[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