providers located within 35 miles of the
dependent's place of residence.
(v) Adjunctive general services (services ``by report''). The
beneficiary or sponsor liability is dependent on the particular service
provided. Emergency oral examinations and palliative emergency
treatment of dental pain are paid in full except for those amounts for
services rendered by nonparticipating providers of care which exceed
the equivalent of the statewide or regional prevailing fee levels as
established by the insurer which are the responsibility of the enrolled
dependents or their sponsors. Enrolled dependents or their sponsors are
responsible for payment of 20 percent of the amounts determined by the
insurer for professional consultations/visits and postsurgical services
and 50 percent for covered medications when provided by participating
providers of care, or these percentage payments plus any remaining
amounts in excess of the prevailing charge limits established by the
insurer for services rendered by nonparticipating providers, subject to
the exceptions for dependent lack of access to participating providers
as provided in paragraphs (e)(3)(i) through (e)(3)(iv) of this section.
The contracting dental insurer may recognize a ``by report'' condition
by providing additional allowance to the primary covered procedure
instead of recognizing or permitting a distinct billing for the ``by
report'' service.
(vi) Amounts over the dental insurer's established allowance for
charges. It is the responsibility of the dental plan insurer to
determine allowable charges for the procedures identified as benefits
of this plan. All benefits of the plan are based on the insurer's
determination of the allowable charges, subject to the exceptions for
lack of access to participating providers as provided in paragraphs
(e)(3)(i) through (e)(3)(iv) of this section.
(vii) Maximum coverage amounts. Enrolled dependents of active duty
members are subject to an annual maximum coverage amount for non-
orthodontic dental benefits and a lifetime maximum coverage amount for
orthodontics as established by the Secretary of Defense or designee.
(f) * * *
(1) * * *
(ii) Conflict of interest. See Sec. 199.9(d).
* * * * *
(vi) Participating provider. An authorized provider may elect to
participate and accept the fee or charge determinations as established
and made known to the provider by the dental plan insurer. The fee or
charge determinations are binding upon the provider in accordance with
the dental plan insurer's procedures for participation. The authorized
provider may not participate on a claim-by-claim basis. The
participating provider must agree to accept, within one day of a
request for appointment, beneficiaries in need of emergency palliative
treatment. Payment to the participating provider is based on the lower
of the actual charge or the insurer's determination of the allowable
charge. Payment is made directly to the participating provider, and the
participating provider may only charge the beneficiary the percent
cost-share of the insurer's allowable charge for those benefit
categories as specified in paragraphs (e)(3)(i) through (e)(3)(v) of
this section, in addition to the charges for any services not
authorized as benefits.
(vii) Nonparticipating provider. An authorized provider may elect
for all beneficiaries not to participate and request the beneficiary or
sponsor to pay any amount of the provider's billed charge in excess of
the dental plan insurer's determination of allowable charges. Neither
the government nor the dental plan insurer shall have any
responsibility for any amounts over the allowable charges as determined
by the dental plan insurer, except where the dental plan insurer is
unable to identify a participating provider of care within 35 miles of
the dependent's place of residence with appointment availability within
21 calendar days. In such instances of the nonavailability of a
participating provider, the nonparticipating provider located within 35
miles of the dependent's place of residence shall be paid his or her
usual fees, less the percent cost-share as specified in paragraphs
(e)(3)(i) through (e)(3)(v) of this section.
(A) Assignment. A nonparticipating provider may accept assignment
of claims for beneficiaries certifying their willingness to make such
assignment by filing the claims completed with the assistance of the
beneficiary or sponsor for direct payment by the dental plan insurer to
the provider.
(B) Nonassignment. A nonparticipating provider for all
beneficiaries may request the beneficiary or sponsor to file the claim
directly with the dental plan insurer, making arrangements with the
beneficiary or sponsor for direct payment by the beneficiary or
sponsor.
* * * * *
(6) * * *
(i) Nonparticipating providers (or the dependents or sponsors for
unassigned claims) shall be reimbursed at the
[[Page 55456]]
equivalent of not less than the 50th percentile of prevailing charges
made for similar services in the same locality (region) or state, or
the provider's actual charge, whichever is lower; less any cost-share
amount due for authorized services, except where the dental plan
insurer is unable to identify a participating provider of care within
35 miles of the dependent's place of residence with appointment
availability within 21 calendar days. In such instances of the
nonavailability of a participating provider, the nonparticipating
provider located within 35 miles of the dependent's place of residence
shall be paid his or her usual fees, less the cost-share for the
authorized services.
(ii) Participating providers shall be reimbursed at the equivalent
of a percentile of prevailing charges sufficiently above the 50th
percentile of prevailing charges made for similar services in the same
locality (region) or state as to constitute a significant financial
incentive for participation, or the provider's actual charge, whichever
is lower; less any cost-share amount due for authorized services.
(g) * * *
(2) Benefit payments made to a participating provider. When the
authorized provider has elected to participate in accordance with the
arrangement and procedures established by the dental plan insurer,
payment is made based on the lower of the actual charge or the
insurer's determination of the allowable charge. Payment is made
directly to the participating provider as payment in full, less the
percent cost-share of the insurer's allowable charge as specified in
paragraphs (e)(3)(i) through (e)(3)(v) of this section.
(3) Benefit payments made to a nonparticipating provider. When the
authorized provider has elected not to participate in accordance with
the arrangement and procedures established by the dental plan, payment
is made by the insurer based on the lower of the actual charge or the
insurer's determination of the allowable charge. The beneficiary is
responsible for payment of a percent cost-share of the insurer's
allowable charge as specified in paragraphs (e)(3)(i) through (e)(3)(v)
of this section. Where the dental plan is unable to identify a
participating provider of care within 35 miles of the dependent's place
of residence with appointment availability within 21 calendar days,
dependents or their sponsors are responsible for payment of a percent
cost-share of the charges made by nonparticipating providers located
within 35 miles of the dependent's place of residence as specified in
paragraphs (e)(3)(i) through (e)(3)(v) of this section.
* * * * *
Dated: October 26, 1995.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 95-27116 Filed 10-31-95; 8:45 am]
BILLING CODE 5000-04-M
