[Federal Register Volume 65, Number 205 (Monday, October 23, 2000)]
[Rules and Regulations]
[Pages 63202-63218]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-27016]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]
RIN 0720-AA53


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

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: This final rule revises the comprehensive CHAMPUS regulation 
pertaining to the Expanded Active Duty Dependents Benefit Plan, or more 
commonly referred to as the TRICARE Family Member Dental Plan (TFMDP). 
The TFMDP limited eligibility to eligible dependents of active duty 
members (under a call or order that does not specify a period of thirty 
(30) day or less). Concurrent with the timeframe of the publication of 
the proposed rule, the Defense Authorization Act for Fiscal Year 2000 
(Public Law 106-65, sec. 711) was signed into law and its provisions 
have been incorporated into this final rule. The Act authorized a new 
plan, titled the TRICARE dental program (TDP), which allows the 
Secretary of Defense to offer a comprehensive premium based indemnity 
dental insurance coverage plan to eligible dependents of active duty 
members (under a call or order that does not specify a period of thirty 
(30) days or less), eligible dependents of members of the Selected 
Reserve and Individual Ready Reserve, and eligible members of the 
Selected Reserve and Individual Ready Reserve. The Act also struck 
section 1076b (Selected Reserve dental insurance), or Chapter 55 of 
title 10, United States Code, since the affected population and the 
authority for that particular dental insurance plan has been 
incorporated in 10 U.S.C. 1076a. Consistent with the proposed rule and 
the provisions of the Defense Authorization Act for Fiscal Year 2000, 
the final rule places the responsibility for TDP enrollment and a large 
portion of the appeals program on the dental plan contractor; allows 
the dental plan contractor to bill beneficiaries for plan premiums in 
certain circumstances; reduces the former TFMDP enrollment period from 
twenty-four (24) to twelve (12) months; excludes Reserve component 
members ordered to active duty in support of a contingency operation 
from the mandatory twelve (12) month enrollment; clarifies dental plan 
requirements for different beneficiary populations; simplifies 
enrollment types and exceptions; reduces cost-shares for certain 
enlisted grades; adds anesthesia as a covered benefit; provides 
clarification on the Department's use of the Congressional waiver for 
surviving dependents; 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 members and 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. The proposed rule was titled the ``TRICARE 
Family Member Dental Plan''.

DATES: Effective February 1, 2001.

FOR FURTHER INFORMATION CONTACT: Major Brian K. Witt, TRICARE 
Management Activity, 303-676-3496.

SUPPLEMENTARY INFORMATION:

I. Background and Legislative Changes

    The Basic Active Duty Dependents Dental Benefits Plan was 
implemented on August 1, 1987, allowing Uniformed Service personnel, on 
active duty for periods of greater than thirty (30) days, 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 Uniformed Service 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 For Fiscal Year 
1993, Public Law 102-484, sec. 701]. The provisions of this Act 
specified the expanded 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.
    Thereafter, Congress granted legislative authority to allow the 
Secretary of Defense to expand the dental plan outside the United 
States and to provide one (1) year of continued dental coverage for 
enrolled dependents of service members who die while on active duty 
[The Defense Authorization Act For Fiscal Year 1995, 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 For Fiscal Year 1998, 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

[[Page 63203]]

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 (1) year, after notification, 
before any benefits could be reduced [The Defense Authorization Act For 
Fiscal Year 1999, Public Law 105-261, sec. 701].
    In Fiscal Year 2000, the Congress authorized the establishment of 
the TRICARE dental program (TDP), by striking 10 U.S.C. 1076a 
(Dependents' dental program) and 10 U.S.C. 1076b (Selected Reserve 
dental insurance) and inserting a revised section 1076a, TRICARE dental 
program [The Defense Authorization Act For Fiscal Year 2000, Public Law 
106-65, sec. 711]. Language in this revision directed the Secretary of 
Defense to establish a voluntary enrollment dental insurance plan for 
members of the Selected Reserve of the Ready Reserve (the former 
Selected Reserve dental insurance plan or more commonly referred to as 
the TRICARE Selected Reserve Dental Program or TSRDP) and for members 
of the Individual Ready Reserve described in 10 U.S.C. 10144(b). It 
also provided authorizing language to allow the Secretary of Defense to 
establish a dental insurance plan for eligible dependents of Uniformed 
Service members who are on active duty for periods of greater than 
thirty (30) days (the former Dependents' dental plan or more commonly 
referred to as the TRICARE Family Member Dental Plan or TFMDP), members 
of the Individual Ready Reserve as described in 10 U.S.C. 10144(a), and 
eligible dependents of members of the Ready Reserve of the Reserve 
components who are not on active duty for more than thirty (30) days. 
Essentially, the authorizing language combined the eligible populations 
of the TFMDP and TSRDP and added, as eligibles, members of the 
Individual Ready Reserve and dependents of members of the Selected 
Reserve and Individual Ready Reserve. Additionally, the Congress 
directed that the insurance plans for the dependents of active duty 
members and for the members of the Selected Reserve and Individual 
Ready Reserve (as described in 10 U.S.C. 10144(b)) would be premium 
sharing plans between the enrollee and the Government. Beneficiaries 
eligible to enroll in the remaining insurance plans would be required 
to pay the full premium as a condition of enrollment. To allow for 
greater participation in the TDP, the Congress allowed the member's 
share of the premium to be paid from their basic or reserve pay 
accounts or, for those who do not receive such pay, through payment 
procedures as specified by the Department. The Congress also authorized 
waiver of dental plan requirements for surviving dependents of members 
of the Ready Reserve if the dependent was enrolled in the dental plan 
on the date of death of the member. This revised the previous waiver 
authority that applied only to enrolled surviving dependents of active 
duty members.
    These legislative provisions have been codified in 10 U.S.C. 1076a, 
TRICARE dental program, and are reflected in the regulatory provisions 
of this final rule. By striking 10 U.S.C. 1076b, its implementing 
regulation, 32 CFR 199.21, TRICARE Selected Reserve Dental Program 
(TSRDP), is also removed and reserved.

II. Programmatic Improvements

    The below programmatic improvements will be effective once the 
follow-on TDP 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. Expansion of Eligible Populations

    With the authorizing legislation (The National Defense 
Authorization Act for Fiscal Year 2000), the final rule extends TDP 
coverage to newly eligible populations. This is an important step 
towards improving Reserve member's dental readiness and in promoting 
proper oral health across the beneficiary population. Designed to be a 
uniform benefit across all enrollees, the TDP offers a comprehensive 
benefit package with a strong focus on preventive and diagnostic 
services as well as pediatric and adolescent oral health. By extending 
coverage to the members of the Individual Ready Reserve and the 
dependents of the Selected Reserve and the Individual Ready Reserve and 
by offering a comprehensive dental benefit to the members of the 
Selected Reserve (versus the limited benefit previously available under 
the TSRDP), the Department and the Reserve components continue on the 
path towards parity with dental insurance plans historically extended 
only to dependents of the Active component. This final rule also 
addresses several administrative clarifications that distinguish dental 
plan requirements for the different beneficiary populations.

B. Contractor Enrollment

    Since the TFMDP (and its earlier versions) began, the Uniformed 
Services have administered the TFMDP 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 service members to contact one 
(1) organization to enroll, disenroll, reenroll and discuss other TDP 
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 
supporting the TFMDP does not allow an active duty member from one (1) 
Service to enroll his or her family members 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 TDP and greatly improves 
customer service.
    An added benefit to contractor enrollment will be the elimination 
of the current required TFMDP 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 TSRDP and the TRICARE Retiree Dental Program (TRDP). The 
Uniformed Services will continue, as with the former dental plans 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).

[[Page 63204]]

C. Contractor Direct Billing

    The current TFMDP 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 deduced 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 or 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. With the authorizing legislation (The 
National Defense Authorization Act for Fiscal Year 2000), 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. The provision of 
contractor direct billing is also extended to those Reserve component 
members and family members who are in similar situations.

D. Reduction in Mandatory Enrollment Period

    A mandatory enrollment period is an essential factor behind 
Government and contractor actuarial estimates in developing the TDP 
premium and provides a guarantee to the contracting community that they 
will collect a certain amount of premiums for the potential benefit 
payout. The final rule reduces the previous longstanding TFMDP twenty-
four (24) month mandatory enrollment period to twelve (12) months under 
the TDP since this twenty-four (24) month period precluded numerous, 
otherwise eligible, active duty dependents from enrolling in the dental 
plan. These eligible dependents include newly eligible dependents of 
active duty members who are near the end of their active service, 
dependents of enlisted service members who are outside of their re-
enlistment window of opportunity, and dependents of Reserve/Guard 
personnel called to active duty for less than twenty-four (24) months 
(such as Reserve/Guard personnel on active duty for training and 
special assignments). Reduction to a twelve (12) month enrollment 
period for the TDP has a precedent with other TRICARE plans, to include 
the TRICARE Managed Care Prime option and the TSRDP. By introducing 
this more liberal enrollment period, the regulation also calls for a 
twelve (12) month ``lock-out'' if the beneficiary disenrolls before 
completing the twelve (12) month enrollment period for any unauthorized 
reason or if the beneficiary fails to pay their premiums. A twelve (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 as provided in paragraph (c)(3)(ii)(C)(2) of this 
final rule. This ``lock-out'' period has a precedent with other 
commercial dental insurance plans as well as the TRICARE Managed Care 
Prime option, the TSRDP and the TRDP. ``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 twelve (12) months' worth of premiums.
    Beneficiaries enrolled in the TFMDP and TSRDP at the time when TDP 
coverage begins must complete their respective two (2) and one (1) year 
enrollment periods established under those superseded plans except if 
one of the conditions for valid disenrollment applies. Once these 
original enrollment periods are met, the beneficiary may continue TDP 
enrollment on month-to-month basis. A new one (1) year enrollment 
period will only be incurred if the beneficiary disenrolls and attempts 
to reenroll in the TDP at a later date.

E. Enrollment Period for Certain Reserve Component Sponsors

    The regulations provides that the twelve (12) month enrollment 
period shall not apply to eligible dependents of Reserve component 
sponsors ordered to active duty for more than thirty (30) days but less 
than twelve (12) months (other than for training) in support of a 
contingency operation as defined in 10 U.S.C. 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 desperate treatment for certain Reserve component 
members is necessary because of the involuntary nature of their call to 
active duty and statutory limitations on their period of active duty.
    By contrast, active duty members are enlisted, reenlisted or 
commissioned for periods of active duty longer than one (1) 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 twelve (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 (1) year; therefore they will 
have the option to enroll family members at any time other than in the 
last twelve (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 nine (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 eighteen (18) 
months; if serving for more than thirty (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 twelve (12) month enrollment 
period for TDP, 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 twelve (12) month enrollment period is therefore 
necessary to preclude such prejudicial treatment of Reserve component 
members ordered to active duty for less than twelve (12) months to 
support a contingency operation. In its place, a separate enrollment 
period is created for the Reserve component member as provided in 
paragraph (c)(3)(ii)(C)(2) if this final rule.

F. 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 
regulation would have a two-tiered maximum cost-share dependent on the 
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.

[[Page 63205]]



 
                              [In percent]
------------------------------------------------------------------------
                                            Cost-share
                                          for pay  grade    Cost-share
            Covered services              E-1,  E-2,  E-   for all other
                                             3 and E-4      pay 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).........................
Prosthodontics..........................              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 sixty (60) 
percent of the total premium for dependents of active duty members and 
members of the Selected Reserve and the Individual Ready Reserve (as 
described in 10 U.S.C. 10144(b)). As such, the greatest effect on 
participation and utilization can best be achieved through a reduction 
in cost-shares.

G. Simplification of Enrollment Options

    Under the final rule, previous TFMDP enrollment options have been 
simplified to assist the beneficiary, Government, provider of care and 
the dental plan contractor. Under the TFMDP (and previous plans), 
dependents were asked to choose from several different enrollment 
options depending on whether they had children under the age of four 
(4). With the advance in pediatric dentistry (pedodontics), dental care 
for children between the ages of one (1) and four (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 one (1) year of age or older. 
Although there will continue to be two (2) separate premiums, a 
``single'' premium for one (1) covered life, and a ``family'' premium 
for more than one (1) 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. A discussion of these enrollment policies and options 
will be found in the TDP contractor's benefit booklet.

H. 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 regulation allows the Department 
to add other types of anesthesia services to the TDP benefit package.

I. Congressional Waiver for Surviving Dependents

    This final rule provides clarification on the Department's use of 
the Congressional waiver for surviving dependents. Since 1993, the 
Department has used the waiver authority to provide one (1) year of 
continued TFMDP enrollment at Government expense to eligible dependents 
of active duty members who die while on active duty for a period of 
thirty-one (31) days or more. To receive the continued enrollment at 
Government expense, the eligible dependents must have been enrolled in 
the TFMDP at the time of the active duty member's death. With the 
authority in the National Defense Authorization Act for Fiscal Year 
2000, the final rule clarifies how the waiver will be used and extends 
use of the waiver to enrolled dependents of deceased members of the 
Selected Reserve and the Individual Ready Reserve (as described in 10 
U.S.C. 10144(b)).

J. Appeals Plan

    Under the TDP, 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 TSRDP and the TRDP, where the contractors administer 
the first two (2) levels of the appeals program, which are termed the 
initial determination and the reconsideration. Under the TDP, 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 levels 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.

K. Plan Transition

    The programmatic improvements are scheduled to take effect when the 
follow-on TDP contract to the current TFMDP contact is awarded and the 
performance period begins. Operations under the current TSRDP contract 
will also cease at that time. Considering the

[[Page 63206]]

magnitude of the planned improvements, the Department plans to ``phase-
out'' operations under the former contractors and methods 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 final rule 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 
TDP.
    The final rule 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'', 
``TRICARE Family Member Dental Plan'', ``TRICARE Selected Reserve 
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. Public Comments

    The proposed rule was published in the Federal Register on 
Wednesday, November 24, 1999, (64 FR 66126). We received one (1) 
comment letter. We thank the commenter and their organization; items 
raised by the commenter and our analysis of the comments are summarized 
below.

1. Enrollment

    The commenter recognized that there were numerous problems in the 
current enrollment and eligibility system that supports the TFMDP. They 
believe though that the Department should totally absorb any increased 
costs related to the contractor's enrollment function under the TDP.
    Response: Under the law, 10 U.S.C. 1076a, the Congress authorized 
that the dental plans offered will be ``premium sharing plans'' and 
``full premium plans''. As such, the Department must share in the cost 
of all programmatic improvements, to include contractor enrollment, for 
the majority of the enrollees.

2. Enrollment

    The commenter suggested that, if problems persist with enrollment 
and eligibility processing under the TDP and which cannot be swiftly 
handled by the dental contractor, consideration should be given to 
establishing some form of beneficiary counselor that would act on 
behalf of the beneficiary.
    Response: As with the current contracts, the Department is 
committed to assisting TDP beneficiaries if problems occur. 
Representatives from the Uniformed Services (to include Health Benefits 
Advisors), the Finance Centers, the Defense Manpower Data Center and 
the TRICARE Management Activity will all be available to act on our 
beneficiaries' behalf, if needed.

3. Enrollment

    The commenter asked if there are any provisions in the TDP to 
assist deployed service members with enrollment issues.
    Response: Numerous options exist under the TDP to assist deployed 
service members. These include web-based and electronic mail 
capabilities, additional toll-free lines, extended hours of operation, 
and use of commercial business practices that allow representatives of 
the sponsor to act on enrollment issues during the sponsor's absence.

4. Enrollment

    The commenter requested that enrollees be offered the option to 
enroll their children who reach the age of four (4) stating that the 
increase in premium by moving to a family premium will result in more 
junior service members opting out of the plan.
    Response: Under the current TFMDP, when a child reaches four (4) 
years old, they are automatically enrolled. This has not been a cause 
of concern with current enrollees nor has it led to measurable 
disenrollments. Continuing this in the TDP is in keeping with the 
accepted standards and direction of pediatric and adolescent dentistry, 
which recommends early preventive and diagnostic intervention and 
distinct care at set age intervals.

5. Survivor Benefit

    The commenter requested that the final rule contain specific 
language that the Government will pay premiums for enrolled survivors 
for the one (1) year period following the sponsor's death.
    Response: We appreciate the comment and have clarified this in the 
final rule.

6. Eligibility

    The commenter questioned eligibility language regarding a child who 
becomes a re-eligible for TDP benefits because the child's marriage 
ends before the child is twenty-one (21) years of age and who loses 
eligibility at twenty-one (21) years of age. The commenter stated that 
this language was inconsistent with eligibility up to age twenty-three 
(23) if the child is a full-time student.
    Response: Full-time student eligibility for the TDP up to age 
twenty-three (23) is listed in the final rule by cross-reference to 32 
CFR 199.3(b)(2)(iv)(C).

7. Alternative Delivery Systems

    The commenter was opposed to language regarding the provision of 
alternative delivery systems and potential implementation of these 
systems under the TDP. Their concern was that alternative delivery 
systems would limit beneficiaries to a dental health maintenance 
organization, preclude beneficiary choice of dental providers, allow 
such entities as Morale, Welfare and Recreation and Exchange 
organizations the opportunity for increased profits if they were 
designated as alternative delivery systems, and that both quality and 
cost could be compromised by the implementation of a closed system.
    Response: The alternative delivery system language has been in this 
regulation since 1988. To date, this provision has not been utilized as 
the

[[Page 63207]]

Department supports a traditional network-oriented dental indemnity 
insurance plan over other forms of managed care. The principle of 
provider choice is an important element of this regulation as well as 
the TDP contract and the Department has no immediate plans to engage in 
``closed'' systems. The Department does reserve the right to explore 
alternative delivery systems in the form of demonstrations or pilot 
programs if the Congress believes this would be in the beneficiary's 
best interest.

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 final rule is not a significant regulatory action under 
Executive Order 12866. The changes set forth in this final rule are 
minor revisions to the existing regulation. Since this final 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:


Sec. 199.13  TRICARE Dental Program.

    (a) General provisions--(1) Purpose. This section prescribes 
guidelines and policies for the delivery and administration of the 
TRICARE Dental Program (TDP) of the Uniformed Services of the Army, the 
Navy, the Air Force, the Marines Corps, the Coast Guard, the 
Commissioned Corps of the U.S. Public Health Service (USPHS) and the 
National Oceanic and Atmospheric Administration (NOAA) Corps. The TDP 
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 (7) 
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 TDP is authorized by 10 U.S.C. 1076a, 
TRICARE dental program, and this section was previously titled the 
``Active Duty Dependents Dental Plan''. The TDP incorporates the former 
10 U.S.C. 1076b, Selected Reserve dental insurance, and the section 
previously titled the ``TRICARE Selected Reserve Dental Program'', 
Sec. 199.21.
    (2) Applicability.--(i) Geographic scope. (A) The TDP is applicable 
geographically within the fifty (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 TDP 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 TDP to areas other than those areas specified in paragraph 
(a)(2)(i)(A) of this section for the eligible members and eligible 
dependents of 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 TDP 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 TDP. 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 for certain 
beneficiary categories. Other differences 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 paragraph (a)(2)(i)(B). Beneficiaries 
will be eligible for the same TDP 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, dependents of active duty, Selected Reserve and Individual 
Ready Reserve members enrolled in the TDP may not obtain those services 
that are benefits of the TDP in military dental care facilities, as 
long as those covered benefits are available for cost-sharing under the 
TDP. Enrolled dependents of active duty, Selected Reserve and 
Individual Ready Reserve members 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 authorized 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 TDP.
    (B) Administration. 10 U.S.C. 1073 authorizes the Secretary of 
Defense to administer the TDP for the Army, Navy, Air Force, and Marine 
Corps under DoD jurisdiction, the Secretary of Transportation to 
administer the TDP 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 TDP for the Commissioned Corps of the 
USPHS and the NOAA Corps.
    (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

[[Page 63208]]

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 TDP.
    (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 Uniformed Service 
beneficiaries 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 TDP 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 
TDP 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, 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 TDP 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 beneficiaries.
    (ii) Disposition of funds. TDP 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 TDP 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 TDP. 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 TDP's policies and procedures and has no authority 
to make benefit determinations or obligate the TDP'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 TDP. 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, Selected Reserve or individual Ready 
Reserve 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

[[Page 63209]]

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 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 from 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 TDP 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 Sec. 199.2. The following definitions apply 
only to this 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, Selected Reserve or 
Individual Ready Reserve member for any remaining amount of the fees 
for services which exceeds the prevailing fee allowance of the insurer.
    (2) Authorized provider. A dentist, dental hygienist, or certified 
and licensed anesthetist specifically authorized to provide benefits 
under the TDP in paragraph (f) of this section.
    (3) Beneficiary. A dependent of an active duty, Selected Reserve or 
Individual Ready Reserve member, or a member of the Selected Reserve or 
Individual Ready Reserve, who has been enrolled in the TDP, 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 TDP, 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 TDP, 
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, Selected Reserve or Individual Ready Reserve 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 (2) phases:
    (i) Enrolling all active duty, Reserve 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 TDP.
    (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 
TDP and further defined in paragraph (e) of the 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 TDP 
claim, a request for TDP 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 TDP. 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 TDP benefits are 
not initial determinations.
    (14) Nonparticipating provider. A dentist or dental hygienist that 
furnished dental services to a TDP 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, Selected Reserve or 
Individual Ready Reserve 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

[[Page 63210]]

pays the beneficiary or active duty, Selected Reserve or Individual 
Ready Reserve 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, Selected Reserve or Individual Ready 
Reserve member) or any cost-share for covered services.
    (18) Party to the initial determination. Includes the TDP, a 
beneficiary of the TDP and a participating provider of services whose 
interests have been adjudicated by the initial determination. In 
addition, provider who has been denied approval as an authorized TDP 
provider is a party to the initial determination, as is a provider who 
is suspended, excluded or terminated as an authorized provider, unless 
the provider is excluded or suspended by another agency of the Federal 
Government, a state, or a local licensing authority.
    (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, refinement, 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, dental hygienist, or certified and 
licensed anesthetist 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.
    (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), 1072(6), 10143 and 10144 set forth those 
persons who are eligible for voluntary enrollment in the TDP. 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) Persons eligible. Eligibility for the TDP is 
continuous in situations where the sponsor or member changes status 
between any of these eligible categories and there is no break in 
service or transfer to a non-eligible status.
    (A) 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 or less) or a member of the Selected Reserve 
(as specified in 10 U.S.C. 10143) or Individual Ready Reserve (as 
specified in 10 U.S.C. 10144):
    (1) Spouse. A lawful husband or wife, regardless of whether or not 
dependent upon the active duty, Selected Reserve or Individual Ready 
Reserve member.
    (2) 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).
    (B) A member of the Selected Reserve of the Ready Reserve (as 
specified in 10 U.S.C. 10143).
    (C) A member of the Individual Ready Reserve of the Ready Reserve 
(as specified in 10 U.S.C. 10144(b)) who is subject to being ordered to 
active duty involuntarily in accordance with 10 U.S.C. 12304.
    (D) All other members of the Individual Ready Reserve of the Ready 
Reserve (as specified in 10 U.S.C. 10144(a)).
    (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 TDP 
is the responsibility of the 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 of a specified person when there is reason to question 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 Service 
identification cards do not distinguish eligibility for the TDP. 
Procedures for the determination of eligibility are identified in 
Sec. 199.3(f)(2), except that Uniformed Service identification cards do 
not provide evidence of eligibility for the TDP. Although OCHAMPUS and 
the dental plan contractor must make determinations concerning a member 
or dependent's eligibility in order to ensure proper enrollment and 
proper disbursement of appropriated funds, ultimate responsibility for 
resolving a member or dependent's eligibility rests with the Uniformed 
Services.
    (C) Evidence of eligibility required. Eligibility and enrollment in 
the TDP will be verified through the DEERS. Eligibility and enrollment 
information established and maintained in the DEERS file is the only 
acceptable evidence of TDP eligibility and enrollment. It is the 
responsibility of the active duty, Selected Reserve or Individual Ready 
Reserve member or TDP beneficiary, parent, or legal representative, 
when appropriate, to provide adequate evidence for entry into the DEERS 
file to establish eligibility for the TDP, and to ensure that all 
changes in status that may affect 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.--(i) 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 (also known as the 
TRICARE Family Member Dental Plan) was effective from August 1, 1993, 
up to the date of implementation of the TDP. The

[[Page 63211]]

Expanded Active Duty Dependents Dental Benefit Plan terminates upon 
implementation of the TDP.
    (ii) TRICARE Dental Program (TDP).--(A) Election of coverage.--(1) 
Except as provided in paragraph (c)(3)(ii)(A)(2) of this section, 
active duty, Selected Reserve and Individual Ready Reserve service 
members may voluntarily elect to enroll their eligible dependents and 
members of the Selected Reserve and Individual Ready Reserve may 
voluntarily elect to enroll themselves following implementation of the 
TDP. In order to obtain TDP coverage, written or telephonic election by 
the active duty, Selected Reserve or Individual Ready Reserve 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 the TDP will automatically be enrolled in the TDP. 
Eligible members of the Selected Reserve enrolled in the TRICARE 
Selected Reserve Dental Program at the time of implementation of the 
TDP will automatically be enrolled in the TDP. No election to enroll in 
the TDP will be required by the active duty or Selected Reserve 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 or one (1) 
covered eligible Selected Reserve or Individual Ready Reserve member.
    (ii) Family premium. Two (2) or more covered eligible dependents. 
Under the family premium, all eligible dependents of the active duty, 
Selected Reserve or Individual Ready Reserve member are enrolled.
    (2) Exceptions.--(i) An active duty, Selected Reserve or Individual 
Ready Reserve member may elect to enroll only those eligible dependents 
residing in one (1) location when the active duty, Selected Reserve or 
Individual Ready Reserve 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 of an active duty member requires 
a hospital or special treatment environment (due to a medical, physical 
handicap, or mental condition) for dental care otherwise covered by the 
TDP, the dependent may be excluded from TDP enrollment and may continue 
to receive care from a military treatment facility.
    (iii) A member of the Selected Reserve or Individual Ready Reserve 
may enroll separately from his or her eligible dependents. A member of 
the Selected Reserve or Individual Ready Reserve does not have to be 
enrolled in order for his or her eligible dependents to enroll under 
the TDP.
    (C) Enrollment period.--(1) General. Enrollment of eligible 
dependents or members is for a period of one (1) year followed by 
month-to-month enrollment as long as the active duty, Selected Reserve 
or Individual Ready Reserve member chooses to continue enrollment. 
Active duty members may enroll their eligible dependents and eligible 
members of the Selected Reserve or Individual Ready Reserve may enroll 
themselves or their eligible dependents in the TDP provided there is an 
intent to remain on active duty or as a member of the Selected Reserve 
or Individual Ready Reserve (or any combination thereof without a break 
in service or transfer to a non-eligible status) for a period of not 
less than one (1) year by the service member and their parent Unformed 
Service. Beneficiaries enrolled in the TDP 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) Special enrollment period for Reserve component members ordered 
to active duty in support of contingency operations. The mandatory 
twelve (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 TDP 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 the TDP and complete the enrollment application within 
thirty (30) days following entry on active duty or within sixty (60) 
days following implementation of the TDP. Following enrollment, 
beneficiaries 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 twelve (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 TDP coverage begins 
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 TDP 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 reenroll in the TDP at a later date.
    (4) Continuation of enrollment from TRICARE Selected Reserve Dental 
Program. Beneficiaries enrolled in the TRICARE Selected Reserve Dental 
Program at the time when TDP coverage begins must complete their one 
(1) year enrollment period established under this former program except 
if one of the conditions for disenrollment specified in paragraph 
(c)(3)(ii)(E) of this section is met. Once this original one (1) year 
enrollment period is met, the Selected Reserve member may continue TDP 
enrollment on a month-to-month basis. A new one (1) year enrollment 
period will only be incurred if the Selected Reserve member disenrolls 
and attempts to reenroll in the TDP at a later date.
    (D) Beginning dates of eligibility. The beginning date of 
eligibility for TDP 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, except that the date of eligibility shall not be 
earlier than the first day of the month in which the TDP is 
implemented. This includes any changes between single and family member 
premium coverage and coverage of newly eligible or enrolled dependents 
or members.
    (E) Changes in and termination of enrollment.--(1) Changes in 
status of active duty, Selected Reserve or Individual Ready Reserve 
member. When the active duty, Selected Reserve or Individual Ready 
Reserve member is separated, discharged, retired, transferred to the 
Standby or Retired Reserve, his or her enrolled dependents and/or the 
enrolled Selected Reserve or Individual Ready Reserve member lose 
eligibility and enrollment as of 11:59 p.m. on the last day of the 
month in which the change in status takes place. When the Selected 
Reserve or Individual Ready Reserve member is ordered to active duty 
for a period of thirty-one (31) days or more without a break in 
service, the member loses their eligibility and is disenrolled, if they

[[Page 63212]]

were previously enrolled; however, their enrolled dependents maintain 
their eligibility and previous enrollment subject to eligibility, 
enrollment and disenrollment provisions described in this section and 
in the TDP contract. When the previously enrolled active duty member is 
transferred back to the Selected Reserve or Individual Ready Reserve 
without a break in service, the member regains eligibility and is 
reenrolled; however, their enrolled dependents maintain their 
eligibility and previous enrollment subject to eligibility, enrollment 
and disenrollment provisions described in this section and in the TDP 
contract. Eligible dependents of an active duty, Selected Reserve or 
Individual Ready Reserve member serving a sentence of confinement in 
conjunction with a sentence of punitive discharge are still eligible 
for the TDP until such time as the active duty, Selected Reserve or 
Individual Ready Reserve member's discharge is executed.
    (2) Continuation of eligibility for dependents of service members 
who die while on active duty or while a member of the Selected Reserve 
or Individual Ready Reserve. Eligible dependents of active duty members 
while on active duty for a period of thirty-one (31) days or more and 
eligible dependents of Selected Reserve or Individual Ready Reserve 
members, as specified in 10 U.S.C. 10143 and 10144(b) respectively, who 
die on or after the implementation date of the TDP, and whose 
dependents are enrolled in the TDP on the date of the death of the 
active duty, Selected Reserve or Individual Ready Reserve member shall 
be eligible for continued enrollment in the TDP for up to one (1) year 
from the date of the active duty, Selected Reserve or Individual Ready 
Reserve member's death. This continued enrollment is not contingent on 
the Selected Reserve or Individual Ready Reserve member's own 
enrollment in the TDP. During the one (1) year period of continuous 
enrollment, the Government will pay both the Government and the 
beneficiary's portion of the premium share.
    (3) Changes in status of dependent.--(i) Divorce. A spouse 
separated from an active duty, Selected Reserve or Individual Ready 
Reserve 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 become final. The eligibility of the 
active duty, Selected Reserve or Individual Ready Reserve 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, Selected 
Reserve or Individual Ready Reserve 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, Selected Reserve or Individual 
Ready Reserve 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, Selected Reserve or 
Individual Ready Reserve member who is adopted by a person, other than 
a person whose dependents are eligible for TDP benefits while the 
active duty, Selected Reserve or Individual Ready Reserve member is 
living, thereby severing the legal relationship between the child and 
the active duty, Selected Reserve or Individual Ready Reserve 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, Selected Reserve 
or Individual Ready Reserve member who marries a person whose 
dependents are not eligible for the TDP, 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 twenty-one (21) years old, the child 
again become 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 
twenty-one (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 twenty-one (21) 
or twenty-two (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 TDP 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 TDP 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 twenty-one (21) or twenty-two (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 twenty-one (21) or twenty-two (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.--(i) Disenrollment because of no eligible beneficiaries. 
When an active duty, Selected Reserve or Individual Ready Reserve 
member ceases to have any eligible beneficiaries, enrollment is 
terminated for those enrolled dependents.
    (ii) Option to disenroll as a result of a change in active duty 
station. When an active duty member transfers with enrolled dependents 
to a duty station where space-available dental care for the enrolled 
dependents is readily available at the local Uniformed Service dental 
treatment facility, the active duty member may elect, within ninety 
(90) calendar days of the transfer, to disenroll their dependents from 
the TDP. 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 reenroll their eligible dependents in the TDP 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. This disenrollment 
provision does not apply to enrolled dependents of members of the 
Selected Reserve or Individual Ready Reserve or to enrolled members of 
the Selected Reserve or Individual Ready Reserve.
    (iii) Option to disenroll due to transfer to OCONUS service area. 
When an enrolled dependent of an active duty, Selected Reserve or 
Individual Ready Reserve member or an enrolled Selected Reserve or 
Individual Ready Reserve member relocates to locations within the 
OCONUS service area, the active duty, Selected Reserve or Individual

[[Page 63213]]

Ready Reserve member may elect, within ninety (90) calendar days of the 
relocation, to disenroll their dependents from the TDP, or in the case 
of enrolled members of the Selected Reserve or Individual Ready 
Reserve, to disenroll themselves from the TDP. The active duty, 
Selected Reserve or Individual Ready Reserve member may reenroll their 
eligible dependents, or in the case of members of the Selected Reserve 
or Individual Ready Reserve, may reenroll themselves in the TDP 
provided the member, as of the date of reenrollment, otherwise meets 
the requirements for enrollment, including the intent to remain on 
active duty or as a member of the Selected Reserve or Individual Ready 
Reserve (or any combination thereof without a break in service or 
transfer to a non-eligible status) for a period of not less than one 
(1) year.
    (iv) Option to disenroll after an initial one (1) year enrollment. 
When a dependent's enrollment under an active duty, Selected Reserve or 
Individual Ready Reserve member or a Selected Reserve or Individual 
Ready Reserve member's own enrollment has been in effect for a 
continuous period of one (1) year, the active duty, Selected Reserve or 
Individual Ready Reserve member may disenroll their dependents, or in 
the case of enrolled members of the Selected Reserve or Individual 
Ready Reserve may disenroll themselves at any time following procedures 
as set up by the dental plan contractor. Subsequent to the 
disenrollment, the active duty, Selected Reserve or Individual Ready 
Reserve member may reenroll their eligible dependents, or in the case 
of members of the Selected Reserve or Individual Ready Reserve may 
reenroll themselves, for another minimum period of one (1) year. If, 
during any one (1) year enrollment period, the active duty, Selected 
Reserve or Individual Ready Reserve member disenrolls their dependents, 
or in the case of members of the Selected Reserve or Individual Ready 
Reserve disenrolls themselves, for reasons other than those listed in 
this paragraph (c)(3)(ii)(E) or fails to make premium payments, 
dependents enrolled under the active duty, Selected Reserve or 
Individual Ready Reserve member, or enrolled members of the Selected 
Reserve and Individual Ready Reserve, will be subject to a lock-out 
period of twelve (12) months. Following this period of time, active 
duty, Selected Reserve or Individual Ready Reserve members will be able 
to reenroll their eligible dependents, or members of the Selected 
Reserve or Individual Ready Reserve will be able to reenroll 
themselves, if they so choose. The twelve (12) month lock-out period 
applies to enrolled dependents of 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, Selected Reserve or 
Individual Ready Reserve members enrolling their eligible dependents, 
or members of the Selected Reserve or Individual Ready Reserve 
enrolling themselves, in the TDP shall be required to pay all or a 
portion of the premium cost depending on their status.
    (i) Members required to pay a portion of the premium cost. This 
premium category includes active duty members (under a call or order to 
active duty that does not specify a period of thirty (30) days or less) 
on behalf of their enrolled dependents. It also includes members of the 
Selected Reserve (as specified in 10 U.S.C. 10143) and the Individual 
Ready Reserve (as specified in 10 U.S.C. 10144(b)) enrolled on their 
own behalf.
    (ii) Members required to pay the full premium cost. This premium 
category includes members of the Selected Reserve (as specified in 10 
U.S.C. 10143), and the Individual Ready Reserve (as specified in 10 
U.S.C. 10144), on behalf of their enrolled dependents. It also includes 
members of the Individual Ready Reserve (as specified in 10 U.S.C. 
10144(a)) enrolled on their own behalf.
    (2) Proportion of premium share. The proportion of premium share to 
be paid by the active duty, Selected Reserve and Individual Reserve 
member pursuant to paragraph (d)(1)(i) of this section is established 
by the ASD(HA), or designee, at not more than forty (40) percent of the 
total premium. The proportion of premium share to be paid by the 
Selected Reserve and Individual Reserve member pursuant to paragraph 
(d)(1)(ii) of this section is established by the ASD(HA), or designee, 
at one hundred (100) percent of the total premium.
    (3) Provision for increases in active duty, Selected Reserve and 
Individual Ready Reserve member's premium share.--(i) Although 
previously capped at $20 per month, the law has been amended to 
authorize the cap on active duty, Selected Reserve and Individual Ready 
Reserve member's premiums pursuant to paragraph (d)(1)(i) of this 
section 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 members of the 
Uniformed Services 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, Selected 
Reserve and Individual Ready Reserve member's TDP premium pursuant to 
paragraph (d)(1)(i) of this section will be applied as if the 
methodology had been in continuous use since December 31, 1993.
    (4) Reduction of premium share for enlisted members. For enlisted 
members in pay grades E-1 through E-4, the ASD(HA) or designee, may 
reduce the monthly premium these active duty, Selected Reserve and 
Individual Ready Reserve members pay pursuant to paragraph (d)(1)(i) of 
this section.
    (5) Reduction of cost-shares for enlisted members. For enlisted 
members in pay grades E-1 through E-4, the ASD(HA) or designee, may 
reduce the cost-shares that active duty, Selected Reserve and 
Individual Ready Reserve members pay on behalf of their enrolled 
dependents and that members of the Selected Reserve and Individual 
Ready Reserve pay on their own behalf for selected benefits as 
specified in paragraph (e)(3)(i) of this section.
    (6) Premium payment method. The active duty, Selected Reserve and 
Individual Ready Reserve member's premium share may be deducted from 
the active duty, Selected Reserve or Individual Ready Reserve member's 
basic pay or compensation paid under 37 U.S.C. 206, if sufficient pay 
is available. For members who are otherwise eligible for TDP benefits 
and who do not receive such pay and dependents who are otherwise 
eligible for TDP benefits and whose sponsors do not receive such pay, 
or if insufficient pay is available, the premium payment may be 
collected pursuant to procedures established by the Director, OCHAMPUS, 
or designee.
    (7) Annual notification of premium rates. TDP 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 TDP 
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

[[Page 63214]]

determinations and authorize plan payments under the TDP 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 Services HBAs and major personnel centers 
at Uniformed Service installations and headquarters to all members 
enrolling themselves or their eligible dependents.
    (iv) Alternative course of treatment policy. The Director, 
OCHAMPUS, or designee, may establish, in accordance with generally 
accepted dental benefit practices, an 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 following conditions:
    (A) The service, procedure, or course of treatment must be 
consistent with sound professional standards of 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 TDP for the dental condition.
    (C) Payment for the alternative service or procedure may not exceed 
the lower of the prevailing limits for 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 
TDP'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.
    (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 removable complete and partial dentures, fixed crowns and 
bridges when performed directly by dentists as authorized under 
paragraph (4) of this section. These include the following categories 
of prosthodontic services:
    (A) Prosthodontics (removable).
    (1) Complete and partial dentures.
    (2) Adjustments to dentures.
    (3) Repairs to complete and partial dentures.
    (4) Denture rebase procedures.
    (5) Denture reline procedures.

[[Page 63215]]

    (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 TDP. For further information on 
adjunctive dental care benefits under TRICARE/CHAMPUS, 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 TDP.
    (xi) Limitation on reduction of benefits. If a reduction in 
benefits is planned, the Secretary of Defense, or designee, may not 
reduce TDP benefits without notifying the appropriate Congressional 
committees. If a reduction is approved, the Secretary of Defense, or 
designee, must wait one (1) 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, Selected Reserve and 
Individual Ready Reserve member and dependent cost-shares for covered 
services for participating and nonparticipating providers of care (see 
paragraph (f)(6) of this section for additional active duty, Selected 
Reserve and Individual Ready Reserve costs). These are percentages of 
the dental plan contractor's determined allowable amount that the 
active duty, Selected Reserve and Individual Ready Reserve member or 
beneficiary must pay to these providers. For care received in the 
OCONUS service area, the ASD(HA), or designee, may pay certain cost-
shares and other portions of a provider's billed charge for enrolled 
dependents of active duty members (under a call or order that does not 
specify a period of thirty (30) days or less), and for members of the 
Selected Reserve (as specified in 10 U.S.C. 10143) and Individual Ready 
Reserve (as specified in 10 U.S.C. 10144(b)) enrolled on their own 
behalf.

 
                              [In percent]
------------------------------------------------------------------------
                                                      Cost-
                                                      share      Cost-
                                                     for pay     share
                 Covered services                   grades E-   for all
                                                     1,  E-2,  other pay
                                                    E-3 and E-   grades
                                                        4
------------------------------------------------------------------------
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, resins,              20         20
 stainless steel crowns)..........................
Endodontic........................................         30         40
Periodontic.......................................         30         40
Oral and Maxilllofacial Surgery...................         30         40
General Anesthesia................................         40         40
Intravenous Sedation..............................         50         50
Other Restorative (example: crowns, onlays, casts)         50         50
Prosthodontics....................................         50         50
Medications.......................................         50         50
Orthodontic.......................................         50         50
Miscellaneous.....................................         50         50
------------------------------------------------------------------------

    (ii) Dental plan contractor liability. When more than twenty-five 
(25) percent or more than two hundred (200) enrollees in a specific 
five (5) digit zip code area are unable to obtain a periodic or initial 
(non-emergency) dentistry appointment with a network provider within 
twenty-one (21) calendar days and within thirty-five (35) miles of the 
enrollee's place of residence, then the TRICARE Management Activity 
(TMA) will designate that area as ``non-compliant with the access 
standard.'' Once so designated, the dental program contractor will 
reimburse the beneficiary, or active duty, Selected Reserve or 
Individual Ready Reserve member, or the nonparticipating provider 
selected by enrollees in that area (or a subset of the area or nearby 
zip codes in other five (5) digit zip code areas as determined by TMA) 
at the level of the provider's usual fees less the applicable enrollee 
cost-share, if any. TMA shall determine when such area becomes 
compliant with the access standards. This access standard and 
associated liability does not apply to care received in the OCONUS 
service area.
    (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. 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 restrictions 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 TDP will automatically pay a claim for 
services or supplies provided by such a provider. The Director, 
OCHAMPUS, or designee, also must determine if the

[[Page 63216]]

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) Utilization 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 TDP. Utilization review and quality assurance assessments shall be 
performed under the TDP 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 TDP authorized provider 
practicing within the scope of his or her license.
    (5) Participating provider. An authorized provider may elect to 
participate for all TDP 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 (1) 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 TDP beneficiaries and request the beneficiary 
or active duty, Selected Reserve or Individual Ready Reserve 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 availability within twenty-one (21) 
calendar days. In such instances of the nonavailability of a 
participating provider and in accordance with the provisions of the 
dental contract, 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)(3)(i) of this section.
    (i) Assignment of benefits. A nonparticipating provider may accept 
assignment of benefits for claims (for beneficiaries certifying their 
willingness to make such assignment of benefits) by filing the claims 
completed with the assistance of the beneficiary or active duty, 
Selected Reserve or Individual Ready Reserve 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, Selected 
Reserve or Individual Ready Reserve member file the claim directly with 
the dental plan contractor, making arrangements with the beneficiary or 
active duty, Selected Reserve or Individual Ready Reserve member for 
direct payment by the beneficiary or active duty, Selected Reserve or 
Individual Ready Reserve 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 
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 
an 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 TDP 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 TDP'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 TDP as an incentive for beneficiary participation 
in the alternative delivery system.
    (g) Benefit payment--(1) General. TDP benefits payments are made 
either directly to the provider or to the beneficiary or active duty, 
Selected Reserve or Individual Ready Reserve 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.

[[Page 63217]]

Beneficiaries using nonparticipating providers may be balance-billed 
amounts in excess of the dental plan contractor's determination of 
allowable charges. The following general requirements for the TDP 
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, Selected Reserve or Individual Ready Reserve members for 
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'', ``TDP beneficiaries'' and ``TPD providers'' respectively 
for the purposes of this section. Examples of fraud include situations 
in which ineligible persons not enrolled in the TDP obtain care and 
file claims for benefits under the name and identification of a 
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 contractor'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'', ``CAMPUS 
participating providers'' and ``CHAMPUS Explanation of Benefits'' in 
Sec. 199.10 shall be construed to mean the ``dental plan contractor'', 
``TDP beneficiaries'', ``TDP participating providers'' and ``Dental 
Explanation of Benefits or DEOB'' respectively for the purposes of this 
section. References to ``OCHAMPUSEUR'' in Sec. 199.10 are not 
applicable to the TDP 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).
    (ii) Participation in an appeal. Participation 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 non-appealable 
issues. 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 TDP 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 TDP. 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.

[[Page 63218]]

    (viii) Levels of appeal. See Sec. 199.10(a)(8)(i). Initial 
determinations involving the sanctioning (exclusion, suspension, or 
termination) of TDP 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. 1.99.10(d) and Sec. 199.10(d)(1) 
through (d)(5) and (d0(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 applicable for the date(s) of service, 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 decisions 
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).


Sec. 199.21  [Removed and Reserved]

    3. Section 199.21 is removed and resrved.

    Dated: October 16, 2000.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 00-27016 Filed 10-20-00; 8:45 am]
BILLING CODE 5001-10-M