[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