[Federal Register Volume 64, Number 226 (Wednesday, November 24, 1999)]
[Proposed Rules]
[Pages 66126-66139]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-30072]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); TRICARE Family Member Dental Plan
AGENCY: Office of the Secretary, DoD.
ACTION: Proposed rule.
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SUMMARY: This proposed rule revises the comprehensive CHAMPUS
regulation pertaining to the Expanded Active Duty Dependents Benefit
Plan. The new plan, and this proposed rule: places the responsibility
for TRICARE Family Member Dental Plan (TFMDP) enrollment and a large
portion of the appeals program on the dental plan contractor; allows
the dental plan contractor to bill eligible dependents for plan
premiums in certain circumstances; reduces the enrollment period from
24 to 12 months; excludes Reserve component members ordered to active
duty in support of a contingency operation from the mandatory 12 month
enrollment; simplifies enrollment types and exceptions; reduces cost-
shares for certain enlisted grades; adds anesthesia as a covered
benefit; incorporates legislative authority for calculating the method
by which premiums may be raised and allowing premium reductions for
certain enlisted grades; and reduces administrative burden by reducing
redundant language, referencing language appearing in other CFR
sections and removing language more appropriate to the actual contract.
These improvements will provide Uniformed Service families with
numerous quality of life benefits that will improve participation in
the plan, significantly reduce enrollment errors and positively effect
utilization of this important dental plan.
DATES: Comments must be received by December 27, 1999.
ADDRESSES: Address all comments concerning this proposed rule to
TRICARE Management Activity/Special Contract Operations Branch, 16401
East Centretech Parkway, Aurora, CO 80011-9043.
FOR FURTHER INFORMATION CONTACT: Lt Col Brian W. Grassi, 303-676-3496.
SUPPLEMENTARY INFORMATION:
I. Background and Legislative Changes
The Basic Active Duty Dependents Dental Benefit Plan was
implemented on August 1, 1987, allowing military personnel to
voluntarily enroll their dependents in a basic dental health care plan.
Under this plan, DoD shared the cost of the premium with the active
duty service member. Although the plan was viewed as a major step in
benefit enhancement for military families, 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 Uniformed Service family.
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, Public Law 102-484,
sec. 701). The provisions of this Act specified the expended benefit
structure, as well as maximum monthly premiums for enrollees. 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 this Act were implemented
on April 1, 1993.
[[Page 66127]]
Thereafter, Congress granted legislative authority to allow the
Secretary of Defense to expand the dental plan outside the United
States and to provide one year of continued dental coverage for
enrolled beneficiaries to service members who die while on active duty
(The Defense Authorization Act, Public Law 103-337, sec. 703). In
addition, the Congress granted subsequent legislative authority to
allow the Secretary of Defense to waive or reduce the cost-shares in
overseas locations (The Defense Authorization Act, Public Law 105-85,
sec. 732).
In Fiscal Year 1999, the Congress authorized a methodology by which
the enrollee's share of the premium could be increased. This
methodology is tied to the lesser of the percent increase in the basic
pay of active duty service members or the basic pay for statutory pay
systems plus one-half percent. In authorizing language, the Secretary
of Defense could apply this premium increase methodology as if it had
been in place continuously since December 31, 1993. To allow for an
expanded and more comprehensive benefit, the Department will apply this
premium increase methodology as authorized. The language further
instructed the Secretary of Defense to advise the Congress of any plans
to reduce dental plan benefits and to wait one year, after
notification, before any benefits could be reduced (The Defense
Authorization Act, Public Law 105-261, sec. 701).
The legislative provisions have been codified in 10 U.S.C. Chapter
55, sec. 1076a, Dependents Dental Program, and are reflected in the
regulatory provisions of this rule.
II. Programmatic Improvements
The below programmatic improvements will be effective once the
follow-on TFMDP contract has been awarded and the performance period
has begun. At the present time, the performance period is expected to
begin on February 1, 2001.
A. Contractor Enrollment
Since the plan began, the Uniformed Services have administered the
dental plan enrollment, disenrollment and eligibility determination
functions. The complexities of the dental plan combined with a high
turnover rate of relatively inexperienced Service personnel and other
competing responsibilities, separate Service procedures, databases and
data transfer processes, high cost and lengthy delays in software
modifications, and Uniformed Service personnel downsizing, created the
need for a centralized and uniform enrollment process. This can be best
achieved by an experienced dental plan contractor and will allow active
duty service members to contact one organization to enroll, disenroll,
re-enroll and discuss other TFMDP benefit and claims adjudication
issues. By allowing the contractor to administer the enrollment
function across all of the Uniformed Services, enrollment becomes
portable whereas the current system does not allow an active duty
member from one Service to enroll through a separate Service.
Contractor enrollment will also simplify the payroll deduction and
eligibility determination process and reduce the possibility of waste
and abuse at the local level. In addition, it maintains a stable,
trained work force at the front end of the TFMDP and greatly improves
customer service.
An added benefit to contractor enrollment will be the elimination
of the current required Uniformed Service enrollment forms. The complex
DD Form 2494, Active Duty Dependent Dental Plan Enrollment Form, and
the DD Form 2494-1, Supplemental Active Duty Dependent Dental Plan
Enrollment Form, will no longer be needed and will be replaced by a
standard, simplified contractor enrollment form as well as telephonic
and fax enrollment options.
Contractor enrollment has proven to be a success with the TRICARE
Managed Care Support contractors as well as with contracted enrollment
via the TRICARE Selected Reserve Dental Program and the Tricare Retiree
Dental Program. The Uniformed Services will continue, as with the
former dental plan and current TRICARE/CHAMPUS programs, to determine
eligibility for the dental plan and process any changes regarding
eligibility through the Defense Enrollment Eligibility Reporting System
(DEERS).
B. Contractor Direct Billing
The dental plan is financed through premiums jointly paid by the
Government and the active duty service member. The active duty service
member's share of the premiums is deducted from their payroll accounts.
In certain situations, otherwise eligible dependents are precluded from
enrolling in the dental plan if their sponsor does not have an active
payroll account nor has insufficient funds in that account. These
eligible dependents include dependents of incarcerated sponsors and
survivors. By allowing the contractor to directly bill these dependents
for their premium share, dependents previously excluded from enrollment
can now receive coverage. This improvement eliminates a previous
enrollment termination provision in the regulation where eligibility
for basic pay was a deciding criterion for continued enrollment in the
dental plan.
C. Reduction in Mandatory Enrollment Period
A mandatory enrollment period is an essential factor behind
Government and contractor actuarial estimates in developing the TFMDP
premium and provides a guarantee to the contracting community that they
will collect a certain amount of premiums for the potential benefit
payout. The proposed regulation reduces the previous longstanding 24-
month mandatory enrollment period to 12 months since this 24-month
period precluded numerous, otherwise eligible, dependents from
enrolling in the dental plan. These eligible dependents include those
that are near the end of their active service and have new eligible
dependents, enlisted service members who are outside of their re-
enlistment window of opportunity, and Reserve/Guard personnel called to
active duty for less than 24 months (such as Reserve/Guard personnel on
active duty for training and special assignments). Reduction to a 12-
month enrollment period for the TFMDP has a precedent with other
TRICARE plans, to include the TRICARE Managed Care Prime option and the
Tricare Selected Reserve Dental Program. By introducing this more
liberal enrollment period, the proposed regulation also calls for a 12-
month ``lock-out'' if the active duty service member disenrolls before
completing the 12-month enrollment period or if the active duty service
member fails to pay their premiums. A 12-month lock-out period also
applies to a Reserve component member who disenrolls before completing
the special mandatory enrollment period for Reserve component members
ordered to active duty in support of a contingency operation. This
``lock-out'' period has a precedent with other commercial dental
insurance plans as well as the TRICARE Managed Care Prime option, the
TRICARE Selected Reserve Dental Program and the TRICARE Retiree Dental
Program. ``Lock-out'' periods also discourage potential beneficiaries
from enrolling in an insurance plan, receiving all of their benefit in
a few months and then disenrolling without paying a full 12 months'
worth of premiums.
Beneficiaries enrolled in the current dental plan at the time when
TFMDP coverage begins must complete their two (2) year enrollment
period established under that superceded plan except if one of the
conditions for valid disenrollment applies. Once this
[[Page 66128]]
original two (2) year enrollment period is met, the active duty member
may continue TFMDP enrollment on a month-to-month basis. A new one (1)
year enrollment period will only be incurred if the active duty member
disenrolls and attempts to re-enroll in the TFMDP at a later date.
D. Enrollment Period for Certain Reserve Component Sponsors
The proposed regulation provides that the 12-month enrollment
period shall not apply to eligible dependents of Reserve component
sponsors ordered to active duty for more than 30 days but less than 12
months (other than for training) in support of a contingency operation
as defined in 10 U.S.C. sec. 101(a)(13). Orders may be issued under
statutory authorities for recalling Reserve component members to active
duty, but must specify that the member is serving in support of a
specific contingency operation under the statutory definition. This
disparate treatment for certain Reserve component members is necessary
because of the involuntary nature of their call to active duty and
statutory limitations on their periods of active duty.
By contrast, active duty members are enlisted, reenlisted or
commissioned for periods of active duty longer than one year. The
active duty member has the option to enroll eligible dependents at any
time during that period of active duty prior to the last 12 months of
service, and at a relatively constant premium cost. Similarly, other
Reserve component members generally volunteer for call to active duty
and serve for at least one year; therefore they will have the option to
enroll family members at any time other than in the last 12 months of
that service.
However Reserve component members ordered to active duty in support
of a contingency operation are normally limited by statute to a period
of active duty of 9 months or less. While 38 U.S.C. Chapter 43 provides
that a Reserve component member who has coverage under a civilian
employer sponsored dental program may elect to continue that coverage
during a period of active duty, for up to 18 months; if serving for
more than 30 days, the member may be required to pay the full premium
cost with employer cost-sharing no longer required. Upon release from
active duty, 38 U.S.C. Chapter 43, provides that the Reserve component
member may be reinstated in his or her civilian employer sponsored
program without a waiting period. Without an exception to the mandatory
12 month enrollment period for TFMDP, members who cannot afford to pay
the full premium for continuing their civilian plan would be unable to
provide dental insurance coverage for their family members while on
active duty. This exclusion to the 12-month enrollment period is
therefore necessary to preclude such prejudicial treatment of Reserve
component members ordered to active duty for less than 12 months to
support a contingency operation. In its place, a separate enrollment
period is created for the Reserve component member.
E. Reduction in Cost-Shares for Certain Enlisted Pay Grades
Although certain cost-shares are mandated by law, the Secretary of
Defense has the prerogative to adjust cost-shares for certain types of
dental procedures. Available data shows that our lower-paid enlisted
families are reluctant to pursue specialized dental care because of the
amount of their cost-share. To allow greater participation and dental
benefit utilization among our younger enlisted families, this proposed
regulation would have a two-tiered maximum cost-share dependent on the
active duty service member's pay grade. With the rates below, this
reduction for enlisted service members does not have a measurable
effect on the overall premium.
[In percent]
------------------------------------------------------------------------
Cost-share for
pay grades E- Cost-share for
Covered services 1, E-2, E-3 all other pay
and E-4 grades
------------------------------------------------------------------------
Diagnostic.............................. 0 0
Preventive, except Sealants............. 0 0
Emergency Services...................... 0 0
Sealants................................ 20 20
Professional Consultations.............. 20 20
Professional Visits..................... 20 20
Post Surgical Services.................. 20 20
Basic Restorative (example: amalgams, 20 20
resins, stainless steel crowns)........
Endodontic.............................. 30 40
Periodontic............................. 30 40
Oral and Maxillofacial Surgery.......... 30 40
General Anesthesia...................... 40 40
Intravenous Sedation.................... 50 50
Other Restorative (example: crowns, 50 50
onlays, casts).........................
Prosthodontic........................... 50 50
Medications............................. 50 50
Orthodontic............................. 50 50
Miscellaneous Services.................. 50 50
------------------------------------------------------------------------
A reduction in cost shares has been chosen over a reduction in
premium rates for enlisted service members in these pay grades because
the premium rates have traditionally been affordable as compared to
similar dental benefits programs administered by commercial dental
insurance plans and given the fact that the Government pays 60 percent
of the total premium. As such, the greatest effect on participation and
utilization can best be achieved through a reduction in cost-shares.
F. Simplification on Enrollment Options
Under the proposed rule, TFMDP enrollment options have been
simplified to assist the beneficiary, Government, provider of care and
the dental plan contractor. Under the prior dental plan, dependents
were asked to choose from several different enrollment options
[[Page 66129]]
depending on whether they had children under the age of 4. With the
advances in pediatric dentistry (pedodontics), dental care for children
between the ages of 1 and 4 is highly recommended. As such, the dental
plan contractor will offer sponsors the opportunity to enroll these
particular dependents when eligibility information indicates a
dependent is 1 year of age or older. Although there will continue to be
two separate premiums, a ``single'' premium for one covered life and a
``family'' premium for more than one covered life, providing additional
exceptions to this rule based on age will advance pediatric care among
our beneficiary population, simplify enrollment processing by the
dental plan contractor and promote greater understanding of enrollment
options by all parties.
G. Addition of Anesthesia Services
Local anesthesia, in conjunction with other covered dental
procedures, is considered integral to the procedure itself and has been
covered for several years. Other anesthesia services were historically
excluded due to their high cost. The proposed regulation allows the
Department to add other types of anesthesia services to the TFMDP
benefit package.
H. Appeals Plan
Under the TFMDP, the Department wishes to procure a responsive,
simple, and two (or greater) tiered appeals program within the dental
plan contractor's operation. We have had similar success with this
approach under the TRICARE Selected Reserve Dental Program and the
TRICARE Retiree Dental Program, where the contractors administer the
first two levels of the appeals program, which are termed the initial
determination and the reconsideration. Under the TFMDP, the appealing
parties would appeal adverse decisions through the contractor's
established appeal process where separate parties would perform the
initial determination and reconsideration reviews (whether internal or
external to the organization). the final level of review would be, as
before, to the Department, subscribing to guidelines under the Formal
Review and Hearing procedures listed in 32 CFR 199.10.
I. Plan Transition
The programmatic improvements are scheduled to take effect when the
follow-on TFMDP contract to the current Expanded Active Duty Dependents
Dental Plan contract is awarded and the performance period begins.
Considering the magnitude of the planned improvements, the Department
plans to ``phase-out'' operations under the former contractor and
method of operation to accommodate late claims processing and to allow
the Uniformed Services time to process retroactive enrollment and
coverage information to assist our beneficiaries. This ``phase-out''
schedule will be jointly determined between the Department and the
outgoing and incoming dental plan contractors.
III. Administrative Changes
The proposed regulation incorporates several administrative
changes. There is revised language on Federal preemption of State and
local laws that conforms the dental regulation language to reflect the
Department's previous exercise of statutory authority in this area.
Other changes include: widespread publication of premium rates;
allowing the Department to modify the benefit package based on
developments in common dental care practices and standard dental
insurance plans; permitting the dental plan contractor to pay ``by
report'' procedures by providing an additional allowance to the primary
covered procedure; removing detailed descriptions of types of
authorized providers in favor of more general language; updating dental
terminology to be consistent with the American Dental Association's
Council on Dental Care Program's Code on Dental Procedures and
Nomenclature; and, reorganizing and adding language on the maximum
amount payable by the TFMDP.
The proposed regulation incorporates plan name and other changes to
reflect current terminology, such as outdated references to the former
TRICARE Management Activity address, ``Active Duty Dependent Dental
Plan'' and superceded regulations. It also reduces redundant language
and reduces the overall size of the regulation through cross-references
to applicable language appearing in other CFR sections. This includes
references to appeals, fraud and abuse, eligibility, and adjunctive
dental care as well as information on the former dental plans. Items
that are more appropriate for inclusion in the actual contract
statement of work have also been removed and transferred to that
document. This includes equality of benefit processing, coordination of
benefits, participating provider lists, Government review of billing
practices, and how a Dental Explanation of Benefits should be
structured. Finally, the regulation has been reorganized for better
flow, ease of reading and understanding.
IV. Costs
The changes in the proposed regulation coincide with the upcoming
recompetition of the TFMDP contract. As such, the Department plans to
include these requirements in the request for proposal. By relaxing or
eliminating some current contractual requirements and adding a greater
number of eligible dependents, we anticipate that costs for the
programmatic improvements can be met through contractor internal
efficiencies and the competitive nature of the bid process and will
result in affordable premiums comparable to what dental plan enrollees
presently pay.
V. Regulatory Procedures
Executive Order 12866 requires certain regulatory assessments for
any ``significant regulatory action'' defined as one that 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 proposed rule is not a significant regulatory action under
Executive Order 12866. The changes set forth in this proposed rule are
minor revisions to the existing regulation. Since this proposed rule
does not impose information collection requirements, 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. Chapter
35).
List of Subjects in 32 CFR Part 199
Administrative practice and procedure, Claims, Dental health,
Fraud, Health care, Health insurance, Individuals with disabilities,
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 revised to read as follows:
[[Page 66130]]
Sec. 199.13 TRICARE Family Member Dental Plan.
(a) General provisions--(1) Purpose. This section prescribes
guidelines and policies for the delivery and administration of the
TRICARE Family Member Dental Plan (TFMDP) of the Uniformed Service of
the Army, the Navy, the Air Force, the Marine Corps, the Coast Guard,
the Commissioned Corps of the U.S. Public Health Service (USPHS) and
the Commissioned Corps of the National Oceanic and Atmospheric
Administration (NOAA). The TFMDP is a premium based indemnity dental
insurance coverage plan that is available to specified categories of
individuals who are qualified for these benefits by virtue of their
relationship to one of the seven Uniformed Services and their voluntary
decision to accept enrollment in the plan and cost share (when
applicable) with the Government in the premium cost of the benefits.
The TFMDP is authorized by 10 U.S.C. 1076a, Dependents' Dental Program,
and this section was previously titled the ``Active Duty Dependents
Dental Plan''.
(2) Applicability--(i) Geographic scope. (A) The TFMDP is
applicable geographically within the 50 States of the United States,
the District of Columbia, the Commonwealth of Puerto Rico, Guam, and
the U.S. Virgin Islands. These areas are collectively referred to as
the ``CONUS (or Continental United States) service area''.
(B) Extension of the TFMDP to areas outside the CONUS service area.
In accordance with the authority cited in 10 U.S.C. 1076a(h), the
Assistant Secretary of Defense (Health Affairs) (ASD(HA)) may extend
the TFMDP to areas other than those areas specified in paragraph
(a)(2)(i)(A) of this section for the eligible dependents of active duty
members of the Uniformed Services. These areas are collectively
referred to as the ``OCONUS (or outside the Continental United States)
service area''. In extending the TFMDP outside the CONUS service area,
the ASD(HA), or designee, is authorized to establish program elements,
methods of administration and payment rates and procedures to providers
that are different from those in effect for the CONUS service area to
the extent the ASD(HA), or designee, determines necessary for the
effective and efficient operation of the TFMDP. This includes
provisions for preauthorization of care if the needed services are not
available in a Uniformed Service overseas dental treatment facility and
payment by the Department of certain cost-shares (or co-payments) and
other portions of a provider's billed charges. Other difference may
occur based on limitations in the availability and capabilities of the
Uniformed Service overseas dental treatment facility and a particular
nation's civilian sector providers in certain areas. These differences
include varying licensure and certification requirements of OCONUS
providers, Uniformed Service provider selection criteria and local
results of provider selection, referral, beneficiary pre-authorization
and marketing procedures, and care for beneficiaries residing in
distant areas. The Director, Office of Civilian Health and Medical
Program of the Uniformed Services (OCHAMPUS) shall issue guidance, as
necessary, to implement the provisions of this paragraph (a)(2)(i)(B).
Beneficiaries will be eligible for the same TFMDP benefits in the
OCONUS service area although services may not be available or
accessible in all OCONUS countries.
(ii) Agency. The provisions of this section apply throughout the
Department of Defense (DoD), the United States Coast Guard, the USPHS
and NOAA.
(iii) 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, beneficiaries enrolled in the TFMDP may not obtain those
services that are benefits of the TFMDP in military dental care
facilities, as long as those covered benefits are available for cost-
sharing under the TFMDP. Enrolled beneficiaries may continue to obtain
noncovered services from military dental care facilities subject to the
provisions for space available care.
(3) Authority and responsibility--(i) Legislative authority-- (A)
Joint regulations. 10 U.S.C. 1076a authorizes the Secretary of Defense,
in consultation with the Secretary of Health and Human Services, and
the Secretary of Transportation, to prescribe regulations for the
administration of the TFMDP.
(B) Administration. 10 U.S.C. 1073 authorizes the Secretary of
Defense to administer the TFMDP for the Army, Navy, Air Force, and
Marine Corps under DoD jurisdiction, the Secretary of Transportation to
administer the TFMDP for the Coast Guard, when the Coast Guard is not
operating as a service in the Navy, and the Secretary of Health and
Human Services to administer the TFMDP for the Commissioned Corps of
the NOAA and the USPHS.
(ii) Organizational delegations and assignments--(A) Assistant
Secretary of Defense (Health Affairs) (ASD(HA)). The Secretary of
Defense, by 32 CFR part 367, delegated authority to the ASD(HA) to
provide policy guidance, management control, and coordination as
required for all DoD health and medical resources and functional areas
including health benefit programs. Implementing authority is contained
in 32 CFR part 367. For additional implementing authority see
Sec. 199.1. Any guidelines or policy necessary for implementation of
this Sec. 199.13 shall be issued by the Director, OCHAMPUS.
(B) Evidence of eligibility. DoD, through the Defense Enrollment
Eligibility Reporting System (DEERS), is responsible for establishing
and maintaining a listing of persons eligible to receive benefits under
the TFMDP.
(4) Preemption of State and local laws. (i) Pursuant to 10 U.S.C.
1103 and section 8025 (fourth proviso) of the Department of Defense
Appropriations Act, 1994, DoD has determined that, in the
administration of 10 U.S.C. chapter 55, 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 DoD, 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.
(ii) Based on the determination set forth in paragraph (a)(4)(i) of
this section, any State or local law relating to health or dental
insurance, prepaid health or dental plans, or other health or dental
care delivery or financing methods is preempted and does not apply in
connection with the TFMDP 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 TFMDP contract. (However, DoD may, by contract, establish legal
obligations on the part of the dental plan contractor to conform with
requirements similar or identical to requirements of State or local
laws or regulations.)
(iii) The preemption of State and local laws set forth in paragraph
(a)(4)(ii) 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,
[[Page 66131]]
within the meaning of the statutes identified in paragraph (a)(4)(i) of
this section. 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 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).
(5) Plan funds.--(i) Funding sources. The funds used by the TFMDP
are appropriated funds furnished by the Congress through the annual
appropriation acts for DoD, the Department of Health and Human Services
and the Department of Transportation and funds collected by the
Uniformed Services or contractor through payroll deductions or through
direct billing as premium shares from enrolled beneficiaries.
(ii) Disposition of funds. TFMDP funds are paid by the Government
(or in the case of direct billing, by the beneficiary) as premiums to
an insurer, service, or prepaid dental care organization under a
contract negotiated by the Director, OCHAMPUS, or a designee, under the
provisions of the Federal Acquisition Regulation (FAR) (48 CFR chapter
1).
(iii) Plan. The Director, OCHAMPUS, or designee provides an
insurance policy, service plan, or prepaid contract of benefits in
accordance with those prescribed by law and regulation; as interpreted
and adjudicated in accord with the policy, service plan, or contract
and a dental benefits brochure; and as prescribed by requirements of
the dental plan contractor's contract with the Government.
(iv) Contracting out. The method of delivery of the TFMDP is
through a competitively procured contract. The Director, OCHAMPUS, or a
designee, is responsible for negotiating, under provisions of the FAR,
a contract for dental benefits insurance or prepayment that includes
responsibility for:
(A) Development, publication, and enforcement of benefit policy,
exclusions, and limitations in compliance with the law, regulation, and
the contract provisions;
(B) Adjudicating and processing claims; and conducting related
supporting activities, such as enrollment, disenrollment, collection of
premiums, eligibility verification, provider relations, and beneficiary
communications.
(6) Role of Health Benefits Advisor (HBA). The HBA is appointed
(generally by the commander of an Uniformed Services medical treatment
facility) to serve as an advisor to patients and staff in matters
involving the TFMPD. The HBA may assist beneficiaries in applying for
benefits, in the preparation of claims, and in their relations with
OCHAMPUS and the dental plan contractor. However, the HBA is not
responsible for the TFMPD's policies and procedures and has no
authority to make benefit determinations or obligate the TFMPD's funds.
Advice given to beneficiaries by HBAs as to determination of benefits
or level of payment is not binding on OCHAMPUS or the dental plan
contractor.
(7) Right to information. As a condition precedent to the provision
of benefits hereunder, the Director, OCHAMPUS, or designee, shall be
entitled to receive information from an authorized provider or other
person, institution, or organization (including a local, State, or
United States Government agency) providing services or supplies to the
beneficiary for which claims for benefits are submitted. While
establishing enrollment and eligibility, benefits, and benefit
utilization and performance reporting information standards, the
Government has established and does maintain a system of records for
dental information under the TFMDP. By contract, the Government audits
the adequacy and accuracy of the dental plan contractor's system of
records and requires access to information and records to meet plan
accountabilities, to assist in contractor surveillance and program
integrity investigations and to audit OCONUS financial transactions
where the Department has a financial stake. Such information and
records may relate to attendance, testing, monitoring, examination, or
diagnosis of dental disease or conditions; or treatment rendered; or
services and supplies furnished to a beneficiary; and shall be
necessary for the accurate and efficient administration and payment of
benefits under this plan. To assist in claims adjudication, grievance
and fraud investigations, and the appeals process, and before an
interim or final determination can be made on a claim of benefits, a
beneficiary or active duty service member must provide particular
additional information relevant to the requested determination, when
necessary. Failure to provide the requested information may result in
denial of the claim and inability to effectively investigate the
grievance or fraud or process the appeal. The recipient of such
information shall in every case hold such records confidential except
when:
(i) Disclosure of such information is necessary to the
determination by a provider or the dental plan contractor of
beneficiary enrollment or eligibility for coverage of specific
services;
(ii) Disclosure of such information is authorized specifically by
the beneficiary;
(iii) Disclosure is necessary to permit authorized Government
officials to investigate and prosecute criminal actions;
(iv) Disclosure constitutes a routine use of a record which is
compatible with the purpose for which it was collected. This includes a
standard and acceptable business practice commonly used among dental
insurers which is consistent with the principle of preserving
confidentiality of personal information and detailed clinical data. For
example, the release of utilization information for the purpose of
determining eligibility for certain services, such as the number of
dental prophylaxis procedures performed for a beneficiary, is
authorized;
(v) Disclosure is pursuant to an order form a court of competent
jurisdiction; or
(vi) Disclosure by the Director, OCHAMPUS, or designee, is for the
purpose of determining the applicability of, and implementing the
provisions of, other dental benefits coverage or entitlement.
(8) Utilization review and quality assurance. Claims submitted for
benefits under the TFMDP are subject to review by the Director,
OCHAMPUS, or designee, for quality of care and appropriate utilization.
The Director, OCHAMPUS, or designee, is responsible for appropriate
utilization review and quality assurance standards, norms, and criteria
consistent with the level of benefits.
(b) Definitions. For most definitions applicable to the provisions
of this section, refer to 199.2. The following definitions apply only
to his section:
(1) Assignment of benefits. Acceptance by a nonparticipating
provider of payment directly from the insurer while reserving the right
to charge the beneficiary or active duty service member for any
remaining amount of the fees for services which exceeds the prevailing
fee allowance of the insurer.
(2) Authoried provider. A dentist, dental hygienist, or certified
and licensed anesthetist specifically authorized to provide benefits
under the TFMPD in paragraph (f) of this section.
[[Page 66132]]
(3) Beneficiary. A dependent of an active duty member who has been
enrolled in the TFMDP, and has been determined to be eligible for
benefits, as set forth in paragraph (c) of this section.
(4) 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 TFMDP, beneficiary liability
includes cost-sharing amounts or 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. In cases where a nonparticipating
provider does not accept assignment of benefits, beneficiaries may have
to pay the nonparticipating provider in full at the time of treatment
and seek reimbursement directly from the insurer for all or a portion
of the nonparticipating provider's fee. Beneficiary liability also
includes any expenses for services and supplies not covered by the
TFMDP, less any available discount provided as a part of the insurer's
agreement with an approved alternative delivery system.
(5) By report. Dental procedures which are authorized as benefits
only in unusual circumstances requiring justification of exceptional
conditions related to otherwise authorized procedures. These services
are further defined in paragraph (e) of this section.
(6) Contingency operation. Defined in 10 U.S.C. 101(a)(13) as a
military operation designated as a contingency operation by the
Secretary of Defense or a military operation that results in the
exercise of authorities for ordering Reserve component members to
active duty without their consent and is therefore automatically a
contingency operation.
(7) Cost-share. The amount of money for which the beneficiary (or
active duty service member) is responsible in connection with otherwise
covered dental services (other than disallowed amounts) as set forth in
paragraph (e) of this section. A cost-share may also be referred to as
a ``co-payment.''
(8) Defense Enrollment Eligibility reporting System (DEERS). The
automated system that is composed of two phases:
(i) Enrolling all active duty and retired service members, their
dependents, and the dependents of deceased service members; and
(ii) Verifying their eligibility for health care benefits in the
direct care facilities and through the TFMDP.
(9) Dental hygienist. Practitioner in rendering complete oral
prophylaxis services, applying medication, performing dental
radiography, and providing dental education services with a
certificate, associate degree, or bachelor's degree in the field, and
licensed by an appropriate authority.
(10) Dentist. Doctor of Dental Medicine (D.M.D.) or Doctor of
Dental Surgery (D.D.S.) who is licensed to practice dentistry by an
appropriate authority.
(11) Diagnostic services. Category of dental services including:
(i) Clinical oral examinations;
(ii) Radiographic examinations; and
(iii) Diagnostic laboratory tests and examinations provided in
connection with other dental procedures authorized as benefits of the
TFMDP and further defined in paragraph (e) of this section.
(12) 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.
(13) Initial determination. A formal written decision on a TFMDP
claim, a request for TFMDP benefit [pre-determination, a request by a
provider for approval as an authorized provider, or a decision
suspending, excluding or terminating a provider as an authorized
provider under the TFMFDP. Rejection of a claim or pre-determination,
or of a request for benefit or provider authorization for failure to
comply with administrative requirements, including failure to submit
reasonably requested information, is not an initial determination.
Responses to general or specific inquiries regarding TFMDP benefits are
not initial determinations.
(14) Nonparticipating provider. A dentist or dental hygienist that
furnished dental services to a TFMDP beneficiary, but who has not
agreed to participate or to accept the insurer's fee allowances and
applicable cost share as the total charge for the services. A
nonparticipating provider looks to the beneficiary or active duty
member for final responsibility for payment of his or her charge, but
may accept payment (assignment of benefits) directly from the insurer
or assist the beneficiary in filing the claim for reimbursement by the
dental plan contractor. Where the nonparticipating provider does not
accept payment directly from the insurer, the insurer pays the
beneficiary or active duty member, not the provider.
(15) Oral and maxillofacial surgery. Surgical procedures performed
in the oral cavity as further defined in paragraph (e) of this section.
(16) Orthodontics. 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 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 as further defined in
paragraph (e) of this section.
(17) 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 active duty member) of any cost-share for covered
services.
(18) Party to the initial determination. Includes the TFMDP, a
beneficiary of the TFMDP and a participating provider of services whose
interests have been adjudicated by the initial determination. In
addition, a provider who has been denied approval as an authorized
TFMDP provider is a party to that initial determination, as is a
provider who is suspended, excluded or terminated as an authorized
provider, unless the provider is excluded under another federal or
federally funded program.
(19) Periodontics. The examination, diagnosis, and treatment of
diseases affecting the supporting structures of the teeth as further
defined in paragraph (e) of this section.
(20) Preventive services. Traditional prophylaxis including scaling
deposits from teeth, polishing teeth, and topical application of
fluoride to teeth as further defined in paragraph (e) of this section.
(21) 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.
(22) Provider. A dentist or dental hygienist as specified in
paragraph (f) of this section. This term, when used in relation to
OCONUS service area providers, may include other recognized professions
authorized to furnish care under laws of that particular country.
(23) Restorative services. Restoration of teeth including those
procedures commonly described as amalgam restorations, resin
restorations, pin retention, and stainless steel crowns for primary
teeth as further defined in paragraph (e) of this section.
[[Page 66133]]
(24) Sealants. A material designed for application on specified
teeth to seal the surface irregularities to prevent ingress of oral
fluids, food, and debris in order to prevent tooth decay.
(c) Eligibility and enrollment--(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 TFMDP. 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 this part in order for dental
benefits to be extended.
(2) Eligibility.--(i) Person eligible (dependent). A person who
bears one of the following relationships to an active duty member
(under a call or order that does not specify a period of thirty (30)
days of less):
(A) Spouse. A lawful husband or wife, regardless of whether or not
dependent upon the active duty member.
(B) Child. To be eligible, the child must be unmarried and meet the
requirements set forth in Sec. 199.3(b)(2)(iv)(A) and
Sec. 199.3(b)(2)(iv)(C).
(ii) Determination of eligibility status and evidence of
eligibility.--(A) Eligibility determination responsibility of the
Uniformed Services. Determination of a person's eligibility for the
TFMDP is the responsibility of the active duty member's Uniformed
Service. For the purpose of program integrity, the appropriate
Uniformed Service shall, upon request of the Director, OCHAMPUS, or
designee, review the eligibility status. In such cases, a report on the
result of the review and any action taken will be submitted to the
Director, OCHAMPUS, or designee.
(B) Procedures for determination of eligibility. Uniformed Services
identification cards do not distinguish eligibility for the TFMDP.
Procedures for the determination of eligibility are identified in
Sec. 199.3(f)(2), except that Uniformed Services identification cards
do not provide evidence of eligibility for the TFMDP. Although OCHAMPUS
and the dental plan contractor must make determinations concerning a
dependent's eligibility in order to ensure proper enrollment and proper
disbursement of appropriated funds, ultimate responsibility for
resolving a dependent's eligibility rests with the Uniformed Services.
(C) Evidence of eligibility required. Eligibility and enrollment in
the TFMDP will be verified through the DEERS. Eligibility and
enrollment information established and maintained in the DEERS file is
the only acceptable evidence of TFMDP eligibility and enrollment. It is
the responsibility of the active duty member or TFMDP beneficiary,
parent, or legal representative, when appropriate, to provide adequate
evidence for entry into the DEERS file to establish eligibility for the
TFMDP, and to ensure that all changes in status that may effect
eligibility are reported immediately to the appropriate Uniformed
Service for action. Ineligibility for benefits is presumed in the
absence of prescribed eligibility evidence in the DEERS file.
(3) Enrollment--Previous plans--(A) Basic active duty dependents
dental benefit plan. The Basic Active Duty Dependents Dental Plan was
effective from August 1, 1987, up to the date of implementation of the
Expanded Active Duty Dependents Dental Benefit Plan. The Basic Active
Duty Dependents Dental Benefit Plan terminated upon implementation of
the expanded plan.
(B) Expanded active duty dependents dental benefit plan. The
Expanded Active Duty Dependents Dental Benefit Plan was effective from
August 1, 1993, up to the date of implementation of the TFMDP. The
Expanded Active Duty Dependents Dental Benefit Plan terminates upon
implementation of the TFMDP.
(ii) TRICARE Family Member Dental Plan (TFMDP)--(A) Election of
coverage. (1) Except as provided in paragraph (c)(3)(ii)(A) (2) of this
section, active duty members may voluntarily elect to enroll their
eligible dependents following implementation of the TFMDP. In order to
obtain TFMDP coverage, written or telephonic election by the active
duty member must be made and will be accomplished by submission or
telephonic completion of an application to the dental plan contractor.
This election can also be accomplished via electronic means.
(2) Eligible dependents of active duty members enrolled in the
Expanded Active Duty Dependents Dental Benefit Plan at the time of
implementation of TFMDP will automatically be enrolled in TFMDP. No
election to enroll in TFMDP will be required by the active duty member.
(B) Premiums. (1) Enrollment will be by either single or family
premium as defined as follows:
(i) Single premium. One (1) covered eligible dependent.
(ii) Family premium. Two (2) or more covered eligible dependents.
Under the family premium, all eligible dependents of the active duty
member are enrolled.
(2) Exceptions. (i) An active duty member may elect to enroll only
those eligible dependents residing in one location when the active duty
member has eligible dependents residing in two or more geographically
separate locations (e.g., children living with a divorced spouse; a
child attending college).
(ii) Instances where a dependent requires a hospital or special
treatment environment (due to a medical, physical handicap, or mental
condition) for dental care otherwise covered by the TFMDP, the
dependent may be excluded from TFMDP enrollment and may continue to
receive care from a military treatment facility.
(C) Enrollment period--(1) General. Enrollment of beneficiaries is
for a period of one (1) year followed by month-to-month enrollment as
long as the active duty member chooses to continue enrollment. Active
duty members may enroll their family members in the TFMDP provided
there is an intent to remain on active duty for a period of not less
than one (1) year by the active duty member and the parent Uniformed
Service. Family members enrolled in the TFMDP must remain enrolled for
a minimum period of one (1) year unless one of the conditions for
disenrollment specified in paragraph (c)(3)(ii)(E) of this section is
met.
(2) Reserve component members ordered to active duty in support of
contingency operations. The mandatory 12 month enrollment period does
not apply to Reserve component members ordered to active duty (other
than for training) in support of a contingency operation as designated
by the Secretary of Defense. Affected Reserve component members may
enroll in the TFMDP only if their orders specify that they are ordered
to active duty in support of a contingency operation, as defined by 10
U.S.C., for a period of thirty-one (31) days or more. An affected
Reserve component member must elect to enroll in TFMDP and complete the
enrollment application within 30 days following entry on active duty.
following enrollment, family members must remain enrolled, with the
member paying premiums, until the end of the member's active duty
period in support of the contingency operation or 12 months, whichever
occurs first unless one of the conditions for disenrollment specified
in paragraph (c)(3)(ii)(E) of this section is met.
(3) Continuation of enrollment from Expanded Active Duty Dependents
Dental Benefit Plan. Beneficiaries enrolled in the Expanded Active Duty
Dependents Dental Benefit Plan at the time when TFMDP coverage begins
[[Page 66134]]
must complete their two (2) year enrollment period established under
this former plan except if one of the conditions for disenrollment
specified in paragraph (c)(3)(ii)(E) of this section is met. Once this
original two (2) year enrollment period is met, the active duty member
may continue TFMDP enrollment on a month-to-month basis. A new one (1)
year enrollment period will only be incurred if the active duty member
disenrolls and attempts to re-enroll in the TFMDP at a later date.
(D) Beginning dates of eligibility. The beginning date of
eligibility for TFMDP benefits is the first day of the month following
the month in which the election of enrollment is completed, signed, and
the enrollment and premium is received by the dental plan contractor,
subject to a predetermined and publicized dental plan contractor
monthly cut-off date. This includes any changes between single and
family member premium coverage and coverage of newly eligible or
enrolled dependents.
(E) Changes in and termination of enrollment--(1) Changes in status
of active duty member. When the active duty member is separated,
discharged, or retired, his or her dependents lose eligibility as of
11:59 p.m. on the last day of the month in which the change in status
takes place. Eligible dependents of an active duty member serving a
sentence of confinement in conjunction with a sentence of punitive
discharge are still eligible for the TFMDP until such time as the
active duty member's discharge is executed.
(2) Continuation of eligibility for dependents of active duty
members who die on active duty. Eligible dependents of active duty
members who die on or after October 1, 1993, while on active duty for a
period of more than thirty (30) days and who are enrolled in the TFMDP
on the date of the death of the active duty member shall be eligible
for continued enrollment in the TFMDP for up to one (1) year from the
date of the active duty member's death.
(3) Changes in status of dependent.--(i) Divorce. A spouse
separated from an active duty member by a final divorce decree loses
all eligibility based on his or her former marital relationship as of
11:59 p.m. of the last day of the month in which the divorce becomes
final. The eligibility of the active duty member's own children
(including adopted and eligible illegitimate children) is unaffected by
the divorce. An unadopted stepchild, however, loses eligibility with
the termination of the marriage, also as of 11:59 p.m. of the last day
of the month in which the divorce becomes final.
(ii) Annulment. A spouse whose marriage to an active duty member is
dissolved by annulment loses eligibility as of 11:59 p.m. of the last
day of the month in which the court grants the annulment order. The
fact that the annulment legally declares the entire marriage void from
its inception does not affect the termination date of eligibility. When
there are children, the eligibility of the active duty member's own
children (including adopted and eligible illegitimate children) is
unaffected by the annulment. An unadopted stepchild, however, loses
eligibility with the annulment of the marriage, also as of 11:59 p.m.
of the last day of the month in which the court grants the annulment
order.
(iii) Adoption. A child of an active duty member who is adopted by
a person, other than a person whose dependents are eligible for TFMDP
benefits while the active duty member is living, thereby severing the
legal relationship between the child and the active duty member, loses
eligibility as of 11:59 p.m. of the last day of the month in which the
adoption becomes final.
(iv) Marriage of child. A child of an active duty member who
marries a person whose dependents are not eligible for the TFMDP, loses
eligibility as of 11:59 p.m. on the last day of the month in which the
marriage takes place. However, should the marriage be terminated by
death, divorce, or annulment before the child is 21 years old, the
child again becomes eligible for enrollment as a dependent as of 12:00
a.m. of the first day of the month following the month in which the
occurrence takes place that terminates the marriage and continues up to
age 21 if the child does not remarry before that time. If the marriage
terminates after the child's 21st birthday, there is no reinstatement
of eligibility.
(v) Disabling illness or injury of child age 21 or 22 who has
eligibility based on his or her student status. A child 21 or 22 years
old who is pursuing a full-time course of higher education and who,
either during the school year or between semesters, suffers a disabling
illness or injury with resultant inability to resume attendance at the
institution remains eligible for the TFMDP for six (6) months after the
disability is removed or until the student passes his or her 23rd
birthday, whichever occurs first. However, if recovery occurs before
the 23rd birthday and there is resumption of a full-time course of
higher education, the TFMDP can be continued until the 23rd birthday.
The normal vacation periods during an established school year do not
change the eligibility status of a dependent child 21 or 22 years old
in full-time student status. Unless an incapacitating condition existed
before, and at the time of, a dependent child's 21st birthday, a
dependent child 21 or 22 years old in student status does not have
eligibility related to mental or physical incapacity as described in
Sec. 199.3(b)(2)(iv)(C)(2).
(4) Other.--(1) Disenrollment because of no eligible beneficiaries.
When an active duty member ceases to have any eligible beneficiaries,
enrollment is terminated.
(ii) Option to disenroll as a result of a change in active duty
station. When an active duty member transfers with beneficiaries to a
duty station where space-available dental care for the beneficiaries is
readily available at the local Uniformed Service dental treatment
facility or to locations within the OCONUS service area, the active
duty member may elect, within ninety (90) calendar days of the
transfer, to disenroll from the TFMDP. If the active duty member is
later transferred to a duty station where dental care for the
dependents is not available in the local Uniformed Service dental
treatment facility, the active duty member may re-enroll his or her
dependents in the TFMDP provided the member, as of the date of
reenrollment, otherwise meets the requirements for enrollment,
including the intent to remain on active duty for a period of not less
than one (1) year.
(iii) Option to disenroll after an initial one (1) year enrollment.
When an active duty member's enrollment has been in effect for a
continuous period of one (1) year, the active duty member may disenroll
at any time following procedures as set up by the dental plan
contractor. Subsequent to the disenrollment, the active duty member may
reenroll for another minimum period of one (1) year. If, during any one
(1) year enrollment period, the active duty member disenrolls for
reasons other than those listed in this paragraph (c)(3)(ii)(E) or
fails to make premium payments, the active duty member and
beneficiaries will be subject to a lock-out period of twelve (12)
months. Following this period of time, active duty members will be able
to reenroll if they so choose. The twelve (12) month lock-out period
applies to a Reserve component member who disenrolls for reasons other
than those listed in this paragraph (c)(3)(ii)(E) or fails to make
premium payments after the member has enrolled pursuant to paragraph
(c)(3)(ii)(C) of this section.
(d) Premium sharing--(1) General. Active duty members enrolling in
the TFMDP shall be required to pay a
[[Page 66135]]
portion of the premium cost for their dependents.
(2) Proportion of active duty member's premium share. The
proportion of premium share to be paid by the active duty member is
established by the ASD (HA), or designee, at not more than forty (40)
percent of the total premium.
(3) Provision for increases in active duty member's premium share.
(i) Although previously capped at $20 per month, the law has been
amended to authorize the cap on active duty members' premiums to rise,
effective as of January 1 of each year, by the percent equal to the
lesser of:
(A) The percent by which the rates of basic pay of active duty
members are increased on such date; or
(B) The sum of one-half percent and the percent computed under 5
U.S.C. 5303(a) for the increase in rates of basic pay for statutory pay
systems for pay periods beginning on or after such date.
(ii) Under the legislation authorizing an increase in the monthly
premium cap, the methodology for determining the active duty member's
TFMDP premium will be applied as if the methodology had been in
continuous use since December 31, 1993.
(4) Reduction of premium share or cost-shares for enlisted members.
For enlisted members in pay grades E-1 through E-4, the ASD (HA) or
designee, may reduce the monthly premium and/or cost-shares these
active duty members pay for selected benefits as specified in paragraph
(e)(3)(i) of this section.
(5) Premium payment method. The active duty member's premium share
shall be deducted from the active duty member's basic pay, if
sufficient pay is available. For dependents who are otherwise eligible
for TFMDP benefits and whose sponsors do not receive such pay, or if
sufficient pay is available, the premium payment may be collected
pursuant to procedures established by the Director, OCHAMPUS, or
designee.
(6) Annual notification of premium rates. TFMDP premium rates will
be determined as part of the competitive contracting process.
Information on the premium rates will be widely distributed by the
dental plan contractor and the Government.
(e) Plan benefits.--(1) General.--(i) Scope of benefits. The TFMDP
provides coverage for diagnostic and preventive services, sealants,
restorative services, endodontics, periodontics, prosthodontics,
orthodontics and oral and maxillofacial surgery.
(ii) Authority to act for the plan. The authority to make benefit
determinations and authorize plan payments under the TFMDP rests
primarily with the insurance, service plan, or prepayment dental plan
contractor, subject to compliance with Federal law and regulation and
Government contract provisions. The Director, OCHAMPUS, or designee,
provides required benefit policy decisions resulting from changes in
Federal law and regulation and appeal decisions. No other persons or
agents (such as dentists or Uniformed Services HBAs) have such
authority.
(iii) Dental benefits brochure.--(A) Content. The Director,
OCHAMPUS, or designee, shall establish a comprehensive dental benefits
brochure explaining the benefits of the plan in common lay terminology.
The brochure shall include the limitations and exclusions and other
benefit determination rules for administering the benefits in
accordance with the law and this part. The brochure shall include the
rules for adjudication and payment of claims, appealable issues, and
appeal procedures in sufficient detail to serve as a common basis for
interpretation and understanding of the rules by providers,
beneficiaries, claims examiners, correspondence specialists, employees
and representatives of other Government bodies, HBAs, and other
interested parties. Any conflict, which may occur between the dental
benefits brochure and law or regulation, shall be resolved in favor of
law and regulation.
(b) Distribution. The dental benefits brochure will be available
through the dental plan contractor and will be distributed with the
assistance of the Uniformed Service HBAs and major personnel centers at
Uniformed Service installations to all members enrolling their
dependents.
(iv) Alternative course of treatment policy. The Director,
OCHAMPUS, or designee, may establish, in accordance with generally
accepted dental benefit practices, alternative course of treatment
policy which provides reimbursement in instances where the dentist and
beneficiary select a more expensive service, procedure, or course of
treatment than is customarily provided. The alternative course of
treatment policy must meet the following conditions:
(A) The service, procedure, or course of treatment must be
consistent with sound professional standards of dental practice for the
dental practice for the dental condition concerned.
(B) The service, procedure, or course of treatment must be a
generally accepted alternative for a service or procedure covered by
the TFMDP for the dental condition.
(C) Payment for the alternative service or procedure may not exceed
the lower of the prevailing limits fro the alternative procedure, the
prevailing limits or dental plan contractor's scheduled allowance for
the otherwise authorized benefit procedure for which the alternative is
substituted, or the actual charge for the alternative procedure.
(2) Benefits. The following benefits are defined (subject to the
TFMDP's exclusions, limitations, and benefit determination rules
approved by OCHAMPUS) using the American Dental Association's Council
on Dental Care Program's Code on Dental Procedures and Nomenclature.
The Director, OCHAMPUS, or designee, may modify these services, to the
extent determined appropriate based on developments in common dental
care practices and standard dental insurance programs.
(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 and dental
hygienists as authorized under paragraph (f) of this section. These
include the following categories of service:
(A) Diagnostic services. (1) Clinical oral examinations.
(2) Radiographs and diagnostic imaging.
(3) Tests and laboratory examinations.
(B) Preventive services. (1) Dental prophylaxis.
(2) Topical fluoride treatment (office procedure).
(3) Other preventive services.
(4) Space maintenance (passive appliances).
(ii) General services and services ``by report''. The following
categories of services are authorized when performed directly by
dentists or dental hygienists, as authorized under paragraph (f) of
this section, 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. The dental plan
contractor 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. These include the following categories of general services:
(A) Unclassified treatment.
(B) Anesthesia.
[[Page 66136]]
(C) Professional consultation.
(D) Professional visits.
(E) Drugs.
(F) Miscellaneous services.
(iii) Restorative services. Benefits may be extended for
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 include the following
categories of restorative services:
(A) Amalgam restorations.
(B) Resin restorations.
(C) Inlay and onlay restorations.
(D) Crowns.
(E) Other restorative services.
(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
include the following categories of endodontic services:
(A) Pulp capping.
(B) Pulpotomy and pulpectomy.
(C) Endodontic therapy.
(D) Apexification and recalcification procedures.
(E) Apicoectomy and periradicular services.
(F) Other endodontic procedures.
(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 include the following categories of periodontic services:
(A) Surgical services.
(B) Periodontal services.
(C) Other periodontal services.
(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 removal of complete and partial dentures, fixed crowns and
bridges when performed directly by dentists as authorized under
paragraph (f) of this section. These include the following categories
of prosthodontic services:
(A) Prosthodontics (removable).
(1) Complete and partial dentures.
(2) Adjustment to dentures.
(3) Repairs to complete and partial dentures.
(4) Denture rebase procedures.
(5) Denture reline procedures.
(6) Other removable prosthetic services.
(B) Prosthodontics (fixed).
(1) Fixed partial denture pontics.
(2) Fixed partial denture retainers.
(3) Other partial denture 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. These include the following categories of orthodontic
services:
(A) Limited orthodontic treatment.
(B) Minor treatment to control harmful habits.
(C) Interceptive orthodontic treatment.
(D) Comprehensive orthodontic treatment.
(E) Other orthodontic services.
(viii) Oral and maxillofacial 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 include the
following categories of oral and maxillofacial surgery services:
(A) Extractions.
(B) Surgical extractions.
(C) Other surgical procedures.
(D) Alveoloplasty--surgical preparation of ridge for denture.
(E) Surgical incision.
(F) Repair of traumatic wounds.
(G) Complicated suturing.
(H) Other repair procedures.
(ix) Exclusion of adjunctive dental care. Adjunctive dental care
benefits are excluded under the TFMP. For further information on
adjunctive dental care benefits under TRICARE/CAMPUS, see
Sec. 199.4(e)(10).
(x) 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 the TFMDP.
(xi) Limitation on reduction of benefits. If a reduction in
benefits is planned, the Secretary of Defense, or designee, may not
reduce TFMDP benefits without notifying the appropriate Congressional
committees. If a reduction is approved, the Secretary of Defense, or
designee, must wait one year from the date of notice before a benefit
reduction can be implemented.
(3) Cost-shares, liability and maximum coverage. (i) Cost-shares.
The following table lists maximum active duty member cost shares for
covered services for participating and nonparticipating providers of
care. These are percentages of the dental plan contractor's determined
allowable amount that the active duty member or beneficiary must pay to
these providers:
[In percent]
------------------------------------------------------------------------
Cost-share for
pay grades E- Cost-share for
Covered services 1, E-2, E-3 all other pay
and E-4 grades
------------------------------------------------------------------------
Diagnostic.............................. 0 0
Preventive, except Sealants............. 0 0
Emergency Services...................... 0 0
Sealants................................ 20 20
Professional Consultations.............. 20 20
Professional Visits..................... 20 20
Post Surgical Services.................. 20 20
Basic Restorative (example: amalgams, 20 20
resins, stainless steel crowns)........
Endodontic.............................. 30 40
Periodontic............................. 30 40
Oral and Maxillofacial Surgery.......... 30 40
General Anesthesia...................... 40 40
[[Page 66137]]
Intravenous Sedation.................... 50 50
Other Restorative (example: crowns, 50 50
onlays, casts).........................
Prostodontic............................ 50 50
Medications............................. 50 50
Orthodontic............................. 50 50
Miscellaneous Services.................. 50 50
------------------------------------------------------------------------
(ii) Dental plan contractor liability. Where the dental program
contractor is unable to identify a participating provider of care
(i.e., a general dentist) within thirty five (35) miles of the
beneficiary's place of residence with appointment availability within
twenty one (21) calendar days, the dental program contractor will
reimburse the beneficiary, or active duty member, or the
nonparticipating provider selected by the beneficiary within thirty
five (35) miles of the beneficiary's place of residence at the level of
the provider's usual fees less the applicable beneficiary cost share,
if any.
(iii) Maximum coverage amounts. Beneficiaries 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 ASD (HA) or designee.
(f) Authorized providers--(1) General. Enrolled beneficiaries may
seek covered services from any provider who is fully licensed and
approved to provide dental care or covered anesthesia benefits in the
state where the provider is located. This includes licensed dental
hygienists, practicing within the scope of their licensure, subject to
any restriction a state licensure or legislative body imposes regarding
their status as independent providers of care.
(2) Authorized provider status does not guarantee payment of
benefits. The fact that a provider is ``authorized'' is not to be
construed to mean that the TFMDP will automatically pay a claim for
services or supplies provided by such a provider. The Director,
OCHAMPUS, or designee, also must determine if the patient is an
eligible beneficiary, whether the services or supplies billed are
authorized and medically necessary, and whether any of the authorized
exclusions of otherwise qualified providers presented in this section
apply.
(3) Utlization review and quality assurance. Services and supplies
furnished by providers of care shall be subject to utilization review
and quality assurance standards, norms, and criteria established under
the TFMDP. Utilization review and quality assurance assessments shall
be performed under the TFMDP. Utilization review and quality assurance
assessments shall be performed under the TFMDP consistent with the
nature and level of benefits of the plan, and shall include analysis of
the data and findings by the dental plan contractor from other dental
accounts.
(4) Provider required. In order to be considered benefits, all
services and supplies shall be rendered by, prescribed by, or furnished
at the direction of, or on the order of a TFMDP authorized provide
practicing within the scope of his or her license.
(5) Participating provider. An authorized provider may elect to
participate for all TFMDP beneficiaries and accept the fee or charge
determinations as established and made known to the provider by the
dental plan contractor. The fee or charge determinations are binding
upon the provider in accordance with the dental plan contractor'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 dental plan contractor's determination of the allowable charge;
however, payments to participating providers shall be in accordance
with the methodology specified in paragraph (g)(2)(ii) of this section.
Payment is made directly to the participating provider, and the
participating provider may only charge the beneficiary the percent
cost-share of the dental plan contractor's allowable charge for those
benefit categories as specified in paragraph (e) of this section, in
addition to the full charges for any services not authorized as
benefits.
(6) Nonparticipating provider. An authorized provider may elect to
not participate for all TFMDP beneficiaries and request the beneficiary
or active duty member to pay any amount of the provider's billed charge
in excess of the dental plan contractor's determination of allowable
charges (to include the appropriate cost share). Neither the Government
nor the dental plan contractor shall have any responsibility for any
amounts over the allowable charges as determined by the dental plan
contractor, except where the dental plan contractor is unable to
identify a participating provider of care within thirty five (35) miles
of the beneficiary's place of residence with appointment availabiltiy
within twenty one (21) calendar days. In such instances of the
nonavailability of a participating provider, the nonparticipating
provider located within thirty five (35) miles of the beneficiary's
place of residence shall be paid his or her usual fees (either by the
beneficiary or the dental plan contractor if the beneficiary elected
assignment of benefits), less the percent cost-share as specified in
paragraph (e)(i) of this section.
(i) Assignment of benefits. A nonparticipating provider may accept
assignment of benefits for claims (for beneficiaries certifying their
wilingness to make such assignment of benefits) by filing the claims
completed with the assistance of the beneficiary or active duty member
for direct payment by the dental plan contractor to the provider.
(ii) No assignment of benefits. A nonparticipating provider for all
beneficiaries may request that the beneficiary or active duty member
file the claim directly with the dental plan contractor, making
arrangements with the beneficiary or active duty member for direct
payment by the beneficiary or active duty member.
(7) Alternative delivery system--(i) General. Alternative delivery
systems may be established by the Director, OCHAMPUS, or designee, as
authorized providers. Only dentists, dental hygienists and licensed
anesthetists shall be authorized to provide or direct the provision of
authorized services and supplies in an approved alternative delivery
system.
(ii) Defined. An alternative delivery system may be any approved
[[Page 66138]]
arrangement for a preferred provider organization, capitation plan,
dental health maintenance or clinic organization, or other contracted
arrangement which is approved by OCHAMPUS in accordance with
requirements and guidelines.
(iii) Elective or exclusive arrangement. Alternative delivery
systems may be established by contract or other arrangement on either
and elective or exclusive basis for beneficiary selection of
participating and authorized providers in accordance with contractual
requirements and guidelines.
(iv) Provider election of participation. Otherwise authorized
providers must be provided with the opportunity of applying for
participation in an alternative delivery system and of achieving
participation status based on reasonable criteria for timeliness of
application, quality of care, cost containment, geographic location,
patient availability, and acceptance of reimbursement allowance.
(v) Limitation on authorized providers. Where exclusive alternative
delivery systems are established, only providers participating in the
alternative delivery system are authorized providers of care. In such
instances, the TFMDP shall continue to pay beneficiary claims for
services rendered by otherwise authorized providers in accordance with
established rules for reimbursement of nonparticipating providers where
the beneficiary has established a patient relationship with the
nonparticipating provider prior to the TFMDP's proposal to subcontract
with the alternative delivery system.
(vi) Charge agreements. Where the alternative delivery system
employs a discounted fee-for-service reimbursement methodology or
schedule of charges or rates which includes all or most dental services
and procedures recognized by the American Dental Association's Council
on Dental Care Program's Code on Dental Procedures and Nomenclature,
the discounts or schedule of charges or rates for all dental services
and procedures shall be extended by its participating providers to
beneficiaries of the TFMDP as and incentive for beneficiary
participation in the alternative delivery system.
(g) Benefit payment.--(1) General. TFMDP benefit payments are made
either directly to the provider or to the beneficiary or active duty
member, depending on the manner in which the claim is submitted or the
terms of the subcontract of an alternative delivery system with the
dental plan contractor.
(2) Benefit payment. Beneficiaries are not required to utilize
participating providers. For beneficiaries who do use these
participating providers, however, these providers shall not balance
bill any amount in excess of the maximum payment allowed by the dental
plan contractor for covered services. Beneficiaries using
nonparticipating providers may be balance-billed amounts in excess of
allowable charges. The following general requirements for the TFMDP
benefit payment methodology shall be met, subject to modifications and
exceptions approved by the Director, OCHAMPUS, or designee:
(i) Nonparticipating providers (or the beneficiaries or active duty
members of unassigned claims) shall be reimbursed at the 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, subject to the exception
listed in paragraph (e)(3)(ii) of this section, less any cost-share
amount due for 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.
(3) Fraud, abuse, and conflict of interest. The provisions of
Sec. 199.9 shall apply except for Sec. 199.9(e). All references to
``CHAMPUS contractors'', ``CHAMPUS beneficiaries'' and ``CHAMPUS
providers'' in Sec. 199.9 shall be construed to mean the ``dental plan
contractor'', ``TFDP beneficiaries'' and ``TFMDP providers''
respectively for the purposes of this section. Examples of fraud
include situations in which ineligible persons not enrolled in the
TFMDP obtain care and file claims for benefits under the name and
identification of an enrolled beneficiary; or when providers submit
claims for services and supplies not rendered to beneficiaries; or when
a participating provider bills the beneficiary for amounts over the
dental plan contractors's determination of allowable charges; or when a
provider fails to collect the specified patient cost-share amount.
(h) Appeal and hearing procedures. The provisions of Sec. 199.10
shall apply except where noted in this section. All references to
``CHAMPUS contractors'', ``CHAMPUS beneficiaries'', ``CHAMPUS
participating providers'' and ``CHAMPUS Explanation of Benefits'' in
Sec. 199.10 shall be construed to mean the ``dental plan contractor'',
``TFMDP beneficiaries'', ``TFMDP participating providers'' and ``Dental
Explanation of Benefits of DEOB'' respectively for the purposes of this
section. References to ``OCAMPUSEUR'' in Sec. 199.10 are not applicable
to the TFMDP or this section.
(1) General. See Sec. 199.10(a).
(i) Initial determination--(A) Notice of initial determination and
right to appeal. See Sec. 199.10(a)(1)(i).
(B) Effect of initial determination. See Sec. 199.10(a)(1)(ii).
(B) Participation in an appeal. Participating in an appeal is
limited to any party to the initial determination, including OCHAMPUS,
the dental plan contractor, and authorized representatives of the
parties. Any party to the initial determination, except OCHAMPUS and
the dental plan contractor, may appeal an adverse determination. The
appealing party is the party who actually files the appeal.
(A) Parties to the initial determination. See Sec. 199.10(a)(2)(i)
and Sec. 199.10(a)(2)(i)(A), (B), (C) and (E). In addition, a third
party other than the dental plan contractor, such as an insurance
company, is not a party to the initial determination and is not
entitled to appeal, even though it may have an indirect interest in the
initial determination.
(B) Representative. See Sec. 199.10(a)(2)(ii).
(iii) Burden of proof. See Sec. 199.10(a)(3).
(iv) Evidence in appeal and hearing cases. See Sec. 199.10(a)(4).
(v) Late filing. If a request for reconsideration, formal review,
or hearing is filed after the time permitted in this section, written
notice shall be issued denying the request. Late filing may be
permitted only if the appealing party reasonably can demonstrate to the
satisfaction of the dental plan contractor, or the Director, OCHAMPUS,
or designee, that timely filing of the request was not feasible due to
extraordinary circumstances over which the appealing party had no
practical control. Each request for an exception to the filing
requirement will be considered on its own merits. The decision of the
Director, OCHAMPUS, or a designee, on the request for an exception to
the filing requirement shall be final.
(vi) Appealable issue. See Sec. 199.10(a)(6), Sec. 199.10(a)(6)(i),
Sec. 199.10(a)(6)(iv), including Sec. 199.10(a)(6)(iv) (A) and (C), and
Sec. 199.10(a)(6)(v) for an explanation and examples of nonappealable
issues.
[[Page 66139]]
Other examples of issues that are not appealable under this section
include:
(A) The amount of the dental plan contractor-determined allowable
charge since the methodology constitutes a limitation on benefits under
the provisions of this section.
(B) Certain other issues on the basis that the authority for the
initial determination is not vested in OCHAMPUS. Such issues include
but are not limited to the following examples:
(1) A determination of a person's enrollment in the TFMDP is the
responsibility of the dental plan contractor and ultimate
responsibility for resolving a beneficiary's enrollment rests with the
dental plan contractor. Accordingly, a disputed question of fact
concerning a beneficiary's enrollment will not be considered an
appealable issue under the provisions of this section, but shall be
resolved in accordance with paragraph (c) of this section and the
dental plan contractor's enrollment policies and procedures.
(2) Decisions relating to the issuance of a nonavailability
statement (NAS) in each case are made by the Uniformed Services.
Disputes over the need for an NAS or a refusal to issue an NAS are not
appealable under this section. The one exception is when a dispute
arises over whether the facts of the case demonstrate a dental
emergency for which an NAS is not required. Denial of payment in this
one situation is an appealable issue.
(3) Any decision or action on the part of the dental plan
contractor to include a provider in their network or to designate a
provider as participating is not appealable under this section.
Similarly, any decision or action on the part of the dental plan
contractor to exclude a provider from their network or to deny
participating provider status is not appealable under this section.
(vii) Amount in dispute. (A) General. An amount in dispute is
required for an adverse determination to be appealed under the
provisions of this section, except as set forth or further explained in
Sec. 199.10(a)(7)(ii), (iii) and (iv).
(B) Calculated amount. The amount in dispute is calculated as the
amount of money the dental plan contractor would pay if the services
involved in the dispute were determined to be authorized benefits of
the TFMDP. Examples of amounts of money that are excluded by this
section from payments for authorized benefits include, but are not
limited to:
(1) Amounts in excess of the dental plan contractor's-determined
allowable charge.
(2) The beneficiary's cost-share amounts.
(3) Amounts that the beneficiary, or parent, guardian, or other
responsible person has no legal obligation to pay.
(4) Amounts excluded under the provisions of Sec. 199.8 of this
part.
(viii) Levels of appeal. See Sec. 199.10(a)(8)(i). Initials
determinations involving the sanctioning (exclusion, suspension, or
termination) of TFMDP providers shall be appealed directly to the
hearing level.
(ix) Appeal decision. See Sec. 199.10(a)(9).
(2) Reconsideration. See Sec. 199.10(b).
(3) Formal review. See Sec. 199.10(c).
(4) Hearing.--(i) General. See Sec. 199.10(d) and Sec. 199.10(d)(1)
through (d)(5) and (d)(7) through (d)(12) for information on the
hearing process.
(ii) Authority of the hearing officer. The hearing officer, in
exercising the authority to conduct a hearing under this part, will be
bound by 10 U.S.C., chapter 55, and this part. The hearing officer in
addressing substantive, appealable issues shall be bound by the dental
benefits brochure, policies, procedures, instructions and other
guidelines issued by the ASD(HA), or a designee, or by the Director,
OCHAMPUS, or a designee, in effect for the period in which the matter
in dispute arose. A hearing officer may not establish or amend the
dental benefits brochure, policy, procedures, instructions, or
guidelines. However, the hearing officer may recommend reconsideration
of the policy, procedures, instructions or guidelines by the ASD(HA),
or a designee, when the final decision is issued in the case.
(5) Final decision. See Sec. 199.10(e)(1) and Sec. 199.10(e)(1)(i)
for information on final decisions in the appeal and hearing process,
with the exception that no recommended decision shall be referred for
review by ASD(HA).
Dated: November 12, 1999.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 99-30072 Filed 11-23-99; 8:45 am]
BILLING CODE 5001-10-M