[Federal Register Volume 62, Number 246 (Tuesday, December 23, 1997)]
[Rules and Regulations]
[Pages 66989-66992]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-33108]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR 199
[DoD 6010.8-R]
RIN 0720-AA40
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); TRICARE Selected Reserve Dental Program
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule establishes the TRICARE Selected Reserve
Dental Program (TSRDP) to provide dental care to members of the
Selected Reserves of the Ready Reserve. The final rule details
operation of the program.
EFFECTIVE DATE: This final rule is effective January 22, 1998.
ADDRESSES: Office of Health Services Financing, Department of Defense,
Room 1B657, Pentagon, Washington, DC 20301-1200.
FOR FURTHER INFORMATION CONTACT:
Cynthia P. Speight, Office of the Assistant Secretary of Defense
(Health Affairs), (703) 697-8975.
SUPPLEMENTARY INFORMATION:
I. Overview of the Final Rule
Implementation of the TRICARE Selected Reserve Dental Program
(TSRDP) was directed by Congress in section 705 of the National Defense
Authorization Act for Fiscal Year 1996, Public Law 104-106, which
amended title 10, United States Code, by adding section 1076b. This law
directed the implementation of a dental program for members of the
Selected Reserve of the Ready Reserve, providing for voluntary
enrollment and premium sharing between DoD and the enrollee. Section
702 of the 1997 National Defense Authorization Act, Pub. L. 104-201
amended 10 U.S.C. 1076b, by revising the program's start date and also
changing several operational requirements.
Included in the program are the 50 United States and the District
of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. Enrollment
in the TSRDP will be voluntary and accomplished via an enrollment
application submitted to the contractor. Initial enrollment shall be
for a period of 12 months followed by month-to-month enrollment as long
as the enrollee chooses to continue enrollment. The costs of the
program will be shared between the government and the enrollee. The
premium payment shall be collected pursuant to procedures established
by the Assistant Secretary of Defense (Health Affairs).
Dental coverage under the TSRDP will consist of basic dental care,
to include diagnostic services, preventive services, basic restorative
services, and emergency oral examinations. Enrollees will be limited to
an annual maximum of $1,000 of paid allowable charges per year. Minor
administrative changes have been made in the benefits plan section in
order to correct outdated codes.
Under this final rule, where possible, Reservists may make use of
participating dental providers in their areas and may benefit from
reduced out of pocket costs and provider submission of claims and
acceptance of contractor allowances and arrangements. Enrollees using
non-network providers may be balance billed amounts in excess of
allowable charges. Dental claims under the TSRDP will be paid at the
lower of the billed charges or the Usual, Customary and Reasonable
(UCR) level, in which the customary rate is calculated at the 85th
percentile or higher of billed charges.
[[Page 66990]]
TSRDP eligible beneficiaries will obtain information concerning the
program and the enrollment process from the dental contractor. In the
event an issue arises regarding the level of dental care received or
the quality of care, all appeals and grievances should first be
directed to the contractor for resolution. Only those issues that
cannot be amicably resolved by the contractor should be forwarded to
the TRICARE Support Office for review.
This final rule adopts the statutory preemption authority of 10
U.S.C. section 1103. This statute broadly authorizes preemption of
state laws in connection with DoD contracts for medical and dental
care. The Assistant Secretary of Defense (Health Affairs) has made the
judgment that preemption is necessary and appropriate to assure the
operation of a consistent, effective, and efficient federal program.
Absent preemption of certain State and local laws on insurance
regulation and other matters, competition would be severely limited and
the process substantially delayed. The final rule incorporates language
to clarify that the preemption of State laws section includes
preemption of State and local laws imposing premium taxes on health or
dental insurance carriers or underwriters or other plan managers, or
similar taxes on such entities.
As directed in the enacting legislation, the Department of Defense
utilized a full and open competition to obtain a dental contractor to
provide dental insurance coverage.
II. Public Comments
The interim final rule was published on May 16, 1997 (62 FR 26939).
We received one public comment. We thank the commenter; significant
items raised by the commenter and our analysis of the comments are
summarized below in the appropriate sections of the preamble.
1. Benefits. The commenter recommended expanding the benefits under
the program to include periodontics.
Response. Under the law, 10 U.S.C. 1076b, the TRICARE Selected
Reserve Dental Program shall provide benefits for basic dental care and
treatment, including diagnostic services, preventive services, basic
restorative services and emergency oral examinations; periodontics was
not included.
2. Benefits. We received a comment suggesting the addition of
crowns as a benefit under the program.
Response. Under the law, 10 U.S.C. 1076b, the TRICARE Selected
Reserve Dental Program shall provide benefits for basic dental care and
treatment, including diagnostic services, preventive services, basic
restorative services and emergency oral examinations. Crowns are not
covered under the program as they are not considered to be a basic
restorative service.
3. Benefits. Another comment we received pointed out that code
00130 had been changed to 00140.
Response. We concur with the comment and procedure code 00130 has
been changed to 00140.
III. Rulemaking Procedures
Executive Order 12866 requires certain regulatory assessments for
any ``significant regulatory action,'' defined as one which would
result in an annual effect on the economy of $100 million or more, or
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 is not a significant regulatory action under the provisions of
Executive Order 12866, and it would not have a significant impact on a
substantial number of small entities.
The final rule will not impose additional information collection
requirements on the public under the Paperwork Reduction Act of 1995
(44 U.S.C. Chapter 55).
List of Subjects in 32 CFR Part 199
Claims, Health insurance, Individuals with disabilities, Military
personnel, Reporting and recordkeeping requirements.
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. Part 199 is amended by revising Sec. 199.21 to read as follows:
Sec. 199.21 TRICARE Selected Reserve Dental Program (TSRDP).
(a) Purpose. The TSRDP is a premium based indemnity dental
insurance coverage program that will be available to members of the
Selected Reserve of the Ready Reserve. Dental coverage will be
available only to members of the Selected Reserve, no family coverage
will be offered. The TSRDP is authorized by 10 U.S.C. 1076b.
(b) General provisions. (1) Benefits are limited to diagnostic
services, preventive services, basic restorative services, and
emergency oral examinations.
(2) Premium costs for this coverage will be shared by the enrollee
and the government.
(3) The program is applicable to authorized providers in the 50
United States and the District of Columbia, Puerto Rico, Guam, and the
U.S. Virgin Islands.
(4) Except as otherwise provided in this section or by the
Assistant Secretary of Defense (Health Affairs) or designee, the TSRDP
is administered in a manner similar to the Active Duty Dependents
Dental Plan under Sec. 199.13 of this part.
(5) The TSRDP shall be administered through a contract.
(c) Definitions. Except as may be specifically provided in this
section, to the extent terms defined in Secs. 199.2 and 199.13(b) of
this part are relevant to the administration of the TRICARE Selected
Reserve Dental Program, the definitions contained in Secs. 199.2 and
199.13(b) of this part shall apply to the TSRDP as they do to CHAMPUS
and the Active Duty Dependents Dental Plan.
(d) Eligibility and enrollment.(1) Eligibility. Enrollment in the
TRICARE Selected Reserve Dental Program is open to members of the
Selected Reserve of the Ready Reserve.
(2) Notification of eligibility. The contractor will notify persons
eligible to receive dental benefits under the TRICARE Selected Reserve
Dental Program.
(3) Election of coverage. Following this notification, interested
Reservists may elect to enroll. In order to obtain dental coverage,
written election by eligible beneficiary must be made.
(4) Enrollment. Enrollment in the TRICARE Selected Reserve Dental
Program is voluntary and will be accomplished by submission of an
application to the TSRDP contractor. Initial enrollment shall be for a
period of 12 months followed by month-to-month enrollment as long as
the enrollee chooses to continue enrollment.
(5) Period of coverage. TRICARE Selected Reserve Dental Program
coverage is terminated on the last day of the month in which the member
is discharged, transferred to the Individual Ready Reserve, Standby
Reserve, or Retired Reserve, or ordered to active duty for a period of
more than 30 days.
(e) Premium sharing. The Government and the enrollee will share in
the monthly premium cost.
(f) Premium payments. The enrollee will be responsible for a
monthly
[[Page 66991]]
premium payment in order to obtain the dental insurance.
(1) Premium payment method. The premium payment may be collected
pursuant to procedures established by the Assistant Secretary of
Defense (Health Affairs).
(2) Effects of failure to make premium payments. Failure to make
monthly renewal premium payments will result in the enrollee being
disenrolled from the TSRDP and subject to a lock-out period of 12
months. Following this period of time, eligible Reservists will be able
to reenroll if they so choose.
(3) Member's share of premiums. The cost of the TSRDP monthly
premium will be shared between the Government and the enrollee.
Interested eligible Reservists may contact the dental contactor to
obtain the enrollee premium cost. The member's share may not exceed $25
per month.
(g) Plan benefits. (1) The TSRDP will provide basic dental
coverage, to include diagnostic services, preventive services, basic
restorative services, and emergency oral examinations. The following is
the TSRDP covered dental benefit (using the American Dental
Association, The Council on Dental Care Program's Code On Dental
Procedures and Nomenclature):
(i) Diagnostic: Comprehensive oral evaluation (00150), and Periodic
oral evaluation (00120), Intraoral-complete series (including
bitewings) (00210); Intraoral-periapical-first film (00220); Intraoral-
periapical-each additional film (00230); Bitewings-single film (00272);
Bitewings-two films (00272); Bitewings-four films (00274); Panoramic
film (00330); Pulp Vitality Tests (00460).
(ii) Preventive: Prophylaxis-adult (limit-two per year) (01110);
Tropical application of fluoride (excluding prophylaxis)-adult (01204).
(iii) Restorative: Amalgam-one surface, permanent (02140); Amalgam-
two surfaces, permanent (02150); Amalgam-three surfaces; permanent
(02160); Amalgam-four or more surfaces, permanent (02161); Resin-one
surface, anterior (02330); Resin-two surfaces, anterior (02331); Resin-
three surfaces, anterior (02332); Resin-four or more surfaces or
involving incisal angle (anterior) (02335); Pin retention-per tooth, in
addition to restoration (02951).
(iv) Oral Surgery: Single tooth (07110); Each additional tooth
(07120); Root removal-exposed roots (07130); Surgical removal of
erupted tooth requiring elevation of mucoperiosteal flap and removal of
bone and/or section of tooth (07210); Surgical removal of residual
tooth roots (cutting procedure) (07250).
(v) Emergency: Limited oral evaluation--problem focused (00140);
Palliative (emergency) treatment of dental pain-minor procedures
(09110). (2) Codes listed in paragraph (g)(1) of this section may be
modified by the Director, OCHAMPUS, to the extent determined
appropriate based on developments in common dental care practices and
standard dental insurance programs.
(h) Maximum annual cap. TSRDP enrollees will be subject to a
maximum $1,000.00 of paid allowable charges per year.
(i) Annual notification of rates. TSRDP premiums will be determined
as part of the competitive contracting process. Information on the
premium rates will be widely distributed.
(j) Authorized providers. The TSRDP enrollee may seek covered
services from any provider who is fully licensed and approved to
provide dental care in the state where the provider is located.
(k) Benefit payment. Enrollees are not required to utilize the
special network of dental providers established by the TSRDP
contractor. For enrollees who do use this network, however, providers
shall not balance bill any amount in excess of the maximum payment
allowable by the TSRDP. Enrollees using non-network providers may be
balance billed amounts in excess of allowable charges. The maximum
payment allowable by the TSRDP (minus the appropriate cost-share) will
be the lesser of:
(1) Billed charges; or
(2) Usual, Customary and Reasonable rates, in which the customary
rate is calculated at the 85th percentile of billed charges in that
geographic area, as measured in an undiscounted charge profile in 1995
or later for that geographic area (as defined by three-digit zip code).
(l) Appeal and hearing procedures. All levels of appeals and
grievances established by the Contractor for internal review shall be
exhausted prior to forwarding to OCHAMPUS for a final review.
Procedures comparable to those established under Sec. 199.13(h) of this
part shall apply.
(m) Preemption of State laws. (1) Pursuant to 10 U.S.C. 1103, the
Department of Defense has determined that in the administration of
chapter 55 of title 10, U.S. Code, preemption of State and local laws
relating to health insurance, prepaid health plans, or other health
care delivery or financing methods is necessary to achieve important
Federal interests, including but not limited to the assurance of
uniform national health programs for military families and the
operation of such programs at the lowest possible cost to the
Department of Defense, that have a direct and substantial effect on the
conduct of military affairs and national security policy of the United
States. This determination is applicable to the dental services
contracts that implement this section.
(2) Based on the determination set forth in paragraph (m)(1) of
this section, any State or local law or regulation pertaining to health
or dental insurance, prepaid health or dental plans, or other health or
dental care delivery, administration, and financing methods is
preempted and does not apply in connection with the TRICARE Selected
Reserve Dental Program contract. Any such law, or regulation pursuant
to such law, is without any force or effect, and State or local
governments have no legal authority to enforce them in relation to the
TRICARE Selected Reserve Dental Program contract. (However, the
Department of Defense may, by contract, establish legal obligations on
the part of the TRICARE Selected Reserve Dental Program contractor to
conform with requirements similar to or identical to requirements of
State or local laws or regulations).
(3) The preemption of State and local laws set forth in paragraph
(m)(2) of this section includes State and local laws imposing premium
taxes on health or dental insurance carriers or underwriters or other
plan managers, or similar taxes on such entities. Such laws are laws
relating to health insurance, prepaid health plans, or other health
care delivery or financing methods, within the meaning of section 1103.
Preemption, however, does not apply to taxes, fees, or other payments
on net income or profit realized by such entities in the conduct of
business relating to DoD health services contracts, if those taxes,
fees or other payments are applicable to a broad range of business
activity. For the purposes of assessing the effect of Federal
preemption of State and local taxes and fees in connection with DoD
health and dental services contracts, interpretations shall be
consistent with those applicable to the Federal Employees Health
Benefits Program under 5 U.S.C. 8909(f).
(n) Administration. The Assistant Secretary of Defense (Health
Affairs) or designee may establish other rules and procedures for the
administration of the TRICARE Selected Reserve Dental Program.
[[Page 66992]]
Dated: December 15, 1997.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 97-33108 Filed 12-22-97; 8:45 am]
BILLING CODE 5000-04-M
