[Federal Register Volume 72, Number 184 (Monday, September 24, 2007)]
[Rules and Regulations]
[Pages 54212-54214]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 07-4658]


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DEPARTMENT OF DEFENSE

Office of the Secretary

[DOD-2006-HA-0210]
RIN 0720-AB12

32 CFR Part 199


TRICARE; TRICARE Retiree Dental Program (TRDP) Basic Benefit 
Descriptions and Administrative Corrections

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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SUMMARY: This final rule amends TRICARE Retiree Dental Program (TRDP) 
Basic benefit descriptions by replacing specific American Dental 
Association (ADA) dental procedure codes and nomenclature with general 
benefit categories and descriptions. This revision is necessary to keep 
the regulation current, since dental procedure codes are added, 
revised, and deleted on a regular basis. This final rule does not 
change or eliminate any benefits that are currently available under the 
TRDP program. This final rule also revises several incorrect, obsolete, 
or historical terms pertaining to the TRICARE program, and removes an 
inaccurate statement regarding appeals and grievances.

DATES: Effective Date: October 24, 2007.

ADDRESSES: TRICARE Management Activity, 16401 East Centretech Parkway, 
Aurora, CO 80011-9066.

FOR FURTHER INFORMATION CONTACT: Debra Hatzel, Program Requirements 
Division, TRICARE Management Activity, telephone (303) 676-3572.

SUPPLEMENTARY INFORMATION: 

1. Introduction and Background

    A. Provisions of the Rule Regarding Dental Procedure Codes and 
Nomenclature. This final rule amends TRICARE Retiree Dental Program 
(TRDP) Basic benefit descriptions by removing specific American Dental 
Association (ADA) dental procedure codes and nomenclature, and 
replacing them with general benefit categories and descriptions from 
the most recent Current Dental Terminology (CDT) Manual (CDT-2005). 
This action is required because dental procedure codes and nomenclature 
are added, revised, and deleted by the ADA every two years; when this 
occurs, the regulation must also be revised to reflect the new codes 
and nomenclature. Maintaining specific procedure codes and nomenclature 
in the regulation is unnecessary, since the TRDP contract and TRDP 
marketing materials (available at http://www.tricare.osd.mil/dental/dm2.cfm) already contain detailed benefit descriptions. Also, the TRDP 
contractor and enrollees are notified when the Government directs any 
changes to TRDP benefits, limits, or exclusions. The TRDP contract and 
TRDP marketing materials will continue to be the primary vehicles for 
communicating specific benefit information to the TRDP contractor and 
beneficiaries. Removal of specific procedure codes and nomenclature 
from this section does not change or eliminate any benefits that are 
currently available under the TRDP. The general categories of benefits 
that are listed in this final rule will be adjusted periodically to 
conform to the current CDT Manual.
    Although there are many similarities between the TRDP and the 
TRICARE Dental Program (TDP), the benefits are not identical. Also, 
there are different dental benefits available under the TRDP Basic 
program and the TRDP Enhanced program. The general benefit categories 
in this TRDP final rule differ from the TDP benefit categories listed 
in 32 CFR Part 199.13. This variance exists because some of the 
benefits offered under the TDP are not benefits under the TRDP Basic 
program (e.g., prosthodontic and orthodontic services), and because the 
TDP benefit categories were derived from an earlier version of the CDT 
Manual.
    B. Provisions of the Rule Regarding the Administrative Correction 
of Incorrect, Obsolete, or Historical Terms and Inaccurate Information. 
The proposed rule addressed the revision of several incorrect, obsolete 
or historical terms that appear in the regulation. Specifically, 
``Director, OCHAMPUS'' was proposed to be amended to ``Director, 
TRICARE Management Activity''; ``Assistant Secretary of Defense (Human 
Affairs)'' was proposed to be amended to ``Assistant Secretary of 
Defense (Health Affairs)''; ``Active Duty Dependents Dental Program'' 
was proposed to be amended to ``TRICARE Dental Program''; ``CHAMPUS'' 
was proposed to be amended to ``TRICARE/CHAMPUS''; and ``OCHAMPUS'' was 
proposed to be amended to ``TRICARE Management Activity.''
    Subsequent to the publication of the proposed rule, TRICARE 
Management Activity identified a long-standing error in the regulation 
regarding appeals and grievances. Specifically, 32 CFR 199.22(k)(1) 
currently states, ``Appeal and hearing procedures. All levels of 
appeals and grievances established by the Contractor for internal 
review shall be exhausted prior to forwarding to OCHAMPUS for a final 
review. Procedures comparable to those established under Sec. 199.13(h) 
of this part shall apply.'' The first sentence in this paragraph is 
inaccurate. TRDP grievances are written complaints regarding non-
appealable issues involving a perceived failure of a provider or 
contractor staff to furnish the expected level or quality of care 
(e.g., demeanor or behavior of providers or their staff). The TRDP 
contractor is responsible for the investigation and resolution of 
grievances; since they are not forwarded to TMA for ``final review'', 
the current CFR language is incorrect. Appeals involve decisions 
related to TRICARE benefits (e.g., denial of preauthorization for 
requested services, or denial of TRICARE payment for services 
received). Appeals are initially sent to the TRDP contractor for 
reconsideration. If the original denial is upheld (and the amount in 
dispute is $50 or more), the beneficiary may

[[Page 54213]]

request a formal review by the TRICARE Management Activity. If the 
beneficiary is dissatisfied with the formal review decision (and the 
amount in dispute is $300 or more, the beneficiary may request that the 
TRICARE Management Activity schedule an independent hearing. Since 
there are two possible levels of action for appeals that are forwarded 
to the TRICARE Management Activity (not a single ``final review''), the 
current CFR language is incorrect. Therefore, the inaccurate sentence 
has been deleted in this final rule as an administrative correction. 
The current TRDP appeal and hearing procedures are comparable to those 
established under Sec. 199.13(h) as required by the regulation, and are 
unchanged by this rule.

II. Public Comments

    The proposed rule was published in the Federal Register on November 
27, 2006. We received no public comments.

III. Regulatory Procedures

    Executive Order 12866 directs agencies to assess all costs and 
benefits available, regulatory alternatives and, when regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety, 
and other advantages; distributive impacts; and equity). The Order 
classifies a rule as a significant regulatory action requiring review 
by the Office of Management and Budget if it meets any one of a number 
of specified conditions, including having an annual effect on the 
national economy of $100 million or more, creating a serious 
inconsistency or interfering with an action of another agency, 
materially altering the budgetary impact of entitlements or the right 
of entitlement recipients, or raising novel legal or policy issues. DoD 
has examined the economic, legal, and policy implications of this final 
rule and has concluded that is not a significant regulatory action. The 
changes set forth in the final rule are minor administrative revisions 
to the existing regulation which do not change the basic TRDP benefit 
structure. This is neither a significant regulatory action under 
Executive Order 12866, nor would it have a significant impact on small 
entities.
    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 major rule under the Congressional Review 
Act because its economic impact will be less than $100 million.
    Executive Order 13132 requires that each Federal Agency shall 
consult with State and local officials and obtain their input if a rule 
has federalism implications which have substantial direct effects on 
the States, on the relationship between the national government and the 
States, or on the distribution of power and responsibilities among the 
various levels of government. We have examined the impact of the final 
rule under Executive Order 13132 and it does not have policies that 
have federalism implications that would have substantial direct effects 
on the States, on the relationship between the national government and 
the States, or on the distribution of power and responsibilities among 
the various levels of government; therefore, consultation with State 
and local officials is not required. In addition, this final rule does 
not impose new information collection requirements for purposes of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3511).

List of Subjects in 32 CFR Part 199

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

0
Accordingly, 32 CFR part 199 is amended as follows:

PART 199--[AMENDED]

0
1. The authority citation for part 199 continues to read as follows:

    Authority:  5 U.S.C. 301; 10 U.S.C. chapter 55.


0
2. Section 199.22 is amended by revising the last sentence of paragraph 
(b)(1), paragraph (b)(4), paragraph (c), paragraph (d)(1)(v), the first 
sentence of paragraph (d)(4)(ii), paragraph (f) introductory text, 
paragraph (f)(1) introductory text, paragraphs (f)(1)(i) through 
(f)(1)(vii), the first sentence of paragraph (f)(3), and paragraph (g); 
and by removing paragraph (f)(1)(viii), paragraph (f)(1)(ix), and the 
first sentence of paragraph (k) to read as follows:


Sec. 199.22  TRICARE Retiree Dental Program (TRDP).

* * * * *
    (b) * * *
    (1) * * * 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, TRICARE Management Activity, or 
designee.
* * * * *
    (4) Except as otherwise provided in this section or by the 
Assistant Secretary of Defense (Health Affairs) or designee, the TRDP 
is administered in a manner similar to the TRICARE Dental Program under 
Sec. 199.13 of this part.
* * * * *
    (c) Except as may be specifically provided in this section, to the 
extent terms defined in Sec. 199.2 and Sec. 199.13(b) are relevant to 
the administration of the TRICARE Retiree Dental Program, the 
definitions contained in Sec. 199.2 and Sec. 199.13(b) shall apply to 
the TRDP as they do to TRICARE/CHAMPUS and the TRICARE Dental Program.
    (d) * * *
    (1) * * *
    (v) The unremarried surviving spouse and eligible child dependents 
of a deceased member who died while in status described in paragraph 
(d)(1)(i) or paragraph (d)(1)(ii) of this section; the unremarried 
surviving spouse and eligible child dependents who receive a surviving 
spouse annuity; or the unremarried surviving spouse and eligible child 
dependents of a deceased member who died while on active duty for a 
period of more than 30 days and whose eligible dependents are not 
eligible or no longer for the TRICARE Dental Program.
* * * * *
    (4) * * *
    (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, TRICARE 
Management Activity, or designee, when such coverage is offered, to be 
a period of not less than 12 months and not more than 24 months. * * *
* * * * *
    (f) Plan benefits. The Director, TRICARE Management Activity, 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, 
TRICARE Management Activity, 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) The minimum TRDP benefit is basic dental care to include 
diagnostic services, preventive services, restorative services, 
endodontic services, periodontic services, oral surgery

[[Page 54214]]

services, and other general services. The following is the minimum TRDP 
covered dental benefit:
    (i) Diagnostic services.
    (A) Clinical oral examinations.
    (B) Radiographs and diagnostic imaging.
    (C) Tests and laboratory examinations.
    (ii) Preventive services.
    (A) Dental prophylaxis.
    (B) Topical fluoride treatment (office procedure).
    (C) Sealants.
    (D) Other preventive services.
    (E) Space maintenance.
    (iii) Restorative services.
    (A) Amalgam restorations.
    (B) Resin-based composite restorations.
    (C) Other restorative services.
    (iv) Endodontic services.
    (A) Pulp capping.
    (B) Pulpotomy and pulpectomy.
    (C) Root canal therapy.
    (D) Apexification and recalcification procedures.
    (E) Apicoectomy and periradicular services.
    (F) Other endodontic procedures.
    (v) Periodontic Services.
    (A) Surgical services.
    (B) Periodontal services.
    (vi) Oral surgery.
    (A) Extractions.
    (B) Surgical extractions.
    (C) Alveoloplasty.
    (D) Biopsy.
    (E) Other surgical procedures.
    (vii) Other general services.
    (A) Palliative (emergenery) treatment of dental pain.
    (B) Therapeutic drug injection.
    (C) Other drugs and/or medicaments.
    (D) Treatment of postsurgical complications.
* * * * *
    (3) Alternative course of treatment policy. The Director, TRICARE 
Management Activity, 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 treatement than in customarily provided. * * *
* * * * *
    (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, TRICARE Management 
Activity, or designee.
* * * * *

    Dated: September 14, 2007.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 07-4658 Filed 9-21-07; 8:45 am]
BILLING CODE 5001-06-M