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

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]

RIN 0720-AA38

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); TRICARE Retiree Dental Program

AGENCY: Office of the Secretary, DoD.

ACTION: Proposed rule.

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SUMMARY: This proposed rule establishes the TRICARE Retiree Dental

Program (TRDP) to provide dental care to military members entitled to

retired pay and eligible family members and their dependents. The rule

details operation of the program and seeks comments on our plan to

implement the TRDP.

DATES: Comments must be received on or before July 24, 1997.

ADDRESSES: Office of Health Services Financing Policy, Department of

Defense, Room 1B657 Pentagon, Washington, DC 20301-1200.

FOR FURTHER INFORMATION CONTACT:

Cynthia P. Speight, Office of the Assistant Secretary of Defense

(Health Affairs), (703) 697-8975.

SUPPLEMENTARY INFORMATION:

I. Overview of the Proposed Rule

Implementation of the TRICARE Retire Dental Program (TRDP) was

directed by Congress in section 703 of the National Defense

Authorization Act for Fiscal year 1997, Pub. L. 104-201, which amended

title 10, United States Code, by adding section 1076c. This law

directed the implementation of a dental program for: (1) Members of the

Armed Forces who are entitled to retired pay, (2) Members of the

Retired Reserve under the age of 60, (3) Eligible dependents of (1) or

(2) who are covered by the enrollment of the member, and (4) The

unremarried surviving spouse and eligible child dependents of a

deceased member who dies while in status described in (1) or (2), or

the unremarried surviving spouse and eligible child dependents who

receive a surviving spouse annuity.

Included in the program are the 50 United States and the District

of Columbia, Canada, Puerto Rico, Guam and the U.S. Virgin Islands.

Enrollment in the program is voluntary and members enrolled in the

dental plan will be responsible for paying the full cost of the

premiums. The premium payment may be collected pursuant to procedures

established by the Assistant Secretary of Defense (Health Affairs).

Dental coverage under the TRDP will provide basic dental care, to

include diagnostic services, preventive services, basic restorative

services (including endodontics), surgical services, and emergency oral

examinations.

Under this approach, where possible, members entitled to retired

pay and eligible family members and their dependents may make use of

participating dental providers in their areas and may benefit from

reduced out-of-pocket costs and provider submission of claims and

acceptance of contractor allowances and arrangements. TRDP eligibles

will obtain information concerning the program and the application

process from the contractor.

This proposed rule adopts the statutory preemption authority of 10

U.S.C., section 1103. This statute broadly authorizes preemption of

state laws in connection with DoD contracts for medical and dental

care. We have made the judgment that preemption is necessary and

appropriate to assure the operation of a consistent, effective, and

efficient federal program. In addition, the enacting legislation for

the TRICARE Retiree Dental Program directs the Department of Defense to

implement this program by October 1, 1997. Absent preemption of certain

State and local laws on insurance regulation and other matters,

competition would be severely limited and the process substantially

delayed.

II. Rulemaking Procedures

Executive Order 12866 requires certain regulatory assessments for

any ``significant regulatory action,'' defined as one which 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.

Pursuant to the Paperwork Reduction Act of 1995, the reporting and

recordkeeping of this proposed rule have been submitted to the OMB for

review under 3507(d) of the Act.

In compliance with section 3506(c)(2)(A) of the Paperwork Reduction

Act of 1995, the Office of the Assistant Secretary of Defense for

Health Affairs announces a proposed information collection and seeks

public comment on the provision thereof. Comments are invited on: (a)

Whether the proposed collection is necessary for the proper performance

of the functions of the agency, including whether the information shall

have practical utility; (b) the accuracy of the agency's estimate of

the burden of the proposed information collection; (c) ways to enhance

quality, utility, and clarity of the information to be collected; and

(d) ways to minimize the burden of the information collection on

respondents, including through the use of automated collection

techniques or other forms of information technology.

The collection of information is necessary to enroll military

members entitled to retired pay and eligible dependents in the TRICARE

Retiree Dental Program. The application will allow the Department of

Defense to identify enrollment applicants, evaluate their eligibility

for the enrollment, and determine other health insurance coverage which

an applicant may have.

Affected Public: Eligible family members and their dependents.

Annual Burden Hours: 71,640.

Number of Respondents: 286,570.

Responses Per Respondent: 1.

Average Burden Per Response: 15 minutes.

Frequency: Once, at time of initial application.

Respondents are military members entitled to retired pay and

eligible family members and their dependents who are seeking enrollment

in the TRICARE Retiree Dental Program. The enrollment application will

allow the Department to collect the information necessary to properly

identify the program's applicants and to determine their eligibility

for enrollment in the TRICARE Retiree Dental Program. In completing and

signing a TRICARE Retiree Dental Program enrollment form, applicants

will acknowledge that they understand the benefits offered under

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the program and the rules they must follow to continue their

participation in the program. Initial enrollment will be for a period

of 12 months followed by month-to-month enrollment as long as the

enrollee chooses to continue enrollment.

Comments on these requirements should be submitted to the Office of

Information and Regulatory Affairs, OMB, 715 17th Street NW.,

Washington, DC 20503, marked ``Attention Desk Officer for Department of

Defense.'' Copies should be sent to the Office of the Assistant

Secretary of Defense (Health Affairs), 1B657 The Pentagon, Washington,

DC 20301, ATTN: Cynthia Speight. When the Department of Defense

promulgates the Final Rule, the Department will respond to comments by

OMB or the public regarding the information collection provisions and

recordkeeping requirements of the rule.

This is a proposed rule. The Department is making an exception to

the normal 60 day public comment period due to the statutory

requirement for implementation by October 1, 1997. Public comments are

invited. All comments will be considered. A discussion of the major

issues received by public comments will be included with issuance of

the final rule, anticipated approximately 90 days after the end of the

comment period.

List of Subjects in 32 CFR Part 199

Claims, Handicapped, Health insurance, and Military personnel.

Accordingly, 32 CFR part 199 is amended as follows:

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. Part 199 is proposed to be amended by adding Sec. 199.22, as

follows:

Sec. 199.22 TRICARE Retiree Dental Program (TRDP).

(a) Purpose. The TRDP is a premium based indemnity dental insurance

coverage program that will be available to retired members of the Armed

Forces, their dependents, and certain other beneficiaries, as specified

in paragraph (d) of this section. The TRDP is authorized by 10 U.S.C.

1076c.

(b) General provisions. (1) Benefits are limited to diagnostic

services, preventive services, basic restorative services (including

endodontics), surgical services, and emergency oral examinations, as

specified in paragraph (f) of this section.

(2) Premium costs for this coverage will be paid by the enrollee.

(3) The program is applicable to authorized providers in the 50

United States and the District of Columbia, Canada, Puerto Rico, Guam

and the U.S. Virgin Islands.

(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 Active Duty Dependents

Dental Plan under Sec. 199.13.

(5) The TRDP shall be administered through a contract.

(c) Definitions. Except as may be specifically provided in this

section, to the extent terms defined in Secs. 199.2 and 199.13(b) are

relevant to the administration of the TRICARE Retiree Dental Program,

the definitions contained in those sections shall apply to the TRDP as

they do to CHAMPUS and the TRICARE active duty dependents dental plan.

(d) Eligibility and enrollment.--(1) Eligibility. Enrollment in the

TRICARE Retiree Dental Program is open to:

(i) Members of the Armed Forces who are entitled to retired pay,

(ii) Members of the Retired Reserve under the age of 60,

(iii) Eligible dependents of paragraph (d)(1)(i) or (ii) of this

section who are covered by the enrollment of the member, and

(iv) The unremarried surviving spouse and eligible child dependents

of a deceased member who dies while in status described in paragraph

(d)(1) (i) or (ii) of this section, or the unremarried surviving spouse

and eligible child dependents who receive a surviving spouse annuity.

(2) Notification of eligibility. The contractor will notify persons

eligible to receive dental benefits under the TRICARE Retiree Dental

Program.

(3) Election of coverage. Following this notification, interested

members entitled to retired pay and eligible family members and their

dependents may elect to enroll. In order to obtain dental coverage,

written election by the eligible beneficiary must be made.

(4) Enrollment. Enrollment in the TRICARE Retiree Dental Program is

voluntary and will be accomplished by submission of an application to

the TRDP contractor. Initial enrollment shall be for a period of 12

months followed by month-to-month enrollment as long as the enrollee

chooses to continue enrollment.

(5) Period of coverage. TRICARE Retiree Dental Program 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 in the case

of remarriage of the surviving spouse.

(6) Continuation of dependents' enrollment upon death of enrollee.

Coverage of a dependent in the TRDP under an enrollment of a member or

surviving spouse who dies during the period of enrollment shall

continue until the end of that period and may be renewed by (or for)

the dependent, so long as the premium paid is sufficient to cover

continuation of the dependent's enrollment. The Secretary may terminate

coverage of the dependent when the premiums paid are no longer

sufficient to cover continuation of the enrollment.

(e) Premium payments. Persons enrolled in the dental plan will be

responsible for paying the full cost of the premiums in order to obtain

the dental insurance.

(1) Premium payment method. The premium payment may be collected

pursuant to procedures established by the Assistant Secretary of

Defense (Health Affairs) or designee.

(2) Effects of failure to make premium payments. Failure to make

monthly renewal premium payments will result in the enrollee's

disenrollment from the TRDP and subject to a lock-out period of 12

months. Following this period of time, persons eligible will be able to

reenroll if they so choose.

(3) Member's payment of premiums. The cost of the TRDP monthly

premium will be paid by the enrollee. Interested beneficiaries may

contact the dental contractor/insurer to obtain the enrollee premium

cost.

(f) Plan benefits. The TRDP will provide basic dental care, to

include diagnostic services, preventive services, basic restorative

services (including endodontics), surgical services, and emergency oral

examinations. The following is the TRDP covered dental benefit (using

the American Dental Association, The Council on Dental Care Program's

Code On Dental Procedures and Nomenclature):

(i) Diagnostic: Periodic oral examination (00120); Comprehensive

oral examination (limited to one exam per year in the same dental

office) (00150), Intraoral-complete series (including bitewings)

(00210); Intraoral-periapical-first film (00220); Intraoral-periapial-

each additional film (00230); Intraoral-occlusal film (00240);

Bitewings-single film (00270); Bitewings-two films (00272); Bitewings-

four films (00274); Panoramic film (00330); Caries susceptibility

tests, by report (00425); Pulp vitality tests (00460).

(ii) Preventive: Prophylaxis-adult (limit-once per year) (01110);

Prophylaxis-child (01120); Topical application of fluoride (excluding

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prophylaxis)-child (01203); Topical application of fluoride (excluding

prophylaxis)-adult, by report, once per year (01204); Sealant-per tooth

(01351); Space maintainer-fixed-unilateral (01510); Space maintainer-

fixed-bilateral (01515); Space maintainer-removable-unilateral (01520);

Space maintainer-removable-bilateral (01525); Recementation of space

maintainer (01550).

(iii) Restorative: Amalgam-one surface, primary (02110); Amalgam-

two surfaces, primary (02120); Amalgam-three surfaces, primary (02130);

Amalgam-four or more surfaces, primary (02131); Amalgam-three surfaces,

permanent (02160); Amalgam-four or more surfaces, permanent (02161);

Resin-one surface, anterior (02330); Resin-two surfaces, anterior

(02331); Resin-three surfaces, anterior (02332); Resin-four or more

surfaces or involving incisal angle (anterior) (02335); Recement inlay

(02910); Recement crown (02920); Prefabricated stainless steel crown-

primary tooth (02930); Prefabricated stainless steel crown-permanent

tooth (02931); Prefabricated resin crown (02932); Prefabricated

stainless steel crown with resin window (02933); Pin retention-per

tooth, in addition to restoration (02951); Temporary crown (fractured

tooth) (02970).

(iv) Endodontic: Pulp cap-indirect (excluding final restoration

(03120); Therapeutic pulpotomy (excluding final restoration) (03220);

Anterior root canal (excluding final restoration) (03310); Bicuspid

root canal (excluding final restoration) (03320); Molar root canal

(Excluding final restoration) (03330); Retreatment-anterior, by report

(03346); Retreatment-bicuspid, by report (03347); Retreatment-molar, by

report (03348); Apexification/recalcification-initial visit (apical

closure/calcific repair of perforations, root resorption, etc.)

(03351); Apexification/recalcification-interim medication replacement

(apical closure/calcific repair of performations, root resorption,

etc.) (03352); Apexification/recalcification-final visit (includes

completed root canal therapy-apical closure/calcific repair of

perforations, root resorption, etc.) (03353); Apicoectomy/Periradicular

surgery-anterior (03410); Apicoectomy/Periradicular surgery-bicuspid

(first root) (03421); Apicoectomy/Periradicular surgery-molar (first

root) (03425); Apicoectomy/Periradicular surgery (each additional root)

(03426); Retrograde filling-per root (03430); Root amputation-per root

(03450); Hemisection (including any root removal), not including root

canal therapy (03920).

(v) Periodontic: Gingivectomy or gingivoplasty--per quadrant

(04210); Gingivectomy or gingivoplasty--per tooth (04211); Gingival

curettage, surgical, per quadrant, by report (04220); Gingival flap

procedure, including root planing--per quadrant (04240); Mucogingival

surgery--per quadrant (04250); Osseous surgery (including flap entry

and closure)--per quadrant (04260); Bone replacement graft--single site

(including flap entry and closure) (04261); Bone replacement graft--

multiple sites (including flap entry and closure) (04262); Guided

tissue regeneration (includes the surgery and reentry) (04268); Pedicle

soft tissue graft procedure (04270); Free soft tissue graft procedure

(including donor site) (04271); Periodontal scaling and root planing--

per quadrant (04341); Periodontal maintenance procedures (following

active therapy) (04910); Unscheduled dressing change (by someone other

than treating dentist) (04920).

(vi) Oral Surgery: Single tooth (07110); Each additional tooth

(07120); Root removal--exposed roots (07130); Surgical removal or

erupted tooth requiring elevation of mucoperiosteal flap and removal of

bone and/or section of tooth (07210); Removal of impacted tooth--soft

tissue (07220); Removal of impacted tooth--partially bony (07230);

Removal of impacted tooth--completely bony (07240); Surgical removal of

residual tooth roots (cutting procedure) (07250); Oral antral fistula

closure (07260); Tooth reimplantation and/or stabilization of

accidentally evulsed or displaced tooth and/or alveolus (07270);

Surgical exposure of impacted or erupted tooth to aid eruption (07281);

Biopsy of oral tissue--hard (07285); Biopsy of oral tissue--soft

(07286); Surgical repositioning of teeth (07290); Alveoloplasty in

conjunction with extractions--per quadrant (07310); Suture of recent

small wounds up to 5 cm (07910); Complicated suture--up to 5 cm

(07911); Complicated suture--greater than 5 cm (07912); Excision of

pericoronal gingiva (07971).

(vii) Emergency: Emergency oral examination (00130); Palliative

(emergency) treatment of dental pain--minor procedures (09110).

(viii) Drugs: Therapeutic drug injection, by report (09610); Other

drugs and/or medications, by report (09630).

(ix) Postsurgical: Treatment of complications (post-surgical)

unusual circumstances, by report (09930).

(g) Maximum annual cap. TRDP enrollees will be subject to a maximum

cap of $1,000.00 of paid allowable charges per enrollee per year, with

the exception of the diagnostic and preventive services.

(h) Annual review of rates. TRDP premiums will be determined as

part of the competitive contracting process. The contractor will

annually notify those eligible for TRDP of the premium rates.

(i) Authorized providers. The TRDP enrollee may seek covered

services from any provider who is fully licensed and approved to

provide dental care in the state where the provider is located.

(j) Benefit payment. Enrollees are not required to utilize the

special network of dental providers established by the TRDP contractor.

For enrollees who do not use these network providers, however,

providers shall not balance bill any amount in excess of the maximum

payment allowable by the TRDP. Enrollees using non-network providers

may be balance billed such an amount. The maximum payment allowable by

the TRDP (minus the appropriate cost-share) will be the lesser of:

(1) billed charges or

(2) Usual, Customary and Reasonable rates, in which the customary

rate is calculated at the 85th percentile of billed charges in that

geographic area, as measured in an undiscounted charge profile in 1995

or later for that geographic area (as defined by three-digit zip code).

(k) 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) shall

apply.

(l) Preemption of State laws. Pursuant to 10 U.S.C., section 1103,

any state or local law or regulation pertaining to health or dental

insurance, prepaid health or dental plans, or other health or dental

care delivery, administration, and financing methods is preempted and

does not apply in connection with the TRICARE Retiree Dental Program

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 TRICARE Retiree Dental

Program contract. (However, the Department of Defense may, by contract,

establish legal obligations on the part of the TRICARE Retiree Dental

Program contractor to conform with requirements similar to or identical

to requirements of State or local laws or regulations).

(m) Administration. The Assistant Secretary of Defense (Health

Affairs) or designee may establish other rules and

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procedures for the administration of the TRICARE Retiree Dental

Program.

Dated: June 18, 1997.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 97-16406 Filed 6-23-97; 8:45 am]

BILLING CODE 5000-04-M