[Federal Register Volume 62, Number 95 (Friday, May 16, 1997)]
[Rules and Regulations]
[Pages 26939-26941]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-12871]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]
RIN 0720-AA40


Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS); Selected Reserve Dental Program

AGENCY: Office of the Secretary, DoD.

ACTION: Interim final rule.

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SUMMARY: This interim 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 rule details operation of 
the program and seeks comments on our plan to implement the TRSDP.

DATES: This rule is effective August 1, 1997. Public comments must be 
received by July 15, 1997.

ADDRESSES: TRICARE Support Office (TSO)/Office of the Civilian Health 
and Medical Program of the Uniformed Services (OCHAMPUS), Program 
Development Branch; Aurora, Colorado 80045-6900.

FOR FURTHER INFORMATION CONTACT:
Mr. Gunther J. Zimmerman, Office of the Assistant Secretary of Defense 
(Health Affairs), (703) 695-3331.

SUPPLEMENTARY INFORMATION:

I. Overview of the Proposed 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 amended 
Title 10, U.S.C., by revising the program's start date, requiring the 
program to start during fiscal year 1997 and also to conform to several 
operational requirements. The costs of the program will be shared 
between the enrollee and the government. The statute directs that a 
members enrolling in the program shall pay a share of the premium 
charged for the insurance coverage.
    Dental coverage under the TSRDP will provide basic dental care, to 
include diagnostic services, preventive services, basic restorative 
services, and emergency oral examinations.
    Under this approach, where possible, reservists may make use of 
participating dental providers in their areas and benefit from the 
reduced copayments and provider submission of claims and acceptance of 
contractor allowances and arrangements. TSRDP eligible beneficiaries 
will obtain information concerning the program and the application 
process from the contractor.
    This interim 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. We have made the judgment that preemption is necessary and 
appropriate to assure the operation of a consistent, effective, and 
efficient federal program. In addition, the enacting legislation for 
the TRICARE Selected Reserve Dental Program directs the Department of 
Defense to utilize full and open competition in selecting a contractor 
and to implement this program during fiscal year 1997. Absent 
preemption of certain state and local laws on insurance regulation and 
other matters, competition would be severely limited and the process 
substantially delayed.

II. 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 interim 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).
    The Department is publishing this rule as an interim final rule in 
order to implement the program in a timely manner. Regulations 
involving military affairs are exempt from the notice and comment 
rulemaking procedures of the Administrative Procedures Act. Because 
this rule deals exclusively with a program for the military reserves, 
there is a heightened impact on the conduct of affairs peculiar to 
military functions of the government, and a significant reduced impact 
on the public. Based on this, it is appropriate, as an exemption to our 
normal practice of providing an opportunity for prior public comment on 
all CHAMPUS regulations, to issue this rule as an interim final rule, 
with a subsequent opportunity for public comment. Public comments are 
invited. All comments will be carefully considered. A discussion of the 
major issues received by public comments will be included with the 
issuance of the permanent final rule, anticipated approximately 90 days 
after the end of the comment period.

[[Page 26940]]

List of Subjects in 32 CFR Part 199

    Claims, Handicapped, Health insurance, Military personnel.

    Accordingly, 32 CFR Part 199 is amended as follows:
    1. The authority citation for part 199 continues to read as 
follows:

    Authority: 10 U.S.C., Chapter 55.5 U.S.C. 301.
    2. Part 199 is amended by adding Sec. 199.21, 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. Benefits are limited to preventive, restorative and 
emergency care. Premium costs for this coverage will be shared by the 
enrollee and the government.
    (b) General provisions. The TSRDP is authorized by 10 U.S.C. 1076b.
    (c) Definitions. Except as may be specifically provided in this 
section, to the extent terms defined in Secs. 199.2 and 199.13(b) are 
relevant to the administration of the TRICARE Selected Reserved Dental 
Program, the definitions contained in those sections 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.
    (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 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 lock-out period of 12 months. 
Following this period of time, eligible reservists will be able to 
enroll 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 contractor to 
obtain the enrollee premium cost. The members's share may not exceed 
$25 per month.
    (g) Plan Benefits. 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):
    (1) Diagnostic: Comprehensive oral examination (00150), and 
Periodic oral examination (00120), Intraoral-complete series (including 
bitewings) (00210); Intraoral-periapical-first film (00220); Intraoral-
periapical-each additional film (00230); Bitewings-single film (00270); 
Bitewings-two films (00272); Bitewings-four films (00274); Panoramic 
film (00330; Pulp Vitality Tests (00460).
    (2) Preventive: Prophylaxis-adult (limit--two per year) (01110); 
Topical application of fluoride (excluding prophylaxis)--adult (01204).
    (3) 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).
    (4) Oral Surgery: Single tooth (07110); Each additional tooth 
(07120); Root removal-exposed roots (07130); Surgical removal of 
erupted tooth requiring evaluation of mucoperiosteal flap and removal 
of bone and/or section of tooth (07210); Surgical removal of residual 
tooth roots (cutting procedure) (07250).
    (5) Emergency: Emergency oral examination (00130); Palliative 
(emergency) treatment of dental pain-minor procedures (09110).
    (h) Maximum Annual Cap. TSRDP enrollees will be subject to a 
maximum $1,000.00 of paid allowable charges per year.
    (i) Annual Review of Rates. TSRDP premiums will be determined as 
part of the competitive contracting process. The contractor will 
annually notify eligible reservists of the TSRDP premium rates.
    (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 
balanced billed such as amount. 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) shall 
apply.
    (m) Preemption of State Laws. Pursuant to 10 U.S.C. 1103, any state 
or local law or regulation relating 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 or identical to

[[Page 26941]]

requirements of State or local laws or regulations.)
    (n) Director, OCHAMPUS. The Director, OCHAMPUS, may establish other 
rules and procedures for the administration of the TRICARE Selected 
Reserve Dental Program.

    Dated: May 12, 1997.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 97-12871 Filed 5-15-97; 8:45 am]
BILLING CODE 5000-04-M