[Federal Register Volume 67, Number 20 (Wednesday, January 30, 2002)]
[Rules and Regulations]
[Pages 4353-4355]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-2172]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720-AA61


Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS); Enhancement of Dental Benefits Under the TRICARE Retiree 
Dental Program

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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SUMMARY: This final rule implements section 704 of the National Defense 
Authorization Act for Fiscal Year 2000, to allow additional benefits 
under the retiree dental insurance plan for Uniformed Services retirees 
and their family members that may be comparable to those under the 
Dependents Dental Program.

EFFECTIVE DATE: This final rule is effective October 1, 2000.

ADDRESSES: TRICARE Management Activity (TMA), Special Contracts and 
Operations Office, 16401 East Centretech Parkway, Aurora, CO 80011-
9043.

FOR FURTHER INFORMATION CONTACT: Linda Winter, Special Contracts and 
Operations Office, TMA, (303) 676-3682.

SUPPLEMENTARY INFORMATION:

I. Background

A. Congressional Action

    The TRICARE Retiree Dental Program (TRDP), a voluntary dental 
insurance plan completely funded by enrollees' premiums, was 
implemented in 1998 to provide benefits for basic dental care and 
treatment based on the authority of 10 U.S.C. 1076c. Under the enabling 
legislation, the benefits that could be provided were limited to 
``basic dental care and treatment, involving diagnostic services, 
preventative services, basic restorative services (including 
endodontics), surgical services, and emergency services.'' Accordingly, 
the implementing regulation, 32 CFR 199.22, limited coverage to the 
most common dental procedures necessary for maintenance of good dental 
health and did not include coverage of major restorative services, 
prosthodontics, orthodontics or other procedures considered to be 
outside of the ``basic dental care and treatment'' range.
    In section 704 of the National Defense Authorization Act for Fiscal 
Year 2000, Pub. L. 106-065, Congress responded to concerns that the 
enabling legislation was too restrictive in the range of benefits 
authorized by amending 10 U.S.C. 1076c to allow the Secretary of 
Defense to offer additional coverage.

[[Page 4354]]

Under provisions of the amendment, the TRDP benefits may now be 
``comparable to the benefits authorized under section 1076a'' of title 
10, the Dependents Dental Plan, commonly known as the TRICARE Family 
Member Dental Plan. Thus, in addition to the original basic services 
described above, which continue to be mandated, coverage of 
``orthodontic services, crowns, gold fillings, bridges, complete or 
partial dentures, and such other services as the Secretary of Defense 
considers to be appropriate'' [10 U.S.C. 1076a(d)(3)] may be covered by 
the TRDP.

B. Public Comments

    On August 14, 2000, an interim final rule was published (65 FR 
49491) to allow the additional dental coverage and address the 
administrative and operational issues associated with the enhanced TRDP 
benefits. No public comments were received.

II. Provisions of the Rule for Enhancement of TRDP Benefits

A. Primary Provisions of the Interim Final Rule

    The interim final rule allows expansion of the TRDP benefits to be 
comparable to the coverage under Active Duty Dental Plan at 32 CFR 
199.13, commonly known as the TRICARE Family Member Dental Plan. It 
maintains the original basic TRDP coverage, with the original initial 
and renewal enrollment periods, until contractual arrangements are in 
place for the additional benefits. Enrollment in the original basic 
plan will be superseded by enrollment in the enhanced plan. Effective 
with the implementation of an enhanced plan, new enrollments for basic 
coverage cease. Enrollees in the basic plan at that time may continue 
their enrollment for basic coverage, subject to the applicable premium 
and eligibility provisions, as long as the contract administering that 
coverage is in effect. Enrollees in the basic plan have an enrollment 
option at the time of the enhanced plan's implementation.

B. Other Provisions of the Interim Final Rule

    One of the aims of the interim final rule was to allow flexibility 
in the design of an enhanced benefit structure to help keep the 
increase in premiums within a reasonable range with the addition of the 
major dental coverage. This takes into account the increase in premiums 
not only for the increased benefits but the potential increase due to 
the risk of adverse selection. Adverse selection is the tendency for 
people who have a greater-than-average likelihood of needing treatment 
to seek coverage more than those who have a lesser likelihood of 
needing treatment. Accordingly, the interim final rule provides for 
renewal enrollment periods of up to 12 months per period for the 
enhanced benefits, thereby allowing the risk to be spread over a 
greater period of time than the month-to-month continuing enrollment 
for the basic coverage. Renewal for the basic program continues to be 
on a monthly basis. To offset the longer renewal periods, the rule 
allows a flexibility in the initial enrollment period for the enhanced 
benefits by permitting it to be in the range of from 12 to 24 months, 
the exact length to be determined through contractual arrangement. The 
initial enrollment period for the basis program will continue to be 24 
months.
    In addition, the interim final rule allows the establishment of an 
alternative course of treatment policy as in the TFMDP, adds a 
provision for orthodontic lifetime maximum should an orthodontic 
benefit be offered, and removes the specific dollar limit on the non-
orthodontic annual benefit maximum while retaining the requirement for 
an annual maximum benefit amount. These changes are being made to 
permit more flexibility in the design and implementation of an enhanced 
TRDP benefit structure and allow ways to mitigate the increased risk 
for adverse selection and unacceptably high premiums that are likely to 
occur with the addition of major coverage.
    Recognizing that occasionally some enrollees experience ``buyers's 
remorse'' shortly after enrolling in the program, this rule adds a 30-
day grace period that allows new enrollees to terminate a TRDP 
enrollment immediately after enrollment provided no benefits have been 
used. This is consistent with the legislative mandate that the retiree 
dental plan be voluntary and provides enrollees an opportunity to 
further consider their dental needs before they are obligated for the 
initial enrollment period.

C. Provisions of the Final Rule

    The final rule is consistent with the interim final rule.

III. Rulemaking 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 that would 
have a significant impact on a substantial number of small entities.
    This rule has been designated as significant and has been reviewed 
by the Office Management and Budget as required under the provisions of 
E.O. 12866.
    This rule will not impose additional information collection 
requirements on the public under the Paperwork Reduction Act of 1995 
(44 U.S.C. Chapter 35). The TRICARE Retiree Dental Program Enrollment 
Form currently in use was approved in December 2001 and the approval 
expires December 2003.

List of Subjects in 32 CFR Part 199

    Claims, Dental health, Health insurance, Individuals with 
disabilities, Military personnel.

    Accordingly, 32 CFR 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 199.22 is amended by revising paragraphs (b)(1) and 
(d)(4); revising paragraph (d)(5); revising paragraph (f) introductory 
text, introductory paragraph (f)(1), and paragraph (f)(2); revising 
paragraph (f)(3); and revising paragraph (g) to read as follows:


Sec. 199.22  TRICARE Retiree Dental Program (TRDP)

* * * * *
    (b) * * * (1) At a minimum, benefits are the diagnostic services, 
preventive services, basic restorative services (including 
endodontics), oral surgery services, and emergency services specified 
in paragraph (f)(1) of this section. Additional services comparable to 
those contained in paragraph (e)(2) of Sec. 199.13 may be covered 
pursuant to benefit policy decisions made by the Director, OCHAMPUS, or 
designee.
* * * * *
    (d) * * *
    (4) Enrollment periods.--(i) Enrollment period for basic benefits. 
The initial enrollment for the basic dental benefits described in 
paragraph (f)(1) of this section shall be for a period of 24 months 
followed by month-to-month enrollment as long as the

[[Page 4355]]

enrollee remains eligible and chooses to continue enrollment. An 
enrollee's disenrollment from the TRDP at any time for any reason, 
including termination for failure to pay premiums, is subject to a 
lockout period of 12 months. After any lockout period, eligible 
individuals may elect to reenroll and are subject to a new initial 
enrollment period. The enrollment periods and conditions stipulated in 
this paragraph apply only to the basic benefit coverage described in 
paragraph (f)(1) of this section. Effective with the implementation of 
an enhanced benefit program, new enrollments for basic coverage will 
cease. Enrollees in the basic program at that time may continue their 
enrollment for basic coverage, subject to the applicable provisions of 
this section, as long as the contract administering that coverage is in 
effect.
    (ii) Enrollment period for enhanced benefits. The initial 
enrollment period for enhanced benefit coverage described in paragraph 
(f)(2) of this section shall be established by the Director, OCHAMPUS, 
or designee, when such coverage is offered, to be a period of not less 
than 12 months and not more than 24 months. The initial enrollment 
period shall be followed by renewal periods of up to 12 months as long 
as the enrollee chooses to continue enrollment and remains eligible. An 
enrollee's disenrollment from the TRDP during an enrollment period for 
any reason, including termination for failure to pay premiums, is 
subject to a lockout period of 12 months. This lockout provision does 
not apply to disenrollment during an enrollment grace period as defined 
in paragraph (d)(5)(ii) of this section or following completion of an 
initial or renewal enrollment period. Eligible individuals who elect to 
reenroll following a lockout period or a disenrollment after completion 
of an enrollment period are subject to a new initial enrollment period.
    (5) Termination of coverage.--(i) Involuntary termination. TRDP 
coverage is terminated when the member's entitlement to retired pay is 
terminated, the member's status as a member of the Retired Reserve is 
terminated, a dependent child loses eligible child dependent status, or 
a surviving spouse remarries.
    (ii) Voluntary termination. Regardless of the reason, TRDP coverage 
shall be canceled, or otherwise terminated, upon written request from 
an enrollee if the request is received by the TRDP contractor within 
thirty (30) calendar days following the enrollment effective date and 
there has been no use of TRDP benefits by the enrolled member, enrolled 
spouse, or enrolled dependents during that period. If such is the case, 
the enrollment is voided and all premium payments are refunded. 
However, use of benefits during this 30-day enrollment grace period 
constitutes acceptance by the enrollee of the enrollment and the 
enrollment period commitment. In this case, a request for voluntary 
disenrollment before the end of the initial enrollment period will not 
be honored, and premiums will not be refunded.
* * * * *
    (f) Plan benefits. The Director, OCHAMPUS, or designee, may modify 
the services covered by the TRDP to the extent determined appropriate 
based on developments in common dental care practices and standard 
dental programs. In addition, 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 TRDP.
    (1) Basic benefits. The minimum TRDP benefit is basic dental care 
to include diagnostic services, preventive services, basic restorative 
services (including endodontics), oral surgery services, and emergency 
services. The following is the minimum TRDP covered dental benefit 
(using the American Dental Association's The Council on Dental Care 
Program's Code on Dental Procedures and Nomenclature):
* * * * *
    (2) Enhanced benefits. In addition to the minimum TRDP services in 
paragraph (f)(1) of this section, other services that are comparable to 
those contained in paragraph (e)(2) of Sec. 199.13 may be covered 
pursuant to TRDP benefit policy decisions made by the Director, 
OCHAMPUS, or designee. In general, these include additional diagnostic 
and preventive services, major restorative services, prosthodontics 
(removable and fixed), additional oral surgery services, orthodontics, 
and additional adjunctive general services (including general 
anesthesia and intravenous sedation). Enrollees in the basis plan will 
be given an enrollment option at the time the enhanced plan is 
implemented.
    (3) 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 TRDP 
enrollee select a more expensive service, procedure, or course of 
treatment than is customarily provided. The alternative course of 
treatment policy must meet the following conditions:
    (i) The service, procedure, or course of treatment must be 
consistent with sound professional standards of generally accepted 
dental practice for the dental condition concerned.
    (ii) The service, procedure, or course of treatment must be a 
generally accepted alternative for a service or procedure covered by 
the TRDP for the dental condition.
    (iii) 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.
    (g) Maximum coverage amounts. Each enrollee is subject to an annual 
maximum coverage amount for non-orthodontic dental benefits and, if an 
orthodontic benefit is offered, a lifetime maximum coverage amount for 
orthodontics as established by the Director, OCHAMPUS, or designee.
* * * * *

    Dated: January 24, 2002.
L. M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 02-2172 Filed 1-29-02; 8:45 am]
BILLING CODE 5001-08-M