Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Expanded Active Duty Dependents Dental Benefit Plan

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]

RIN 0720-AA19

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); Expanded Active Duty Dependents Dental Benefit Plan

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

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

SUMMARY: The rule establishes an expanded dental program for dependents

of active duty members of the Uniformed Services. The amendment

specifically describes: the legislative authority for expansion of

dental benefits outside the United States; the continuation of dental

benefits for active duty survivors; eligibility for pre-adoptive wards;

the enhanced benefit structure; enrollment and eligibility

requirements; premium cost-sharing; and benefit payment levels. The

provisions of this rule will provide military families with the high

quality of care they desire at an affordable price.

EFFECTIVE DATE: This final rule is effective December 1, 1995.

FOR FURTHER INFORMATION CONTACT:

David E. Bennett, Program Development Branch, OCHAMPUS, Aurora,

Colorado 80045-6900, telephone (303) 361-1094.

SUPPLEMENTARY INFORMATION: In the Federal Register of September 16,

1993 (58 FR 48473), The Office of the Secretary of Defense published

for public comment a proposed rule establishing an expanded dental

program for dependents of active duty members of the Uniformed

Services.

Background

The Basic Active Duty Dependents Dental Benefit Plan, was

implemented on August 1, 1987, allowing military personnel to

voluntarily enroll their dependents in a dental health care program

that included diagnostic and preventative benefits, as well as simple

restorative services. Under this program, DoD shared the cost of the

premium with the military sponsor. Although the program was viewed as a

major step in benefit enhancement for military families, with

enrollment levels reaching as high as 60 percent, 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 military family.

[[Page 55449]]

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, section 701, Revisions to Dependents Dental

Program Under CHAMPUS). The provisions of this Act specified the

expanded benefit structure, as well as maximum monthly premiums for

members and their families, the application of which was not allowed

until April 1, 1993. 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 section 701 of The Defense Authorization Act for

Fiscal Year 1993, were implemented on April 1, 1993, while the

Department proceeded with the rulemaking process required for

regulations which have a substantial and direct impact on the CHAMPUS

population. This interim Expanded Active Duty Dependents Dental Benefit

Plan was initiated based on Congressional direction that improvements

take effect April 1, 1993. Revisions were to be made as a result of the

rulemaking process in establishment/implementation of a permanent

Expanded Active Duty Dependents Dental Benefit Plan.

Coverage/Benefits

Under the Basic Dependents Dental Program which was in effect prior

to April 1, 1993, coverage was limited to two categories of dental

benefits: diagnostic, oral examination, preventive services and

palliative emergency care paid at the lower of the actual charge or 100

percent of the insurer's determined allowable charge; and basic

restorative services of amalgam and composite restorations and

stainless steel crowns for primary teeth, and dental appliance repairs

paid at 80 percent of the allowable charge. Payment to a participating

provider was considered payment in full, less the 20 percent cost-share

of the allowable charge for restorative services. Nonparticipating

providers were paid the same amounts; however, the beneficiary was

responsible for the amount of the charge for all services above the

allowable charge, except when the dental plan was unable to identify a

participating provider of care within 35 miles of the dependent's place

of residence with appointment availability within 21 calendar days.

Under the Expanded Active Duty Dependents Dental Benefit Plan,

Congress authorizes a broad range of dental services, the payment

levels of which are based on actuarial projections and budgeted program

costs. The enhanced plan includes those services which were offered

under the Basic Active Duty Dependents Dental Plan (examinations, x-

rays, cleanings, sealants, fillings) along with the following expanded

benefit categories and payment levels:

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

Payment

Covered benefits levels

(percent)

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

Sealants............................................ 80

Endodontics (root canal treatment).................. 60

Periodontics (treatment of gum disease)............. 60

Oral surgery (extractions).......................... 60

Prosthodontics (bridges and dentures)............... 50

Orthodontics (braces)............................... 50

Crowns and Casts.................................... 50

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

Preventive and diagnostic services will continue to be paid at 100

percent of the insurer's allowable charge, with the exception of

sealants which will now be paid at the 80 percent level. Basic

restorative services will also remain at the current level (80 percent

of the allowable).

``By-report'' professional services (i.e., those services for which

a dentist must explain on the claim the unusual circumstances about the

case that make them necessary) will be paid at the following payment

levels:

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

Payment

By report professional services levels

(percent)

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

Miscellaneous Emergency............................. 100

Professional Consultation........................... 80

Professional Visits................................. 80

Drugs............................................... 50

Post-Surgical....................................... 80

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

The beneficiary or sponsor will be responsible for the difference

between the insurer's allowable charge and the established payment

level for each category of benefit. This cost-share amount will

represent the beneficiary's or sponsor's total liability when dealing

with participating providers. If the dentist is non-participating, the

beneficiary will have to pay any difference between the insurer's

allowed amount and the amount charged by the non-participating dentist.

The new benefit program will also be limited by an annual maximum

amount of not less than $1000 per beneficiary for non-orthodontic

dental care and not less than a $1200 lifetime limit per beneficiary

for orthodontics.

Enrollment

The Basic Active Duty Dependents Dental Plan was terminated upon

implementation of the interim Expanded Dependents Dental Plan. The

effective date of this change was April 1, 1993. Enrollment in this

interim plan was automatic for all active duty families in the United

States, the District of Columbia, the Commonwealth of Puerto Rico, Guam

and the U.S. Virgin Islands, whose military sponsors were known to have

at least 24 months remaining in service, and for those dependents

enrolled in the Basic Active Duty Dependents Dental Plan regardless of

their sponsors' remaining time in service. Enrollment criteria for

sponsors outside the continental United States remained unchanged.

Those who intended to remain in the service for 24 or more months

and whose families were not automatically enrolled in the new plan,

could have enrolled them at their military personnel office by

completing DD Form 2494, Uniformed Services Active Duty Dependent

Dental Plan (DDP) Enrollment Election Form. DD Form 2494-1,

Supplemental Uniformed Services Active Duty Dependent Dental Plan (DDP)

Enrollment Election Form, would have been used if dependents had

resided in two or more physically separate locations and only the

family members in one location were to be enrolled.

Service members who wanted to remove their families from the new

interim Expanded Active duty Dependents Dental Benefit Plan were

allowed to do so during the one-month period before the date on which

the expanded plan went into effect, and for 4 months after the

beginning date. They received a full refund of all premiums deducted,

so long as the program had not been used following the implementation

date. Use of the new plan during the disenrollment period constituted

acceptance of the plan by the military sponsor and his or her family.

Once the new plan was used, the family could not be disenrolled, and

the premiums could not be refunded.

Premium Payments

Monthly premiums for the interim Expanded Active Duty Dependents

Dental Benefit Plan were $9.65 for a single member, and $19.30 for two

or more family members. Payroll deductions for the new premiums began a

month prior to the starting date of the interim plan. These premium

rates were

[[Page 55450]]

selected to maximize benefits while at the same time maintaining an

approximate 60 percent government/40 percent sponsor cost-share

specified in congressional reports and meet appropriated budget levels.

There were no reductions in premiums for enlisted members in pay grades

E-4 and below.

Monthly premiums were increased effective August 1, 1994. The

increases were assessed beginning with the September 1994 payroll

deduction for active-duty military sponsors. The new premiums are $10

for one enrolled active-duty family member, and $20 for active-duty

sponsors with two or more enrolled family members.

Legislative Changes

The Defense Authorization Act (Pub. L. 103-337, October 5, 1994)

established: authority for the Secretary of Defense to expand dental

benefits outside the United States and to provide continued dental

coverage for eligible dependents of service members who die on or after

October 1, 1993, while on active duty for up to one year from the date

of the member's death; and CHAMPUS eligibility for children placed in

the custody of a service member by a court or recognized adoption

agency on or after October 5, 1994, in anticipation of a legal

adoption. These provisions have been codified in 10 U.S.C. Chapter 55,

sections 1072(6) and 1076a--Dependent's Dental Program--and are

reflected in the regulatory provisions of this rule.

Review of Comments

As a result of the publication of the proposed rule, the following

comments were received from interested associations and agencies.

Comment 1. One commentor felt that all references to

``orthodontia'' should be changed to ``orthodontics'' since it was a

more contemporary term and preferred by the specialty.

All references to ``orthodontia'' have been changed to

``orthodontics'' in the final rule.

Comment 2. The same commentor provided a definition which was felt

to more accurately describe the scope of orthodontic practice. The

commentor felt that the definition contained in the proposed rule

failed to adequately address the dentofacial orthopedic aspects of

orthodontic practice.

The definition of ``orthodontics'' has been changed to: ``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 the 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.''

Comment 3. Several commentors expressed concern over specific

reference to American Dental Association (ADA) codes in the Regulation

since they would become outdated and require continual revision. They

pointed out that the ADA's Code on Dental Procedures and Nomenclature

was currently under revision and that it would likely result in

deletion of several existing codes and the addition of new codes. It

was recommended that a general reference be made to the use of codes

contained in the current edition of the ADA's Code on Dental Procedures

and Nomenclature, without reference to specific codes.

Specific ADA codes have been deleted from the final rule and

replaced with a general reference to the use of the American Dental

Association's Code on Dental Procedures and Nomenclature as listed in

the Current Dental Terminology (CDT) manual.

Comment 4. One commentor felt that ADA code 08999--Unspecified

orthodontic procedures--should be included under ``Orthodontics''

[paragraph (e)(2)(vi)] if specific codes continued to be referenced in

the final rule.

This is no longer an issue since specific ADA codes have been

deleted from the final rule.

Comment 5. One commentor felt that the statement ``subject to the

dental plan's exclusions, limitations, and benefit determination rules

as adopted by OCHAMPUS'' should be deleted from the final rule since it

could be used by the insurance carrier to reduce the actual benefits

which would be contrary to the intent of the 1993 law.

All benefit programs must have exclusions and limitations, the

intent of which are to define what is and what is not covered and the

conditions under which the procedures are benefits. These limitations

and exclusions are taken into consideration when determining the cost

(premiums). The policies, limitations and exclusions are approved by

OCHAMPUS and agreed to by contract.

Comment 6. Another commentor wanted to know how providers will be

able to tell who is covered under the old plan (Basic Dependents Dental

Plan) and distinguish them from those who are covered under the new

plan (Expanded Dependents Dental Plan).

The Basic Active Duty Dependents Dental Benefit Plan was terminated

upon implementation of the interim Expanded Active Duty Dependents

Dental Benefit Plan on April 1, 1993. Enrollment in this interim plan

was automatic for all active duty families in the United States, the

District of Columbia, the Commonwealth of Puerto Rico, Guam and the

U.S. Virgin Islands, whose military sponsors were known to have at

least 24 months remaining in service, and for those dependents that

were already enrolled in the Basic Active Duty Dependents Dental

Benefits Plan regardless of their sponsors' remaining time in service.

Implementation of the interim Expanded Active Duty Dependents Dental

Benefit Plan has been addressed in the Supplementary Information

section of this rule.

Comment 7. One commentor recommended that the definition of

sealants be changed to remove the word ``resinous''.

The word ``resinous'' has been removed from the definition of

sealants.

Comment 8. The same commentor felt that the definition of sealants

should be further revised by substituting ``on tooth surface'' for ``on

the occlusal surfaces.''

The suggestion was not adopted since the existing definition/

specification only allows sealants on the unrestored occlusal surface.

This applies even when the facial and/or lingual surfaces require a

restoration. This was instituted because the previous definition

resulted in denial of sealants when any surface of the tooth was

carious or restored.

Comment 9. Another commentor recommended that coverage of resin

restorations be extended to one to four or more surfaces.

CHAMPUS coverage of resin restorations is extended to one to four

or more surfaces under the Expanded Active Duty Dependents Dental

Benefit Plan. Specific ADA codes and nomenclature have been deleted

from the final rule and replaced with general categories of coverage

along with a reference to the use of American Dental Association's Code

on Dental Procedures and Nomenclature as listed in the current Dental

Terminology manual.

Comment 10. One commentor felt that an appropriate inlay code

should be reported along with the onlay code under restorative services

since onlays cannot be done without an inlay.

The current procedure code nomenclature and fees define the inlay

in addition to the onlay. However, this is to only pay benefits for

onlays if the tooth qualified on the basis of breakdown. Simple inlays

(not covering cusps) are converted to a comparable

[[Page 55451]]

amalgam restoration. Inlays, per se, are not benefits.

Comment 11. One commentor pointed out that 03350 and 04265 were no

longer valid ADA codes and should be removed.

Specific ADA codes have been deleted from the final rule and

replaced with general categories of coverage along with a reference to

the use of the American Dental Association's Code on Dental Procedure

and Nomenclature as listed in the current Dental Terminology manual.

Comment 12. Another commentor felt that ``periodontal root

planing'' should be expanded to read ``periodontal scaling and root

planing.''

Although it is agreed that ``periodontal root planing'' should be

expanded to read ``periodontal scaling and root planing,'' specific ADA

codes and nomenclature have been deleted from the final rule and

replaced with general coverage categories, along with a reference to

the use of the American Dental Association's Code on Dental Procedure

and Nomenclature as listed in the current Dental Terminology manual.

Comment 13. One commentor felt that ``Periodontal prophylaxis''

should be changed to read ``Periodontal maintenance procedures.''

The terminology of ``periodontal prophylaxis'' clarifies that it is

considered a prophylaxis and counts toward the limitations.

Comment 14. One commentor felt that an appropriate inlay code

should accompany the onlay code under prosthodontic services.

The current procedure code nomenclature and fees define the inlay

in addition to the onlay. However, this is to only pay benefits for

onlays if the tooth qualified on the basis of breakdown. Simple inlays

(not covering cusps) are converted to a comparable amalgam restoration.

Inlays are not benefits.

Comment 15. Another commentor expressed concern over the fact that

active duty members could no longer disenroll because of permanent

changes in duty station if dental care was available to the members'

dependents under a program other than the Dependents Dental Plan. The

commentor felt that the proposed regulation did not reflect the

statutory right established by 10 U.S.C. Section 1076a(f) to disenroll

from the program and subsequently reenroll.

The option to disenroll as a result of a change in active duty

station has been reinstated with removal of the mileage restriction.

Summary of Regulatory Modifications

The following revisions were made as a result of legislative

mandates, contract modifications, and suggestions received during the

public comment period: established authority for expansion of dental

benefits outside the United States; provided coverage for eligible

dependents of services members who died on active duty for up to one

year from date of member's death; established CHAMPUS eligibility for

pre-adoptive wards of service members; raised the cost-share from 50 to

60 percent of the insurer's determined allowed charges for endodontics,

periodontics and oral surgery; raised the lifetime orthodontic limits

from $1000 to $1200; provided payment levels for ``by-report''

professional services; provided new monthly premiums which went into

effect on October 1, 1994; reinstated the option to disenroll as a

result of a change in active duty station; established a new definition

for orthodontics; and removed specific ADA codes/nomenclature and

replaced them with general coverage categories and a reference to the

use of the American Dental Association's Code on Dental Procedures and

Nomenclature as listed in the current Dental Terminology manual.

Regulatory Procedures

Executive Order 12866 requires that a regulatory impact analysis be

performed on any significant regulatory action, defined as one which

would result in an annual effect on the national economy of $100

million or more, or which would 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 existing regulation. In addition, this rule will

have very minor impact and will not significantly affect a substantial

number of small entities. In light of the above, no regulatory impact

analysis is required.

This final rule does not impose information collection

requirements. Therefore, 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. 3501-3520).

List of Subjects in 32 CFR Part 199

Claims, Handicapped, Health insurance, and 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 amended as follows:

a. By removing paragraph (c)(5)(vi).

b. By redesignating paragraphs (c)(2)(ii)(G) as (c)(2)(ii)(H) and

(c)(5)(vii) as (c)(5)(vi).

c. By adding paragraph (a)(3)(i)(C), (c)(2)(ii)(G) and (c)(8).

d. Paragraph (b) by adding definitions ``endodontics,'' ``oral

surgery,'' ``orthodontics,'' ``periodontics,'' ``Prosthodontics,'' and

``sealants'' and placing them in alphabetical order.

e. Paragraph (b) by revising the definitions for ``beneficiary

liability'' and ``participating provider.''

f. By revising paragraphs (c)(1), (c)(3) and (c)(4); (c)(5)(iv) and

(c)(5)(v); (e)(1)(i); (e)(2) and (e)(3); (f)(1)(ii); (f)(1)(vi) and

(f)(1)(vii); (f)(6)(i) and (f)(6)(ii); (g)(2) and (g)(3) introductory

text.

Sec. 199.13 Active duty dependents dental plan.

* * * * *

(a) * * *

(3) * * *

(i) * * *

(C) Care outside the United States. 10 U.S.C. 1076a authorizes the

Secretary of Defense to establish basic dental benefit plans for

eligible dependents of members of the uniform services accompanying the

member on permanent assignments of duty outside the United States.

* * * * *

(b) * * *

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 Active Duty Dependents Dental

Benefit Plan, beneficiary liability includes cost-sharing amounts and

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.

Beneficiary liability also includes any expenses for services and

supplies not covered by the Active

[[Page 55452]]

Duty Dependents Dental Benefit Plan, less any discount provided as a

part of the insurer's agreement with an approved alternative delivery

system.

* * * * *

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.

* * * * *

Oral surgery. Surgical procedures performed in the oral cavity as

further defined in paragraph (e) of this section.

* * * * *

Orthodontics. The supervision, guidance, and correction of the

growing or mature dentofacial structures, including those conditions

that require movement of teeth or correction or 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.

* * * * *

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 sponsor) of any cost-share for services.

* * * * *

Periodontics. The examination, diagnosis, and treatment of diseases

affecting the supporting structures of the teeth as further defined in

paragraph (e) of this section.

* * * * *

Prosthodontics. The diagnosis, planning, making, insertion,

adjustment, relinement, and repair of artificial devices intended for

the replacement of missing teeth and associated tissues as further

defined in paragraph (e) of this section.

* * * * *

Sealants. A material designed for application on the occlusal

surfaces of specified teeth to seal the surface irregularities to

prevent ingress of oral fluids, food, and debris in order to prevent

tooth decay.

* * * * *

(c) * * *

(1) General. 10 U.S.C. 1076a, 1072(2)(A), (D) or (I) and 1072(6)

set forth those persons who are eligible for voluntary enrollment in

the Active Duty Dependents Dental Benefit Plan. 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 other sections of this part in

order for dental benefits to be extended.

* * * * *

(2) * * *

(ii) * * *

(G) A child placed in the custody of a service member by a court or

recognized adoption agency on or after October 5, 1994, in anticipation

of a legal adoption.

* * * * *

(3) Enrollment.

(i) Basic active duty dependents dental benefit plan. The dependent

dental plan is effective from August 1, 1987, up to the date of

implementation of the Expanded Active Duty Dependents Dental Benefit

Plan.

(A) Initial enrollment. Eligible dependents of members on active

duty status as of August 1, 1987 are automatically enrolled in the

Active Duty Dependents Dental Plan, except where any of the following

conditions apply:

(1) Remaining period of active duty at the time of contemplated

enrollment is expected by the active duty member or the Uniformed

Service to be less than two years, except that such members' dependents

may be enrolled during the initial enrollment period for benefits

beginning August 1, 1987 provided that the member had at least six

months remaining in the initial enlistment term. Enrollment of

dependents is for a period of 24 months, subject to the exceptions

provided in paragraph (c)(5) of this section.

(2) Active duty member had completed an election to disenroll his

or her dependents from the Basic Active Duty Dependents Dental Benefit

Plan.

(3) Active duty member had only one dependent who is under four

years of age as of August 1, 1987, and the member did not complete an

election form to enroll the child.

(B) Subsequent enrollment. Eligible active duty members may elect

to enroll their dependents for a period of not less than 24 months,

provided there is an intent to remain on active duty for a period of

not less than two years by the member and the Uniformed Service.

(C) Inclusive family enrollment. All eligible dependents of the

active duty member must be enrolled if any were enrolled, except that a

member may elect to enroll only those dependents who are remotely

located from the member (e.g., a child living with a divorced spouse or

a child in college).

(ii) Expanded active duty dependents dental benefit plan. The

expanded dependents dental plan is effective on August 1, 1993. The

Basic Active Duty Dependents Dental Benefit Plan terminated upon

implementation of the expanded plan.

(A) Initial enrollment. Enrollment in the Expanded Active Duty

Dependents Dental Benefit Plan is automatic for all eligible dependents

of active duty members known to have at least 24 months remaining in

service, and for those dependents enrolled in the Basic Dependents

Dental Benefit Plan regardless of the military member's remaining time

in service unless the active duty member elects to disenroll his or her

dependents during the one-time disenrollment option period (one-month

period before the date on which the expanded plan went into effect, and

for 4 months after the beginning date). Those active duty members who

intend to remain in the service for 24 months or more, whose dependents

were not automatically enrolled, may enroll them at their military

personnel office by completing the appropriate Uniformed Services

Active Duty Dependents Dental Plan Enrollment Election Form. Use of the

new plan during the one-time disenrollment option period by a dependent

enrolled in the Basic Active Duty Dependents Dental Benefit Plan,

constitutes acceptance of the plan by the military sponsor and his or

her family. Once the new plan is used, the family cannot be

disenrolled, and the premiums will not be refunded.

(B) Subsequent enrollment. Eligible active duty members may elect

to enroll their dependents for a period of not less than 24 months,

provided there is an intent to remain on active duty for a period of

not less than two years by the member and the Uniformed Service.

(C) Inclusive family enrollment. All eligible dependents of the

active duty member must be enrolled if any are enrolled, except as

defined in paragraphs (c)(3)(ii)(C) (1) and (2) of this section.

(1) Enrollment will be by either single or family premium as

defined herein:

(i) Single premium.

(A) Sponsors with only one family member age four (4) or older who

elect to enroll that family member; or

(B) Sponsors who have more than one family member under age four

(4) may elect to enroll one (1) family member under age four (4); or

(C) Sponsors who elect to enroll one (1) family member age four or

older but may have any number of family members under age four (4) who

are not

[[Page 55453]]

elected to be covered. At such time when the sponsor elects to enroll

more than one (1) eligible family member, regardless of age, the

sponsor must then enroll under a family premium which covers all

eligible family members.

(ii) Family premium.

(A) Sponsors with two (2) or more eligible family members age four

(4) or older must enroll under the family premium.

(B) Sponsors with one (1) eligible family member age four (4) or

older and one (1) or more eligible family members under the age of four

may elect to enroll under a family premium.

(C) Under the family premium, all eligible family members of the

sponsor are enrolled.

(2) Exceptions.

(i) A sponsor may elect to enroll only those eligible family

members residing in one location when the sponsor has other eligible

family members residing in two or more physically separate locations

(e.g., children living with a divorced spouse; children attending

college).

(ii) Instances where a family member requires hospital or special

treatment environment (due to a medical, physical handicap, or mental

condition) for dental care otherwise covered by the dental plan, the

family member may be excluded from the dental plan enrollment and may

continue to receive care from a military treatment facility.

(D) Enrollment period. Enrollment of dependents is for a period of

24 months except when:

(1) The dependent's enrollment is based on his or her enrollment in

the Basic Active Duty Dependents Dental Benefit; or

(2) One of the conditions for disenrollment in paragraph (c)(5) of

this section is met.

(4) Beginning dates of eligibility.

(i) Basic active duty dependents dental benefit plan.

(A) Initial enrollment. The beginning date of eligibility for

benefits is August 1, 1987.

(B) Subsequent enrollment. The beginning date of eligibility for

benefits is the first day of the month following the month in which the

election of enrollment is completed, signed, and received by the active

duty member's Service representative, except that the date of

eligibility shall not be earlier than September 1, 1987.

(ii) Expanded active duty dependents dental benefit plan.

(A) Initial enrollment. The beginning date of eligibility for

benefits is April 1, 1993.

(B) Subsequent enrollment. The beginning date of eligibility for

benefits is the first day of the month following the month in which the

election of enrollment is completed, signed, and received by the active

duty member's Service representative, except that the date of

eligibility shall not be earlier than the first of the month following

the month of implementation of the expanded benefit.

* * * * *

(5) * * *

(iv) Disenrollment because of no eligible dependents. When an

active duty member ceases to have any eligible dependents, the member

must disenroll.

(v) Option to disenroll as a result of a change in active duty

station. When an active duty member transfers with enrolled family

members to a duty station where space-available dental care is readily

available at the local military clinic, the member may elect within 90

days of the transfer to disenroll from the plan. If the member is later

transferred to a duty station where dental care is not available in the

local military clinic, the member may re-enroll his or her dependents

in the plan.

* * * * *

(8) Continuation of eligibility for dependents of service members

who die on active duty. Eligible dependents of service members who die

on or after October 1, 1993, while on active duty for a period of more

than 30 days and who are enrolled in the dental benefits plan on the

date of the death of the member shall be eligible for continued

enrollment in the dental benefits plan for up to one year from the date

of the service member's death.

* * * * *

(e) * * *

(1) * * *

(i) Scope of benefits. The Active Duty Dependents Dental Benefit

Plan provides coverage for diagnostic and preventive services,

sealants, restorative services, endodontics, periodontics,

prosthodontics, orthodontics and oral surgery to eligible, enrolled

dependents of active duty members as set forth in paragraph (c) of this

section.

* * * * *

(2) Benefits.

(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 or dental

hygienists as authorized under paragraph (f) of this section. These

services are defined (subject to the dental plan's exclusions,

limitations, and benefit determination rules approved by OCHAMPUS)

using the American Dental Association's Code on Dental Procedures and

Nomenclature as listed in the Current Dental Terminology manual to

include the following categories of services:

(A) Diagnostic services.

(1) Clinical Oral examinations.

(2) Radiographs.

(3) Tests and laboratory examinations.

(B) Preventive services.

(1) Dental prophylaxis.

(2) Topical fluoride treatment (office procedure).

(3) Sealants.

(4) Space maintenance (passive appliances).

(ii) Adjunctive general services (services ``by report''). The

following categories of services are authorized when performed directly

by dentists or dental hygienists 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. These services are defined (subject to the dental plan's

exclusions, limitations, and benefit determination rules as adopted by

OCHAMPUS) using the American Dental Association's Code on Dental

Procedures and Nomenclature as listed in the Current Dental Terminology

manual to include the following categories of service:

(A) Emergency oral examinations.

(B) Palliative emergency treatment of dental pain.

(C) Professional consultation.

(D) Professional visits.

(E) Drugs.

(F) Post-surgical complications.

(iii) Restorative. Benefits may be extended for basic 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 services are defined (subject to the dental

plan's exclusions, limitations, and benefit determination rules as

adopted by OCHAMPUS) using the American Dental Association's Code on

Dental Procedures and Nomenclature as listed in the Current Dental

Terminology manual to include the following categories of services:

(A) Restorative services.

(1) Amalgam restorations.

(2) Silicate restorations.

(3) Resin restorations.

(4) Prefabricated crowns.

(5) Pin retention.

(B) Other restorative services.

(1) Diagnostic casts.

[[Page 55454]]

(2) Onlay restoration--metallic.

(3) Crowns.

(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

services are defined (subject to the dental plan's exclusions,

limitations, and benefit determination rules as adopted by OCHAMPUS)

using the American Dental Association's Code on Dental Procedures and

Nomenclature as listed in the Current Dental Terminology manual to

include the following categories of services:

(A) Pulp capping--indirect.

(B) Pulpotomy.

(C) Root canal therapy.

(D) Periapical services.

(E) Hemisection.

(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 services are defined (subject to the dental plan's exclusions,

limitations, and benefit determination rules as adopted by OCHAMPUS)

using the American Dental Association's Code on Dental Procedures and

Nomenclature as listed in the Current Dental Terminology manual to

include the following categories of services:

(A) Surgical services.

(B) Periodontal scaling and root planing.

(C) Unscheduled dressing change.

(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 (f) of this section. These services are defined (subject to

the dental plan's exclusions, limitations, and benefit determination

rules as adopted by OCHAMPUS) using the American Dental Association's

Code on Dental Procedures and Nomenclature as listed in the Current

Dental Terminology manual to include the following categories of

services:

(A) Prosthodontics (removable).

(1) Complete/partial dentures.

(2) Adjustments to removable prosthesis.

(3) Repairs to complete/partial dentures.

(4) Denture rebase procedures.

(5) Denture reline procedures.

(6) Interim complete/partial dentures.

(7) Tissue conditioning.

(B) Prosthodontics (fixed).

(1) Bridge pontics.

(2) Retainers (by report).

(3) Bridge retainers-crowns.

(4) Other fixed prosthetic 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. Coverage of in-process orthodontics is limited to

services rendered on or after the date of enrollment in the expanded

dependents dental play. These services are defined (subject to the

dental plan's exclusions, limitations, and benefit determination rules

as adopted by OCHAMPUS) using the American Dental Association's Code on

Dental Procedures and Nomenclature as listed in the Current Dental

Terminology manual to include the following categories of services:

(A) Minor treatment for tooth guidance.

(B) Minor treatment to control harmful habits.

(C) Interceptive orthodontic treatment.

(D) Comprehensive orthodontic treatment--transitional dentition.

(E) Comprehensive orthodontic treatment--permanent dentition.

(F) Treatment of the atypical or extended skeletal case.

(G) Post-treatment stabilization.

(viii) Oral 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

services are defined (subject to the dental plan's exclusions,

limitations, and benefit determination rules as adopted by OCHAMPUS)

using the American Dental Association's Code on Dental Procedures and

Nomenclature as listed in the Current Dental Terminology manual to

include the following categories of services:

(A) Extractions.

(B) Surgical extractions.

(C) Other surgical procedures.

(D) Alveoloplasty--surgical preparation of ridge for denture.

(E) Surgical incision and drainage of abscess--intraoral soft

tissue.

(F) Repair of traumatic wounds.

(G) Complicated suturing.

(H) Excision of pericoronal gingiva.

(ix) Exclusion of adjunctive dental care. Under limited

circumstances, benefits are available for dental services and supplies

under CHAMPUS when the dental care is medically necessary in the

treatment of an otherwise covered medical (not dental) condition, is an

integral part of the treatment of such medical condition, and is

essential to the control of the primary medical condition; or is

required in preparation for, or as the result of, dental trauma which

may be or is caused by medically necessary treatment of an injury or

disease (iatrogenic). These benefits are excluded under the Active Duty

Dependents Dental Plan. For further information on adjunctive dental

care benefits under CHAMPUS, see Sec. 199.4(e)(10).

(x) 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 enrolled in the Active Duty Dependents Dental Plan

may not obtain those services which are benefits of the Plan in

military dental care facilities. Enrolled dependents may continue to

obtain noncovered services from military dental care facilities subject

to the provisions for space available care.

(xi) 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 this dental plan.

(3) Beneficiary and sponsor liability.

(i) Diagnostic and preventive services. Enrolled dependents of

active duty members or their sponsors are responsible for the payment

of only those amounts which are for services rendered by

nonparticipating providers of care which exceed the equivalent of the

statewide or regional prevailing fee levels as established by the

insurer, except in the case of sealants where the dependents or their

sponsors will also be responsible for payment of 20 percent of the

insurer's determined allowable amount. Where the dental plan is unable

to identify a participating provider of care within 35 miles of the

dependent's place of residence with appointment availability within 21

calendar days, the dental plan will reimburse the dependent, or

sponsor, or

[[Page 55455]]

the nonparticipating provider selected by the dependent within 35 miles

of the dependent's place of residence at the level of the provider's

usual fees less 20 percent of the insurer's allowable amount for

sealants.

(ii) Restorative services. Enrolled dependents of active duty

members or their sponsors are responsible for payment of 20 percent of

the amounts determined by the insurer for services rendered by

participating providers of care, or 20 percent of these amounts plus

any remainder of the charges made by nonparticipating providers of

care, except in the case of crowns and casts where the dependents or

their sponsors will be responsible for payment of 50 percent of the

insurer's determined allowable amount. Where the dental plan is unable

to identify a participating provider of care within 35 miles of the

dependent's place of residence with appointment availability within 21

calendar days, dependents or their sponsors are responsible for payment

of 20 percent (50 percent in the case of crowns and casts) of the

charges made by nonparticipating providers located within 35 miles of

the dependent's place of residence.

(iii) Endodontic, periodontic, and oral surgery services. Enrolled

dependents of active duty members or their sponsors are responsible for

payment of 40 percent of the amounts determined by the insurer for

services rendered by participating providers of care, or 40 percent of

these amounts plus any remainder of the charges made by

nonparticipating providers of care. Where the dental plan is unable to

identify a participating provider of care within 35 miles of the

dependent's place of residence with appointment availability within 21

calendar days, dependents or their sponsors are responsible for payment

of 40 percent of the charges made by nonparticipating providers located

within 35 miles of the dependent's place of residence.

(iv) Prosthodontic and orthodontic services. Enrolled dependents of

active duty members or their sponsors are responsible for payment of 50

percent of the amounts determined by the insurer for services rendered

by participating providers of care, or 50 percent of these amounts plus

any remainder of the charges made by nonparticipating providers of

care. Where the dental plan is unable to identify a participating

provider of care within 35 miles of the dependent's place of residence

with appointment availability within 21 calendar days, dependents or

their sponsors are responsible for payment of 50 percent of the charges

made by nonparticipating providers located within 35 miles of the

dependent's place of residence.

(v) Adjunctive general services (services ``by report''). The

beneficiary or sponsor liability is dependent on the particular service

provided. Emergency oral examinations and palliative emergency

treatment of dental pain are paid in full except for those amounts for

services rendered by nonparticipating providers of care which exceed

the equivalent of the statewide or regional prevailing fee levels as

established by the insurer which are the responsibility of the enrolled

dependents or their sponsors. Enrolled dependents or their sponsors are

responsible for payment of 20 percent of the amounts determined by the

insurer for professional consultations/visits and postsurgical services

and 50 percent for covered medications when provided by participating

providers of care, or these percentage payments plus any remaining

amounts in excess of the prevailing charge limits established by the

insurer for services rendered by nonparticipating providers, subject to

the exceptions for dependent lack of access to participating providers

as provided in paragraphs (e)(3)(i) through (e)(3)(iv) of this section.

The contracting dental insurer 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.

(vi) Amounts over the dental insurer's established allowance for

charges. It is the responsibility of the dental plan insurer to

determine allowable charges for the procedures identified as benefits

of this plan. All benefits of the plan are based on the insurer's

determination of the allowable charges, subject to the exceptions for

lack of access to participating providers as provided in paragraphs

(e)(3)(i) through (e)(3)(iv) of this section.

(vii) Maximum coverage amounts. Enrolled dependents of active duty

members 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 Secretary of Defense or designee.

(f) * * *

(1) * * *

(ii) Conflict of interest. See Sec. 199.9(d).

* * * * *

(vi) Participating provider. An authorized provider may elect to

participate and accept the fee or charge determinations as established

and made known to the provider by the dental plan insurer. The fee or

charge determinations are binding upon the provider in accordance with

the dental plan insurer's procedures for participation. The authorized

provider may not participate on a claim-by-claim basis. The

participating provider must agree to accept, within one day of a

request for appointment, beneficiaries in need of emergency palliative

treatment. Payment to the participating provider is based on the lower

of the actual charge or the insurer's determination of the allowable

charge. Payment is made directly to the participating provider, and the

participating provider may only charge the beneficiary the percent

cost-share of the insurer's allowable charge for those benefit

categories as specified in paragraphs (e)(3)(i) through (e)(3)(v) of

this section, in addition to the charges for any services not

authorized as benefits.

(vii) Nonparticipating provider. An authorized provider may elect

for all beneficiaries not to participate and request the beneficiary or

sponsor to pay any amount of the provider's billed charge in excess of

the dental plan insurer's determination of allowable charges. Neither

the government nor the dental plan insurer shall have any

responsibility for any amounts over the allowable charges as determined

by the dental plan insurer, except where the dental plan insurer is

unable to identify a participating provider of care within 35 miles of

the dependent's place of residence with appointment availability within

21 calendar days. In such instances of the nonavailability of a

participating provider, the nonparticipating provider located within 35

miles of the dependent's place of residence shall be paid his or her

usual fees, less the percent cost-share as specified in paragraphs

(e)(3)(i) through (e)(3)(v) of this section.

(A) Assignment. A nonparticipating provider may accept assignment

of claims for beneficiaries certifying their willingness to make such

assignment by filing the claims completed with the assistance of the

beneficiary or sponsor for direct payment by the dental plan insurer to

the provider.

(B) Nonassignment. A nonparticipating provider for all

beneficiaries may request the beneficiary or sponsor to file the claim

directly with the dental plan insurer, making arrangements with the

beneficiary or sponsor for direct payment by the beneficiary or

sponsor.

* * * * *

(6) * * *

(i) Nonparticipating providers (or the dependents or sponsors for

unassigned claims) shall be reimbursed at the

[[Page 55456]]

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; less any cost-share

amount due for authorized services, except where the dental plan

insurer is unable to identify a participating provider of care within

35 miles of the dependent's place of residence with appointment

availability within 21 calendar days. In such instances of the

nonavailability of a participating provider, the nonparticipating

provider located within 35 miles of the dependent's place of residence

shall be paid his or her usual fees, less the cost-share for the

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.

(g) * * *

(2) Benefit payments made to a participating provider. When the

authorized provider has elected to participate in accordance with the

arrangement and procedures established by the dental plan insurer,

payment is made based on the lower of the actual charge or the

insurer's determination of the allowable charge. Payment is made

directly to the participating provider as payment in full, less the

percent cost-share of the insurer's allowable charge as specified in

paragraphs (e)(3)(i) through (e)(3)(v) of this section.

(3) Benefit payments made to a nonparticipating provider. When the

authorized provider has elected not to participate in accordance with

the arrangement and procedures established by the dental plan, payment

is made by the insurer based on the lower of the actual charge or the

insurer's determination of the allowable charge. The beneficiary is

responsible for payment of a percent cost-share of the insurer's

allowable charge as specified in paragraphs (e)(3)(i) through (e)(3)(v)

of this section. Where the dental plan is unable to identify a

participating provider of care within 35 miles of the dependent's place

of residence with appointment availability within 21 calendar days,

dependents or their sponsors are responsible for payment of a percent

cost-share of the charges made by nonparticipating providers located

within 35 miles of the dependent's place of residence as specified in

paragraphs (e)(3)(i) through (e)(3)(v) of this section.

* * * * *

Dated: October 26, 1995.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 95-27116 Filed 10-31-95; 8:45 am]

BILLING CODE 5000-04-M