[Federal Register Volume 62, Number 121 (Tuesday, June 24, 1997)]
[Proposed Rules]
[Pages 34032-34035]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-16406]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
RIN 0720-AA38
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); TRICARE Retiree Dental Program
AGENCY: Office of the Secretary, DoD.
ACTION: Proposed rule.
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SUMMARY: This proposed rule establishes the TRICARE Retiree Dental
Program (TRDP) to provide dental care to military members entitled to
retired pay and eligible family members and their dependents. The rule
details operation of the program and seeks comments on our plan to
implement the TRDP.
DATES: Comments must be received on or before July 24, 1997.
ADDRESSES: Office of Health Services Financing Policy, 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 Proposed Rule
Implementation of the TRICARE Retire Dental Program (TRDP) was
directed by Congress in section 703 of the National Defense
Authorization Act for Fiscal year 1997, Pub. L. 104-201, which amended
title 10, United States Code, by adding section 1076c. This law
directed the implementation of a dental program for: (1) Members of the
Armed Forces who are entitled to retired pay, (2) Members of the
Retired Reserve under the age of 60, (3) Eligible dependents of (1) or
(2) who are covered by the enrollment of the member, and (4) The
unremarried surviving spouse and eligible child dependents of a
deceased member who dies while in status described in (1) or (2), or
the unremarried surviving spouse and eligible child dependents who
receive a surviving spouse annuity.
Included in the program are the 50 United States and the District
of Columbia, Canada, Puerto Rico, Guam and the U.S. Virgin Islands.
Enrollment in the program is voluntary and members enrolled in the
dental plan will be responsible for paying the full cost of the
premiums. The premium payment may be collected pursuant to procedures
established by the Assistant Secretary of Defense (Health Affairs).
Dental coverage under the TRDP will provide basic dental care, to
include diagnostic services, preventive services, basic restorative
services (including endodontics), surgical services, and emergency oral
examinations.
Under this approach, where possible, members entitled to retired
pay and eligible family members and their dependents 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. TRDP eligibles
will obtain information concerning the program and the application
process from the contractor.
This proposed 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 Retiree Dental Program directs the Department of Defense to
implement this program by October 1, 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.
Pursuant to the Paperwork Reduction Act of 1995, the reporting and
recordkeeping of this proposed rule have been submitted to the OMB for
review under 3507(d) of the Act.
In compliance with section 3506(c)(2)(A) of the Paperwork Reduction
Act of 1995, the Office of the Assistant Secretary of Defense for
Health Affairs announces a proposed information collection and seeks
public comment on the provision thereof. Comments are invited on: (a)
Whether the proposed collection is necessary for the proper performance
of the functions of the agency, including whether the information shall
have practical utility; (b) the accuracy of the agency's estimate of
the burden of the proposed information collection; (c) ways to enhance
quality, utility, and clarity of the information to be collected; and
(d) ways to minimize the burden of the information collection on
respondents, including through the use of automated collection
techniques or other forms of information technology.
The collection of information is necessary to enroll military
members entitled to retired pay and eligible dependents in the TRICARE
Retiree Dental Program. The application will allow the Department of
Defense to identify enrollment applicants, evaluate their eligibility
for the enrollment, and determine other health insurance coverage which
an applicant may have.
Affected Public: Eligible family members and their dependents.
Annual Burden Hours: 71,640.
Number of Respondents: 286,570.
Responses Per Respondent: 1.
Average Burden Per Response: 15 minutes.
Frequency: Once, at time of initial application.
Respondents are military members entitled to retired pay and
eligible family members and their dependents who are seeking enrollment
in the TRICARE Retiree Dental Program. The enrollment application will
allow the Department to collect the information necessary to properly
identify the program's applicants and to determine their eligibility
for enrollment in the TRICARE Retiree Dental Program. In completing and
signing a TRICARE Retiree Dental Program enrollment form, applicants
will acknowledge that they understand the benefits offered under
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the program and the rules they must follow to continue their
participation in the program. Initial enrollment will be for a period
of 12 months followed by month-to-month enrollment as long as the
enrollee chooses to continue enrollment.
Comments on these requirements should be submitted to the Office of
Information and Regulatory Affairs, OMB, 715 17th Street NW.,
Washington, DC 20503, marked ``Attention Desk Officer for Department of
Defense.'' Copies should be sent to the Office of the Assistant
Secretary of Defense (Health Affairs), 1B657 The Pentagon, Washington,
DC 20301, ATTN: Cynthia Speight. When the Department of Defense
promulgates the Final Rule, the Department will respond to comments by
OMB or the public regarding the information collection provisions and
recordkeeping requirements of the rule.
This is a proposed rule. The Department is making an exception to
the normal 60 day public comment period due to the statutory
requirement for implementation by October 1, 1997. Public comments are
invited. All comments will be considered. A discussion of the major
issues received by public comments will be included with issuance of
the final rule, anticipated approximately 90 days after the end of the
comment period.
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, and Military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
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 proposed to be amended by adding Sec. 199.22, as
follows:
Sec. 199.22 TRICARE Retiree Dental Program (TRDP).
(a) Purpose. The TRDP is a premium based indemnity dental insurance
coverage program that will be available to retired members of the Armed
Forces, their dependents, and certain other beneficiaries, as specified
in paragraph (d) of this section. The TRDP is authorized by 10 U.S.C.
1076c.
(b) General provisions. (1) Benefits are limited to diagnostic
services, preventive services, basic restorative services (including
endodontics), surgical services, and emergency oral examinations, as
specified in paragraph (f) of this section.
(2) Premium costs for this coverage will be paid by the enrollee.
(3) The program is applicable to authorized providers in the 50
United States and the District of Columbia, Canada, 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 TRDP
is administered in a manner similar to the Active Duty Dependents
Dental Plan under Sec. 199.13.
(5) The TRDP 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) are
relevant to the administration of the TRICARE Retiree Dental Program,
the definitions contained in those sections shall apply to the TRDP as
they do to CHAMPUS and the TRICARE active duty dependents dental plan.
(d) Eligibility and enrollment.--(1) Eligibility. Enrollment in the
TRICARE Retiree Dental Program is open to:
(i) Members of the Armed Forces who are entitled to retired pay,
(ii) Members of the Retired Reserve under the age of 60,
(iii) Eligible dependents of paragraph (d)(1)(i) or (ii) of this
section who are covered by the enrollment of the member, and
(iv) The unremarried surviving spouse and eligible child dependents
of a deceased member who dies while in status described in paragraph
(d)(1) (i) or (ii) of this section, or the unremarried surviving spouse
and eligible child dependents who receive a surviving spouse annuity.
(2) Notification of eligibility. The contractor will notify persons
eligible to receive dental benefits under the TRICARE Retiree Dental
Program.
(3) Election of coverage. Following this notification, interested
members entitled to retired pay and eligible family members and their
dependents may elect to enroll. In order to obtain dental coverage,
written election by the eligible beneficiary must be made.
(4) Enrollment. Enrollment in the TRICARE Retiree Dental Program is
voluntary and will be accomplished by submission of an application to
the TRDP 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 Retiree Dental Program coverage is
terminated when the member's entitlement to retired pay is terminated,
the member's status as a member of the Retired Reserve is terminated, a
dependent child loses eligible child dependent status, or in the case
of remarriage of the surviving spouse.
(6) Continuation of dependents' enrollment upon death of enrollee.
Coverage of a dependent in the TRDP under an enrollment of a member or
surviving spouse who dies during the period of enrollment shall
continue until the end of that period and may be renewed by (or for)
the dependent, so long as the premium paid is sufficient to cover
continuation of the dependent's enrollment. The Secretary may terminate
coverage of the dependent when the premiums paid are no longer
sufficient to cover continuation of the enrollment.
(e) Premium payments. Persons enrolled in the dental plan will be
responsible for paying the full cost of the premiums 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) or designee.
(2) Effects of failure to make premium payments. Failure to make
monthly renewal premium payments will result in the enrollee's
disenrollment from the TRDP and subject to a lock-out period of 12
months. Following this period of time, persons eligible will be able to
reenroll if they so choose.
(3) Member's payment of premiums. The cost of the TRDP monthly
premium will be paid by the enrollee. Interested beneficiaries may
contact the dental contractor/insurer to obtain the enrollee premium
cost.
(f) Plan benefits. The TRDP will provide basic dental care, to
include diagnostic services, preventive services, basic restorative
services (including endodontics), surgical services, and emergency oral
examinations. The following is the TRDP covered dental benefit (using
the American Dental Association, The Council on Dental Care Program's
Code On Dental Procedures and Nomenclature):
(i) Diagnostic: Periodic oral examination (00120); Comprehensive
oral examination (limited to one exam per year in the same dental
office) (00150), Intraoral-complete series (including bitewings)
(00210); Intraoral-periapical-first film (00220); Intraoral-periapial-
each additional film (00230); Intraoral-occlusal film (00240);
Bitewings-single film (00270); Bitewings-two films (00272); Bitewings-
four films (00274); Panoramic film (00330); Caries susceptibility
tests, by report (00425); Pulp vitality tests (00460).
(ii) Preventive: Prophylaxis-adult (limit-once per year) (01110);
Prophylaxis-child (01120); Topical application of fluoride (excluding
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prophylaxis)-child (01203); Topical application of fluoride (excluding
prophylaxis)-adult, by report, once per year (01204); Sealant-per tooth
(01351); Space maintainer-fixed-unilateral (01510); Space maintainer-
fixed-bilateral (01515); Space maintainer-removable-unilateral (01520);
Space maintainer-removable-bilateral (01525); Recementation of space
maintainer (01550).
(iii) Restorative: Amalgam-one surface, primary (02110); Amalgam-
two surfaces, primary (02120); Amalgam-three surfaces, primary (02130);
Amalgam-four or more surfaces, primary (02131); 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); Recement inlay
(02910); Recement crown (02920); Prefabricated stainless steel crown-
primary tooth (02930); Prefabricated stainless steel crown-permanent
tooth (02931); Prefabricated resin crown (02932); Prefabricated
stainless steel crown with resin window (02933); Pin retention-per
tooth, in addition to restoration (02951); Temporary crown (fractured
tooth) (02970).
(iv) Endodontic: Pulp cap-indirect (excluding final restoration
(03120); Therapeutic pulpotomy (excluding final restoration) (03220);
Anterior root canal (excluding final restoration) (03310); Bicuspid
root canal (excluding final restoration) (03320); Molar root canal
(Excluding final restoration) (03330); Retreatment-anterior, by report
(03346); Retreatment-bicuspid, by report (03347); Retreatment-molar, by
report (03348); Apexification/recalcification-initial visit (apical
closure/calcific repair of perforations, root resorption, etc.)
(03351); Apexification/recalcification-interim medication replacement
(apical closure/calcific repair of performations, root resorption,
etc.) (03352); Apexification/recalcification-final visit (includes
completed root canal therapy-apical closure/calcific repair of
perforations, root resorption, etc.) (03353); Apicoectomy/Periradicular
surgery-anterior (03410); Apicoectomy/Periradicular surgery-bicuspid
(first root) (03421); Apicoectomy/Periradicular surgery-molar (first
root) (03425); Apicoectomy/Periradicular surgery (each additional root)
(03426); Retrograde filling-per root (03430); Root amputation-per root
(03450); Hemisection (including any root removal), not including root
canal therapy (03920).
(v) Periodontic: Gingivectomy or gingivoplasty--per quadrant
(04210); Gingivectomy or gingivoplasty--per tooth (04211); Gingival
curettage, surgical, per quadrant, by report (04220); Gingival flap
procedure, including root planing--per quadrant (04240); Mucogingival
surgery--per quadrant (04250); Osseous surgery (including flap entry
and closure)--per quadrant (04260); Bone replacement graft--single site
(including flap entry and closure) (04261); Bone replacement graft--
multiple sites (including flap entry and closure) (04262); Guided
tissue regeneration (includes the surgery and reentry) (04268); Pedicle
soft tissue graft procedure (04270); Free soft tissue graft procedure
(including donor site) (04271); Periodontal scaling and root planing--
per quadrant (04341); Periodontal maintenance procedures (following
active therapy) (04910); Unscheduled dressing change (by someone other
than treating dentist) (04920).
(vi) Oral Surgery: Single tooth (07110); Each additional tooth
(07120); Root removal--exposed roots (07130); Surgical removal or
erupted tooth requiring elevation of mucoperiosteal flap and removal of
bone and/or section of tooth (07210); Removal of impacted tooth--soft
tissue (07220); Removal of impacted tooth--partially bony (07230);
Removal of impacted tooth--completely bony (07240); Surgical removal of
residual tooth roots (cutting procedure) (07250); Oral antral fistula
closure (07260); Tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth and/or alveolus (07270);
Surgical exposure of impacted or erupted tooth to aid eruption (07281);
Biopsy of oral tissue--hard (07285); Biopsy of oral tissue--soft
(07286); Surgical repositioning of teeth (07290); Alveoloplasty in
conjunction with extractions--per quadrant (07310); Suture of recent
small wounds up to 5 cm (07910); Complicated suture--up to 5 cm
(07911); Complicated suture--greater than 5 cm (07912); Excision of
pericoronal gingiva (07971).
(vii) Emergency: Emergency oral examination (00130); Palliative
(emergency) treatment of dental pain--minor procedures (09110).
(viii) Drugs: Therapeutic drug injection, by report (09610); Other
drugs and/or medications, by report (09630).
(ix) Postsurgical: Treatment of complications (post-surgical)
unusual circumstances, by report (09930).
(g) Maximum annual cap. TRDP enrollees will be subject to a maximum
cap of $1,000.00 of paid allowable charges per enrollee per year, with
the exception of the diagnostic and preventive services.
(h) Annual review of rates. TRDP premiums will be determined as
part of the competitive contracting process. The contractor will
annually notify those eligible for TRDP of the premium rates.
(i) Authorized providers. The TRDP 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.
(j) Benefit payment. Enrollees are not required to utilize the
special network of dental providers established by the TRDP contractor.
For enrollees who do not use these network providers, however,
providers shall not balance bill any amount in excess of the maximum
payment allowable by the TRDP. Enrollees using non-network providers
may be balance billed such an amount. The maximum payment allowable by
the TRDP (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).
(k) 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.
(l) Preemption of State laws. Pursuant to 10 U.S.C., section 1103,
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 Retiree 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 Retiree Dental
Program contract. (However, the Department of Defense may, by contract,
establish legal obligations on the part of the TRICARE Retiree Dental
Program contractor to conform with requirements similar to or identical
to requirements of State or local laws or regulations).
(m) Administration. The Assistant Secretary of Defense (Health
Affairs) or designee may establish other rules and
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procedures for the administration of the TRICARE Retiree Dental
Program.
Dated: June 18, 1997.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 97-16406 Filed 6-23-97; 8:45 am]
BILLING CODE 5000-04-M