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

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD 6010.8-R]

Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS); TRICARE Family Member Dental Plan

AGENCY: Office of the Secretary, DoD.

ACTION: Proposed rule.

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SUMMARY: This proposed rule revises the comprehensive CHAMPUS

regulation pertaining to the Expanded Active Duty Dependents Benefit

Plan. The new plan, and this proposed rule: places the responsibility

for TRICARE Family Member Dental Plan (TFMDP) enrollment and a large

portion of the appeals program on the dental plan contractor; allows

the dental plan contractor to bill eligible dependents for plan

premiums in certain circumstances; reduces the enrollment period from

24 to 12 months; excludes Reserve component members ordered to active

duty in support of a contingency operation from the mandatory 12 month

enrollment; simplifies enrollment types and exceptions; reduces cost-

shares for certain enlisted grades; adds anesthesia as a covered

benefit; incorporates legislative authority for calculating the method

by which premiums may be raised and allowing premium reductions for

certain enlisted grades; and reduces administrative burden by reducing

redundant language, referencing language appearing in other CFR

sections and removing language more appropriate to the actual contract.

These improvements will provide Uniformed Service families with

numerous quality of life benefits that will improve participation in

the plan, significantly reduce enrollment errors and positively effect

utilization of this important dental plan.

DATES: Comments must be received by December 27, 1999.

ADDRESSES: Address all comments concerning this proposed rule to

TRICARE Management Activity/Special Contract Operations Branch, 16401

East Centretech Parkway, Aurora, CO 80011-9043.

FOR FURTHER INFORMATION CONTACT: Lt Col Brian W. Grassi, 303-676-3496.

SUPPLEMENTARY INFORMATION:

tively effect

utilization of this important dental plan.

DATES: Comments must be received by December 27, 1999.

ADDRESSES: Address all comments concerning this proposed rule to

TRICARE Management Activity/Special Contract Operations Branch, 16401

East Centretech Parkway, Aurora, CO 80011-9043.

FOR FURTHER INFORMATION CONTACT: Lt Col Brian W. Grassi, 303-676-3496.

SUPPLEMENTARY INFORMATION:

I. Background and Legislative Changes

The Basic Active Duty Dependents Dental Benefit Plan was

implemented on August 1, 1987, allowing military personnel to

voluntarily enroll their dependents in a basic dental health care plan.

Under this plan, DoD shared the cost of the premium with the active

duty service member. Although the plan was viewed as a major step in

benefit enhancement for military families, there were still complaints

that the enabling legislation was too restrictive in scope and that

there should be expansion of services to better meet the dental needs

of the Uniformed Service family.

Congress responded to these concerns by authorizing the Secretary

of Defense to develop and implement an Expanded Active Duty Dependents

Dental Benefit Plan (the Defense Authorization Act, Public Law 102-484,

sec. 701). The provisions of this Act specified the expended benefit

structure, as well as maximum monthly premiums for enrollees. Cost-

sharing levels for the expanded benefits were left up to the discretion

of the Secretary of Defense after consultation with the other

Administering Secretaries. The provisions of this Act were implemented

on April 1, 1993.

horization Act, Public Law 102-484,

sec. 701). The provisions of this Act specified the expended benefit

structure, as well as maximum monthly premiums for enrollees. Cost-

sharing levels for the expanded benefits were left up to the discretion

of the Secretary of Defense after consultation with the other

Administering Secretaries. The provisions of this Act were implemented

on April 1, 1993.

Thereafter, Congress granted legislative authority to allow the

Secretary of Defense to expand the dental plan outside the United

States and to provide one year of continued dental coverage for

enrolled beneficiaries to service members who die while on active duty

(The Defense Authorization Act, Public Law 103-337, sec. 703). In

addition, the Congress granted subsequent legislative authority to

allow the Secretary of Defense to waive or reduce the cost-shares in

overseas locations (The Defense Authorization Act, Public Law 105-85,

sec. 732).

In Fiscal Year 1999, the Congress authorized a methodology by which

the enrollee's share of the premium could be increased. This

methodology is tied to the lesser of the percent increase in the basic

pay of active duty service members or the basic pay for statutory pay

systems plus one-half percent. In authorizing language, the Secretary

of Defense could apply this premium increase methodology as if it had

been in place continuously since December 31, 1993. To allow for an

expanded and more comprehensive benefit, the Department will apply this

premium increase methodology as authorized. The language further

instructed the Secretary of Defense to advise the Congress of any plans

to reduce dental plan benefits and to wait one year, after

notification, before any benefits could be reduced (The Defense

Authorization Act, Public Law 105-261, sec. 701).

The legislative provisions have been codified in 10 U.S.C. Chapter

55, sec. 1076a, Dependents Dental Program, and are reflected in the

regulatory provisions of this rule.

II. Programmatic Improvements

ngress of any plans

to reduce dental plan benefits and to wait one year, after

notification, before any benefits could be reduced (The Defense

Authorization Act, Public Law 105-261, sec. 701).

The legislative provisions have been codified in 10 U.S.C. Chapter

55, sec. 1076a, Dependents Dental Program, and are reflected in the

regulatory provisions of this rule.

II. Programmatic Improvements

The below programmatic improvements will be effective once the

follow-on TFMDP contract has been awarded and the performance period

has begun. At the present time, the performance period is expected to

begin on February 1, 2001.

A. Contractor Enrollment

Since the plan began, the Uniformed Services have administered the

dental plan enrollment, disenrollment and eligibility determination

functions. The complexities of the dental plan combined with a high

turnover rate of relatively inexperienced Service personnel and other

competing responsibilities, separate Service procedures, databases and

data transfer processes, high cost and lengthy delays in software

modifications, and Uniformed Service personnel downsizing, created the

need for a centralized and uniform enrollment process. This can be best

achieved by an experienced dental plan contractor and will allow active

duty service members to contact one organization to enroll, disenroll,

re-enroll and discuss other TFMDP benefit and claims adjudication

issues. By allowing the contractor to administer the enrollment

function across all of the Uniformed Services, enrollment becomes

portable whereas the current system does not allow an active duty

member from one Service to enroll through a separate Service.

Contractor enrollment will also simplify the payroll deduction and

eligibility determination process and reduce the possibility of waste

and abuse at the local level. In addition, it maintains a stable,

trained work force at the front end of the TFMDP and greatly improves

customer service

rrent system does not allow an active duty

member from one Service to enroll through a separate Service.

Contractor enrollment will also simplify the payroll deduction and

eligibility determination process and reduce the possibility of waste

and abuse at the local level. In addition, it maintains a stable,

trained work force at the front end of the TFMDP and greatly improves

customer service.

An added benefit to contractor enrollment will be the elimination

of the current required Uniformed Service enrollment forms. The complex

DD Form 2494, Active Duty Dependent Dental Plan Enrollment Form, and

the DD Form 2494-1, Supplemental Active Duty Dependent Dental Plan

Enrollment Form, will no longer be needed and will be replaced by a

standard, simplified contractor enrollment form as well as telephonic

and fax enrollment options.

Contractor enrollment has proven to be a success with the TRICARE

Managed Care Support contractors as well as with contracted enrollment

via the TRICARE Selected Reserve Dental Program and the Tricare Retiree

Dental Program. The Uniformed Services will continue, as with the

former dental plan and current TRICARE/CHAMPUS programs, to determine

eligibility for the dental plan and process any changes regarding

eligibility through the Defense Enrollment Eligibility Reporting System

(DEERS).

B. Contractor Direct Billing

The dental plan is financed through premiums jointly paid by the

Government and the active duty service member. The active duty service

member's share of the premiums is deducted from their payroll accounts.

In certain situations, otherwise eligible dependents are precluded from

enrolling in the dental plan if their sponsor does not have an active

payroll account nor has insufficient funds in that account. These

eligible dependents include dependents of incarcerated sponsors and

survivors. By allowing the contractor to directly bill these dependents

for their premium share, dependents previously excluded from enrollment

can now receive coverage

ts are precluded from

enrolling in the dental plan if their sponsor does not have an active

payroll account nor has insufficient funds in that account. These

eligible dependents include dependents of incarcerated sponsors and

survivors. By allowing the contractor to directly bill these dependents

for their premium share, dependents previously excluded from enrollment

can now receive coverage. This improvement eliminates a previous

enrollment termination provision in the regulation where eligibility

for basic pay was a deciding criterion for continued enrollment in the

dental plan.

C. Reduction in Mandatory Enrollment Period

A mandatory enrollment period is an essential factor behind

Government and contractor actuarial estimates in developing the TFMDP

premium and provides a guarantee to the contracting community that they

will collect a certain amount of premiums for the potential benefit

payout. The proposed regulation reduces the previous longstanding 24-

month mandatory enrollment period to 12 months since this 24-month

period precluded numerous, otherwise eligible, dependents from

enrolling in the dental plan. These eligible dependents include those

that are near the end of their active service and have new eligible

dependents, enlisted service members who are outside of their re-

enlistment window of opportunity, and Reserve/Guard personnel called to

active duty for less than 24 months (such as Reserve/Guard personnel on

active duty for training and special assignments). Reduction to a 12-

month enrollment period for the TFMDP has a precedent with other

TRICARE plans, to include the TRICARE Managed Care Prime option and the

Tricare Selected Reserve Dental Program. By introducing this more

liberal enrollment period, the proposed regulation also calls for a 12-

month ``lock-out'' if the active duty service member disenrolls before

completing the 12-month enrollment period or if the active duty service

member fails to pay their premiums

h other

TRICARE plans, to include the TRICARE Managed Care Prime option and the

Tricare Selected Reserve Dental Program. By introducing this more

liberal enrollment period, the proposed regulation also calls for a 12-

month ``lock-out'' if the active duty service member disenrolls before

completing the 12-month enrollment period or if the active duty service

member fails to pay their premiums. A 12-month lock-out period also

applies to a Reserve component member who disenrolls before completing

the special mandatory enrollment period for Reserve component members

ordered to active duty in support of a contingency operation. This

``lock-out'' period has a precedent with other commercial dental

insurance plans as well as the TRICARE Managed Care Prime option, the

TRICARE Selected Reserve Dental Program and the TRICARE Retiree Dental

Program. ``Lock-out'' periods also discourage potential beneficiaries

from enrolling in an insurance plan, receiving all of their benefit in

a few months and then disenrolling without paying a full 12 months'

worth of premiums.

Beneficiaries enrolled in the current dental plan at the time when

TFMDP coverage begins must complete their two (2) year enrollment

period established under that superceded plan except if one of the

conditions for valid disenrollment applies. Once this

original two (2) year enrollment period is met, the active duty member

may continue TFMDP enrollment on a month-to-month basis. A new one (1)

year enrollment period will only be incurred if the active duty member

disenrolls and attempts to re-enroll in the TFMDP at a later date.

D. Enrollment Period for Certain Reserve Component Sponsors

conditions for valid disenrollment applies. Once this

original two (2) year enrollment period is met, the active duty member

may continue TFMDP enrollment on a month-to-month basis. A new one (1)

year enrollment period will only be incurred if the active duty member

disenrolls and attempts to re-enroll in the TFMDP at a later date.

D. Enrollment Period for Certain Reserve Component Sponsors

The proposed regulation provides that the 12-month enrollment

period shall not apply to eligible dependents of Reserve component

sponsors ordered to active duty for more than 30 days but less than 12

months (other than for training) in support of a contingency operation

as defined in 10 U.S.C. sec. 101(a)(13). Orders may be issued under

statutory authorities for recalling Reserve component members to active

duty, but must specify that the member is serving in support of a

specific contingency operation under the statutory definition. This

disparate treatment for certain Reserve component members is necessary

because of the involuntary nature of their call to active duty and

statutory limitations on their periods of active duty.

By contrast, active duty members are enlisted, reenlisted or

commissioned for periods of active duty longer than one year. The

active duty member has the option to enroll eligible dependents at any

time during that period of active duty prior to the last 12 months of

service, and at a relatively constant premium cost. Similarly, other

Reserve component members generally volunteer for call to active duty

and serve for at least one year; therefore they will have the option to

enroll family members at any time other than in the last 12 months of

that service.

However Reserve component members ordered to active duty in support

of a contingency operation are normally limited by statute to a period

of active duty of 9 months or less. While 38 U.S.C

bers generally volunteer for call to active duty

and serve for at least one year; therefore they will have the option to

enroll family members at any time other than in the last 12 months of

that service.

However Reserve component members ordered to active duty in support

of a contingency operation are normally limited by statute to a period

of active duty of 9 months or less. While 38 U.S.C. Chapter 43 provides

that a Reserve component member who has coverage under a civilian

employer sponsored dental program may elect to continue that coverage

during a period of active duty, for up to 18 months; if serving for

more than 30 days, the member may be required to pay the full premium

cost with employer cost-sharing no longer required. Upon release from

active duty, 38 U.S.C. Chapter 43, provides that the Reserve component

member may be reinstated in his or her civilian employer sponsored

program without a waiting period. Without an exception to the mandatory

12 month enrollment period for TFMDP, members who cannot afford to pay

the full premium for continuing their civilian plan would be unable to

provide dental insurance coverage for their family members while on

active duty. This exclusion to the 12-month enrollment period is

therefore necessary to preclude such prejudicial treatment of Reserve

component members ordered to active duty for less than 12 months to

support a contingency operation. In its place, a separate enrollment

period is created for the Reserve component member.

E. Reduction in Cost-Shares for Certain Enlisted Pay Grades

s while on

active duty. This exclusion to the 12-month enrollment period is

therefore necessary to preclude such prejudicial treatment of Reserve

component members ordered to active duty for less than 12 months to

support a contingency operation. In its place, a separate enrollment

period is created for the Reserve component member.

E. Reduction in Cost-Shares for Certain Enlisted Pay Grades

Although certain cost-shares are mandated by law, the Secretary of

Defense has the prerogative to adjust cost-shares for certain types of

dental procedures. Available data shows that our lower-paid enlisted

families are reluctant to pursue specialized dental care because of the

amount of their cost-share. To allow greater participation and dental

benefit utilization among our younger enlisted families, this proposed

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

active duty service member's pay grade. With the rates below, this

reduction for enlisted service members does not have a measurable

effect on the overall premium.

[In percent]

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

Cost-share for

pay grades E- Cost-share for

Covered services 1, E-2, E-3 all other pay

and E-4 grades

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Diagnostic.............................. 0 0

Preventive, except Sealants............. 0 0

Emergency Services...................... 0 0

Sealants................................ 20 20

Professional Consultations.............. 20 20

Professional Visits..................... 20 20

Post Surgical Services.................. 20 20

Basic Restorative (example: amalgams, 20 20

resins, stainless steel crowns)........

Endodontic.............................. 30 40

Periodontic............................. 30 40

Oral and Maxillofacial Surgery.......... 30 40

General Anesthesia...................... 40 40

Intravenous Sedation...................

sional Visits..................... 20 20

Post Surgical Services.................. 20 20

Basic Restorative (example: amalgams, 20 20

resins, stainless steel crowns)........

Endodontic.............................. 30 40

Periodontic............................. 30 40

Oral and Maxillofacial Surgery.......... 30 40

General Anesthesia...................... 40 40

Intravenous Sedation.................... 50 50

Other Restorative (example: crowns, 50 50

onlays, casts).........................

Prosthodontic........................... 50 50

Medications............................. 50 50

Orthodontic............................. 50 50

Miscellaneous Services.................. 50 50

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

A reduction in cost shares has been chosen over a reduction in

premium rates for enlisted service members in these pay grades because

the premium rates have traditionally been affordable as compared to

similar dental benefits programs administered by commercial dental

insurance plans and given the fact that the Government pays 60 percent

of the total premium. As such, the greatest effect on participation and

utilization can best be achieved through a reduction in cost-shares.

F. Simplification on Enrollment Options

Under the proposed rule, TFMDP enrollment options have been

simplified to assist the beneficiary, Government, provider of care and

the dental plan contractor. Under the prior dental plan, dependents

were asked to choose from several different enrollment options

t on participation and

utilization can best be achieved through a reduction in cost-shares.

F. Simplification on Enrollment Options

Under the proposed rule, TFMDP enrollment options have been

simplified to assist the beneficiary, Government, provider of care and

the dental plan contractor. Under the prior dental plan, dependents

were asked to choose from several different enrollment options

depending on whether they had children under the age of 4. With the

advances in pediatric dentistry (pedodontics), dental care for children

between the ages of 1 and 4 is highly recommended. As such, the dental

plan contractor will offer sponsors the opportunity to enroll these

particular dependents when eligibility information indicates a

dependent is 1 year of age or older. Although there will continue to be

two separate premiums, a ``single'' premium for one covered life and a

``family'' premium for more than one covered life, providing additional

exceptions to this rule based on age will advance pediatric care among

our beneficiary population, simplify enrollment processing by the

dental plan contractor and promote greater understanding of enrollment

options by all parties.

G. Addition of Anesthesia Services

Local anesthesia, in conjunction with other covered dental

procedures, is considered integral to the procedure itself and has been

covered for several years. Other anesthesia services were historically

excluded due to their high cost. The proposed regulation allows the

Department to add other types of anesthesia services to the TFMDP

benefit package.

H. Appeals Plan

of Anesthesia Services

Local anesthesia, in conjunction with other covered dental

procedures, is considered integral to the procedure itself and has been

covered for several years. Other anesthesia services were historically

excluded due to their high cost. The proposed regulation allows the

Department to add other types of anesthesia services to the TFMDP

benefit package.

H. Appeals Plan

Under the TFMDP, the Department wishes to procure a responsive,

simple, and two (or greater) tiered appeals program within the dental

plan contractor's operation. We have had similar success with this

approach under the TRICARE Selected Reserve Dental Program and the

TRICARE Retiree Dental Program, where the contractors administer the

first two levels of the appeals program, which are termed the initial

determination and the reconsideration. Under the TFMDP, the appealing

parties would appeal adverse decisions through the contractor's

established appeal process where separate parties would perform the

initial determination and reconsideration reviews (whether internal or

external to the organization). the final level of review would be, as

before, to the Department, subscribing to guidelines under the Formal

Review and Hearing procedures listed in 32 CFR 199.10.

I. Plan Transition

The programmatic improvements are scheduled to take effect when the

follow-on TFMDP contract to the current Expanded Active Duty Dependents

Dental Plan contract is awarded and the performance period begins.

Considering the magnitude of the planned improvements, the Department

plans to ``phase-out'' operations under the former contractor and

method of operation to accommodate late claims processing and to allow

the Uniformed Services time to process retroactive enrollment and

coverage information to assist our beneficiaries. This ``phase-out''

schedule will be jointly determined between the Department and the

outgoing and incoming dental plan contractors.

III. Administrative Changes

t'' operations under the former contractor and

method of operation to accommodate late claims processing and to allow

the Uniformed Services time to process retroactive enrollment and

coverage information to assist our beneficiaries. This ``phase-out''

schedule will be jointly determined between the Department and the

outgoing and incoming dental plan contractors.

III. Administrative Changes

The proposed regulation incorporates several administrative

changes. There is revised language on Federal preemption of State and

local laws that conforms the dental regulation language to reflect the

Department's previous exercise of statutory authority in this area.

Other changes include: widespread publication of premium rates;

allowing the Department to modify the benefit package based on

developments in common dental care practices and standard dental

insurance plans; permitting the dental plan contractor to pay ``by

report'' procedures by providing an additional allowance to the primary

covered procedure; removing detailed descriptions of types of

authorized providers in favor of more general language; updating dental

terminology to be consistent with the American Dental Association's

Council on Dental Care Program's Code on Dental Procedures and

Nomenclature; and, reorganizing and adding language on the maximum

amount payable by the TFMDP.

The proposed regulation incorporates plan name and other changes to

reflect current terminology, such as outdated references to the former

TRICARE Management Activity address, ``Active Duty Dependent Dental

Plan'' and superceded regulations. It also reduces redundant language

and reduces the overall size of the regulation through cross-references

to applicable language appearing in other CFR sections. This includes

references to appeals, fraud and abuse, eligibility, and adjunctive

dental care as well as information on the former dental plans

ment Activity address, ``Active Duty Dependent Dental

Plan'' and superceded regulations. It also reduces redundant language

and reduces the overall size of the regulation through cross-references

to applicable language appearing in other CFR sections. This includes

references to appeals, fraud and abuse, eligibility, and adjunctive

dental care as well as information on the former dental plans. Items

that are more appropriate for inclusion in the actual contract

statement of work have also been removed and transferred to that

document. This includes equality of benefit processing, coordination of

benefits, participating provider lists, Government review of billing

practices, and how a Dental Explanation of Benefits should be

structured. Finally, the regulation has been reorganized for better

flow, ease of reading and understanding.

IV. Costs

The changes in the proposed regulation coincide with the upcoming

recompetition of the TFMDP contract. As such, the Department plans to

include these requirements in the request for proposal. By relaxing or

eliminating some current contractual requirements and adding a greater

number of eligible dependents, we anticipate that costs for the

programmatic improvements can be met through contractor internal

efficiencies and the competitive nature of the bid process and will

result in affordable premiums comparable to what dental plan enrollees

presently pay.

V. Regulatory Procedures

By relaxing or

eliminating some current contractual requirements and adding a greater

number of eligible dependents, we anticipate that costs for the

programmatic improvements can be met through contractor internal

efficiencies and the competitive nature of the bid process and will

result in affordable premiums comparable to what dental plan enrollees

presently pay.

V. Regulatory Procedures

Executive Order 12866 requires certain regulatory assessments for

any ``significant regulatory action'' defined as one that would result

in an annual effect on the economy of $100 million or more, or have

other substantial impacts. The Regulatory Flexibility Act (RFA)

requires that each federal agency prepare, and make available for

public comment, a regulatory flexibility analysis when the agency

issues a regulation which would have a significant impact on a

substantial number of small entities.

This proposed rule is not a significant regulatory action under

Executive Order 12866. The changes set forth in this proposed rule are

minor revisions to the existing regulation. Since this proposed rule

does not impose information collection requirements, it does not need

to be reviewed by the Executive Office of Management and Budget under

authority of the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter

35).

List of Subjects in 32 CFR Part 199

Administrative practice and procedure, Claims, Dental health,

Fraud, Health care, Health insurance, Individuals with disabilities,

Military personnel.

Accordingly, 32 CFR part 199 is amended as follows:

PART 199--[AMENDED]

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

follows:

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

2. Section 199.13 is revised to read as follows:

Sec. 199.13 TRICARE Family Member Dental Plan.

Dental health,

Fraud, Health care, Health insurance, Individuals with disabilities,

Military personnel.

Accordingly, 32 CFR part 199 is amended as follows:

PART 199--[AMENDED]

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

follows:

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

2. Section 199.13 is revised to read as follows:

Sec. 199.13 TRICARE Family Member Dental Plan.

(a) General provisions--(1) Purpose. This section prescribes

guidelines and policies for the delivery and administration of the

TRICARE Family Member Dental Plan (TFMDP) of the Uniformed Service of

the Army, the Navy, the Air Force, the Marine Corps, the Coast Guard,

the Commissioned Corps of the U.S. Public Health Service (USPHS) and

the Commissioned Corps of the National Oceanic and Atmospheric

Administration (NOAA). The TFMDP is a premium based indemnity dental

insurance coverage plan that is available to specified categories of

individuals who are qualified for these benefits by virtue of their

relationship to one of the seven Uniformed Services and their voluntary

decision to accept enrollment in the plan and cost share (when

applicable) with the Government in the premium cost of the benefits.

The TFMDP is authorized by 10 U.S.C. 1076a, Dependents' Dental Program,

and this section was previously titled the ``Active Duty Dependents

Dental Plan''.

(2) Applicability--(i) Geographic scope. (A) The TFMDP is

applicable geographically within the 50 States of the United States,

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

the U.S. Virgin Islands. These areas are collectively referred to as

the ``CONUS (or Continental United States) service area''.

(B) Extension of the TFMDP to areas outside the CONUS service area.

In accordance with the authority cited in 10 U.S.C. 1076a(h), the

Assistant Secretary of Defense (Health Affairs) (ASD(HA)) may extend

the TFMDP to areas other than those areas specified in paragraph

he U.S. Virgin Islands. These areas are collectively referred to as

the ``CONUS (or Continental United States) service area''.

(B) Extension of the TFMDP to areas outside the CONUS service area.

In accordance with the authority cited in 10 U.S.C. 1076a(h), the

Assistant Secretary of Defense (Health Affairs) (ASD(HA)) may extend

the TFMDP to areas other than those areas specified in paragraph

(a)(2)(i)(A) of this section for the eligible dependents of active duty

members of the Uniformed Services. These areas are collectively

referred to as the ``OCONUS (or outside the Continental United States)

service area''. In extending the TFMDP outside the CONUS service area,

the ASD(HA), or designee, is authorized to establish program elements,

methods of administration and payment rates and procedures to providers

that are different from those in effect for the CONUS service area to

the extent the ASD(HA), or designee, determines necessary for the

effective and efficient operation of the TFMDP. This includes

provisions for preauthorization of care if the needed services are not

available in a Uniformed Service overseas dental treatment facility and

payment by the Department of certain cost-shares (or co-payments) and

other portions of a provider's billed charges. Other difference may

occur based on limitations in the availability and capabilities of the

Uniformed Service overseas dental treatment facility and a particular

nation's civilian sector providers in certain areas. These differences

include varying licensure and certification requirements of OCONUS

providers, Uniformed Service provider selection criteria and local

results of provider selection, referral, beneficiary pre-authorization

and marketing procedures, and care for beneficiaries residing in

distant areas. The Director, Office of Civilian Health and Medical

Program of the Uniformed Services (OCHAMPUS) shall issue guidance, as

necessary, to implement the provisions of this paragraph (a)(2)(i)(B)

formed Service provider selection criteria and local

results of provider selection, referral, beneficiary pre-authorization

and marketing procedures, and care for beneficiaries residing in

distant areas. The Director, Office of Civilian Health and Medical

Program of the Uniformed Services (OCHAMPUS) shall issue guidance, as

necessary, to implement the provisions of this paragraph (a)(2)(i)(B).

Beneficiaries will be eligible for the same TFMDP benefits in the

OCONUS service area although services may not be available or

accessible in all OCONUS countries.

(ii) Agency. The provisions of this section apply throughout the

Department of Defense (DoD), the United States Coast Guard, the USPHS

and NOAA.

(iii) Exclusion of benefit services performed in military dental

care facilities. Except for emergency treatment, dental care provided

outside the United States, and services incidental to noncovered

services, beneficiaries enrolled in the TFMDP may not obtain those

services that are benefits of the TFMDP in military dental care

facilities, as long as those covered benefits are available for cost-

sharing under the TFMDP. Enrolled beneficiaries may continue to obtain

noncovered services from military dental care facilities subject to the

provisions for space available care.

(3) Authority and responsibility--(i) Legislative authority-- (A)

Joint regulations. 10 U.S.C. 1076a authorizes the Secretary of Defense,

in consultation with the Secretary of Health and Human Services, and

the Secretary of Transportation, to prescribe regulations for the

administration of the TFMDP.

(B) Administration. 10 U.S.C

facilities subject to the

provisions for space available care.

(3) Authority and responsibility--(i) Legislative authority-- (A)

Joint regulations. 10 U.S.C. 1076a authorizes the Secretary of Defense,

in consultation with the Secretary of Health and Human Services, and

the Secretary of Transportation, to prescribe regulations for the

administration of the TFMDP.

(B) Administration. 10 U.S.C. 1073 authorizes the Secretary of

Defense to administer the TFMDP for the Army, Navy, Air Force, and

Marine Corps under DoD jurisdiction, the Secretary of Transportation to

administer the TFMDP for the Coast Guard, when the Coast Guard is not

operating as a service in the Navy, and the Secretary of Health and

Human Services to administer the TFMDP for the Commissioned Corps of

the NOAA and the USPHS.

(ii) Organizational delegations and assignments--(A) Assistant

Secretary of Defense (Health Affairs) (ASD(HA)). The Secretary of

Defense, by 32 CFR part 367, delegated authority to the ASD(HA) to

provide policy guidance, management control, and coordination as

required for all DoD health and medical resources and functional areas

including health benefit programs. Implementing authority is contained

in 32 CFR part 367. For additional implementing authority see

Sec. 199.1. Any guidelines or policy necessary for implementation of

this Sec. 199.13 shall be issued by the Director, OCHAMPUS.

(B) Evidence of eligibility. DoD, through the Defense Enrollment

Eligibility Reporting System (DEERS), is responsible for establishing

and maintaining a listing of persons eligible to receive benefits under

the TFMDP.

367. For additional implementing authority see

Sec. 199.1. Any guidelines or policy necessary for implementation of

this Sec. 199.13 shall be issued by the Director, OCHAMPUS.

(B) Evidence of eligibility. DoD, through the Defense Enrollment

Eligibility Reporting System (DEERS), is responsible for establishing

and maintaining a listing of persons eligible to receive benefits under

the TFMDP.

(4) Preemption of State and local laws. (i) Pursuant to 10 U.S.C.

1103 and section 8025 (fourth proviso) of the Department of Defense

Appropriations Act, 1994, DoD has determined that, in the

administration of 10 U.S.C. chapter 55, preemption of State and local

laws relating to health insurance, prepaid health plans, or other

health care delivery or financing methods is necessary to achieve

important Federal interests, including, but not limited to, the

assurance of uniform national health programs for military families and

the operation of such programs at the lowest possible cost to DoD, that

have a direct and substantial effect on the conduct of military affairs

and national security policy of the United States. This determination

is applicable to the dental services contracts that implement this

section.

(ii) Based on the determination set forth in paragraph (a)(4)(i) of

this section, any State or local law relating to health or dental

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

care delivery or financing methods is preempted and does not apply in

connection with the TFMDP 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 TFMDP contract. (However, DoD may, by contract, establish legal

obligations on the part of the dental plan contractor to conform with

requirements similar or identical to requirements of State or local

laws or regulations.)

(iii) The preemption of State and local laws set forth in paragraph

or effect, and State or

local governments have no legal authority to enforce them in relation

to the TFMDP contract. (However, DoD may, by contract, establish legal

obligations on the part of the dental plan contractor to conform with

requirements similar or identical to requirements of State or local

laws or regulations.)

(iii) The preemption of State and local laws set forth in paragraph

(a)(4)(ii) of this section includes State and local laws imposing

premium taxes on health or dental insurance carriers or underwriters or

other plan managers, or similar taxes on such entities. Such laws are

laws relating to health insurance, prepaid health plans, or other

health care delivery or financing methods,

within the meaning of the statutes identified in paragraph (a)(4)(i) of

this section. Preemption, however, does not apply to taxes, fees, or

other payments on net income or profit realized by such entities in the

conduct of business relating to DoD health services contracts, if those

taxes, fees, or other payments are applicable to a broad range of

business activity. For purposes of assessing the effect of Federal

preemption of State and local taxes and fees in connection with DoD

health and dental services contracts, interpretations shall be

consistent with those applicable to the Federal Employees Health

Benefits Program under 5 U.S.C. 8909(f).

(5) Plan funds.--(i) Funding sources. The funds used by the TFMDP

are appropriated funds furnished by the Congress through the annual

appropriation acts for DoD, the Department of Health and Human Services

and the Department of Transportation and funds collected by the

Uniformed Services or contractor through payroll deductions or through

direct billing as premium shares from enrolled beneficiaries.

n funds.--(i) Funding sources. The funds used by the TFMDP

are appropriated funds furnished by the Congress through the annual

appropriation acts for DoD, the Department of Health and Human Services

and the Department of Transportation and funds collected by the

Uniformed Services or contractor through payroll deductions or through

direct billing as premium shares from enrolled beneficiaries.

(ii) Disposition of funds. TFMDP funds are paid by the Government

(or in the case of direct billing, by the beneficiary) as premiums to

an insurer, service, or prepaid dental care organization under a

contract negotiated by the Director, OCHAMPUS, or a designee, under the

provisions of the Federal Acquisition Regulation (FAR) (48 CFR chapter

1).

(iii) Plan. The Director, OCHAMPUS, or designee provides an

insurance policy, service plan, or prepaid contract of benefits in

accordance with those prescribed by law and regulation; as interpreted

and adjudicated in accord with the policy, service plan, or contract

and a dental benefits brochure; and as prescribed by requirements of

the dental plan contractor's contract with the Government.

(iv) Contracting out. The method of delivery of the TFMDP is

through a competitively procured contract. The Director, OCHAMPUS, or a

designee, is responsible for negotiating, under provisions of the FAR,

a contract for dental benefits insurance or prepayment that includes

responsibility for:

(A) Development, publication, and enforcement of benefit policy,

exclusions, and limitations in compliance with the law, regulation, and

the contract provisions;

(B) Adjudicating and processing claims; and conducting related

supporting activities, such as enrollment, disenrollment, collection of

premiums, eligibility verification, provider relations, and beneficiary

communications.

ity for:

(A) Development, publication, and enforcement of benefit policy,

exclusions, and limitations in compliance with the law, regulation, and

the contract provisions;

(B) Adjudicating and processing claims; and conducting related

supporting activities, such as enrollment, disenrollment, collection of

premiums, eligibility verification, provider relations, and beneficiary

communications.

(6) Role of Health Benefits Advisor (HBA). The HBA is appointed

(generally by the commander of an Uniformed Services medical treatment

facility) to serve as an advisor to patients and staff in matters

involving the TFMPD. The HBA may assist beneficiaries in applying for

benefits, in the preparation of claims, and in their relations with

OCHAMPUS and the dental plan contractor. However, the HBA is not

responsible for the TFMPD's policies and procedures and has no

authority to make benefit determinations or obligate the TFMPD's funds.

Advice given to beneficiaries by HBAs as to determination of benefits

or level of payment is not binding on OCHAMPUS or the dental plan

contractor.

(7) Right to information. As a condition precedent to the provision

of benefits hereunder, the Director, OCHAMPUS, or designee, shall be

entitled to receive information from an authorized provider or other

person, institution, or organization (including a local, State, or

United States Government agency) providing services or supplies to the

beneficiary for which claims for benefits are submitted. While

establishing enrollment and eligibility, benefits, and benefit

utilization and performance reporting information standards, the

Government has established and does maintain a system of records for

dental information under the TFMDP

including a local, State, or

United States Government agency) providing services or supplies to the

beneficiary for which claims for benefits are submitted. While

establishing enrollment and eligibility, benefits, and benefit

utilization and performance reporting information standards, the

Government has established and does maintain a system of records for

dental information under the TFMDP. By contract, the Government audits

the adequacy and accuracy of the dental plan contractor's system of

records and requires access to information and records to meet plan

accountabilities, to assist in contractor surveillance and program

integrity investigations and to audit OCONUS financial transactions

where the Department has a financial stake. Such information and

records may relate to attendance, testing, monitoring, examination, or

diagnosis of dental disease or conditions; or treatment rendered; or

services and supplies furnished to a beneficiary; and shall be

necessary for the accurate and efficient administration and payment of

benefits under this plan. To assist in claims adjudication, grievance

and fraud investigations, and the appeals process, and before an

interim or final determination can be made on a claim of benefits, a

beneficiary or active duty service member must provide particular

additional information relevant to the requested determination, when

necessary. Failure to provide the requested information may result in

denial of the claim and inability to effectively investigate the

grievance or fraud or process the appeal. The recipient of such

information shall in every case hold such records confidential except

when:

active duty service member must provide particular

additional information relevant to the requested determination, when

necessary. Failure to provide the requested information may result in

denial of the claim and inability to effectively investigate the

grievance or fraud or process the appeal. The recipient of such

information shall in every case hold such records confidential except

when:

(i) Disclosure of such information is necessary to the

determination by a provider or the dental plan contractor of

beneficiary enrollment or eligibility for coverage of specific

services;

(ii) Disclosure of such information is authorized specifically by

the beneficiary;

(iii) Disclosure is necessary to permit authorized Government

officials to investigate and prosecute criminal actions;

(iv) Disclosure constitutes a routine use of a record which is

compatible with the purpose for which it was collected. This includes a

standard and acceptable business practice commonly used among dental

insurers which is consistent with the principle of preserving

confidentiality of personal information and detailed clinical data. For

example, the release of utilization information for the purpose of

determining eligibility for certain services, such as the number of

dental prophylaxis procedures performed for a beneficiary, is

authorized;

(v) Disclosure is pursuant to an order form a court of competent

jurisdiction; or

(vi) Disclosure by the Director, OCHAMPUS, or designee, is for the

purpose of determining the applicability of, and implementing the

provisions of, other dental benefits coverage or entitlement.

(8) Utilization review and quality assurance. Claims submitted for

benefits under the TFMDP are subject to review by the Director,

OCHAMPUS, or designee, for quality of care and appropriate utilization.

The Director, OCHAMPUS, or designee, is responsible for appropriate

utilization review and quality assurance standards, norms, and criteria

consistent with the level of benefits.

entitlement.

(8) Utilization review and quality assurance. Claims submitted for

benefits under the TFMDP are subject to review by the Director,

OCHAMPUS, or designee, for quality of care and appropriate utilization.

The Director, OCHAMPUS, or designee, is responsible for appropriate

utilization review and quality assurance standards, norms, and criteria

consistent with the level of benefits.

(b) Definitions. For most definitions applicable to the provisions

of this section, refer to 199.2. The following definitions apply only

to his section:

(1) Assignment of benefits. Acceptance by a nonparticipating

provider of payment directly from the insurer while reserving the right

to charge the beneficiary or active duty service member for any

remaining amount of the fees for services which exceeds the prevailing

fee allowance of the insurer.

(2) Authoried provider. A dentist, dental hygienist, or certified

and licensed anesthetist specifically authorized to provide benefits

under the TFMPD in paragraph (f) of this section.

(3) Beneficiary. A dependent of an active duty member who has been

enrolled in the TFMDP, and has been determined to be eligible for

benefits, as set forth in paragraph (c) of this section.

(4) Beneficiary liability. The legal obligation of a beneficiary,

his or her estate, or responsible family member to pay for the costs of

dental care or treatment received. Specifically, for the purposes of

services and supplies covered by the TFMDP, beneficiary liability

includes cost-sharing amounts or any amount above the prevailing fee

determination by the insurer where the provider selected by the

beneficiary is not a participating provider or a provider within an

approved alternative delivery system

pay for the costs of

dental care or treatment received. Specifically, for the purposes of

services and supplies covered by the TFMDP, beneficiary liability

includes cost-sharing amounts or any amount above the prevailing fee

determination by the insurer where the provider selected by the

beneficiary is not a participating provider or a provider within an

approved alternative delivery system. In cases where a nonparticipating

provider does not accept assignment of benefits, beneficiaries may have

to pay the nonparticipating provider in full at the time of treatment

and seek reimbursement directly from the insurer for all or a portion

of the nonparticipating provider's fee. Beneficiary liability also

includes any expenses for services and supplies not covered by the

TFMDP, less any available discount provided as a part of the insurer's

agreement with an approved alternative delivery system.

(5) By report. Dental procedures which are authorized as benefits

only in unusual circumstances requiring justification of exceptional

conditions related to otherwise authorized procedures. These services

are further defined in paragraph (e) of this section.

(6) Contingency operation. Defined in 10 U.S.C. 101(a)(13) as a

military operation designated as a contingency operation by the

Secretary of Defense or a military operation that results in the

exercise of authorities for ordering Reserve component members to

active duty without their consent and is therefore automatically a

contingency operation.

(7) Cost-share. The amount of money for which the beneficiary (or

active duty service member) is responsible in connection with otherwise

covered dental services (other than disallowed amounts) as set forth in

paragraph (e) of this section. A cost-share may also be referred to as

a ``co-payment.''

(8) Defense Enrollment Eligibility reporting System (DEERS). The

automated system that is composed of two phases:

e amount of money for which the beneficiary (or

active duty service member) is responsible in connection with otherwise

covered dental services (other than disallowed amounts) as set forth in

paragraph (e) of this section. A cost-share may also be referred to as

a ``co-payment.''

(8) Defense Enrollment Eligibility reporting System (DEERS). The

automated system that is composed of two phases:

(i) Enrolling all active duty and retired service members, their

dependents, and the dependents of deceased service members; and

(ii) Verifying their eligibility for health care benefits in the

direct care facilities and through the TFMDP.

(9) Dental hygienist. Practitioner in rendering complete oral

prophylaxis services, applying medication, performing dental

radiography, and providing dental education services with a

certificate, associate degree, or bachelor's degree in the field, and

licensed by an appropriate authority.

(10) Dentist. Doctor of Dental Medicine (D.M.D.) or Doctor of

Dental Surgery (D.D.S.) who is licensed to practice dentistry by an

appropriate authority.

(11) Diagnostic services. Category of dental services including:

(i) Clinical oral examinations;

(ii) Radiographic examinations; and

(iii) Diagnostic laboratory tests and examinations provided in

connection with other dental procedures authorized as benefits of the

TFMDP and further defined in paragraph (e) of this section.

(12) Endodontics. The etiology, prevention, diagnosis, and

treatment of diseases and injuries affecting the dental pulp, tooth

root, and periapical tissue as further defined in paragraph (e) of this

section.

Diagnostic laboratory tests and examinations provided in

connection with other dental procedures authorized as benefits of the

TFMDP and further defined in paragraph (e) of this section.

(12) Endodontics. The etiology, prevention, diagnosis, and

treatment of diseases and injuries affecting the dental pulp, tooth

root, and periapical tissue as further defined in paragraph (e) of this

section.

(13) Initial determination. A formal written decision on a TFMDP

claim, a request for TFMDP benefit [pre-determination, a request by a

provider for approval as an authorized provider, or a decision

suspending, excluding or terminating a provider as an authorized

provider under the TFMFDP. Rejection of a claim or pre-determination,

or of a request for benefit or provider authorization for failure to

comply with administrative requirements, including failure to submit

reasonably requested information, is not an initial determination.

Responses to general or specific inquiries regarding TFMDP benefits are

not initial determinations.

(14) Nonparticipating provider. A dentist or dental hygienist that

furnished dental services to a TFMDP beneficiary, but who has not

agreed to participate or to accept the insurer's fee allowances and

applicable cost share as the total charge for the services. A

nonparticipating provider looks to the beneficiary or active duty

member for final responsibility for payment of his or her charge, but

may accept payment (assignment of benefits) directly from the insurer

or assist the beneficiary in filing the claim for reimbursement by the

dental plan contractor. Where the nonparticipating provider does not

accept payment directly from the insurer, the insurer pays the

beneficiary or active duty member, not the provider.

(15) Oral and maxillofacial surgery. Surgical procedures performed

in the oral cavity as further defined in paragraph (e) of this section.

or assist the beneficiary in filing the claim for reimbursement by the

dental plan contractor. Where the nonparticipating provider does not

accept payment directly from the insurer, the insurer pays the

beneficiary or active duty member, not the provider.

(15) Oral and maxillofacial surgery. Surgical procedures performed

in the oral cavity as further defined in paragraph (e) of this section.

(16) Orthodontics. The supervision, guidance, and correction of the

growing or mature dentofacial structures, including those conditions

that require movement of teeth or correction of malrelationships and

malformations of their related structures and adjustment of

relationships between and among teeth and facial bones by the

application of forces and/or the stimulation and redirection of

functional forces within the craniofacial complex as further defined in

paragraph (e) of this section.

(17) Participating provider. A dentist or dental hygienist who has

agreed to accept the insurer's reasonable fee allowances or other fee

arrangements as the total charge (even though less than the actual

billed amount), including provision for payment to the provider by the

beneficiary (or active duty member) of any cost-share for covered

services.

(18) Party to the initial determination. Includes the TFMDP, a

beneficiary of the TFMDP and a participating provider of services whose

interests have been adjudicated by the initial determination. In

addition, a provider who has been denied approval as an authorized

TFMDP provider is a party to that initial determination, as is a

provider who is suspended, excluded or terminated as an authorized

provider, unless the provider is excluded under another federal or

federally funded program.

(19) Periodontics. The examination, diagnosis, and treatment of

diseases affecting the supporting structures of the teeth as further

defined in paragraph (e) of this section.

provider is a party to that initial determination, as is a

provider who is suspended, excluded or terminated as an authorized

provider, unless the provider is excluded under another federal or

federally funded program.

(19) Periodontics. The examination, diagnosis, and treatment of

diseases affecting the supporting structures of the teeth as further

defined in paragraph (e) of this section.

(20) Preventive services. Traditional prophylaxis including scaling

deposits from teeth, polishing teeth, and topical application of

fluoride to teeth as further defined in paragraph (e) of this section.

(21) Prosthodontics. The diagnosis, planning, making, insertion,

adjustment, 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.

(22) Provider. A dentist or dental hygienist as specified in

paragraph (f) of this section. This term, when used in relation to

OCONUS service area providers, may include other recognized professions

authorized to furnish care under laws of that particular country.

(23) Restorative services. Restoration of teeth including those

procedures commonly described as amalgam restorations, resin

restorations, pin retention, and stainless steel crowns for primary

teeth as further defined in paragraph (e) of this section.

(24) Sealants. A material designed for application on specified

teeth to seal the surface irregularities to prevent ingress of oral

fluids, food, and debris in order to prevent tooth decay.

including those

procedures commonly described as amalgam restorations, resin

restorations, pin retention, and stainless steel crowns for primary

teeth as further defined in paragraph (e) of this section.

(24) Sealants. A material designed for application on specified

teeth to seal the surface irregularities to prevent ingress of oral

fluids, food, and debris in order to prevent tooth decay.

(c) Eligibility and enrollment--(1) General. 10 U.S.C. 1076a,

1072(2)(A), (D), or (I) and 1072(6) set forth those persons who are

eligible for voluntary enrollment in the TFMDP. A determination that a

person is eligible for voluntary enrollment does not automatically

entitle that person to benefit payments. The person must be enrolled in

accordance with the provisions set forth in this section and meet any

additional eligibility requirements in this part in order for dental

benefits to be extended.

(2) Eligibility.--(i) Person eligible (dependent). A person who

bears one of the following relationships to an active duty member

(under a call or order that does not specify a period of thirty (30)

days of less):

(A) Spouse. A lawful husband or wife, regardless of whether or not

dependent upon the active duty member.

(B) Child. To be eligible, the child must be unmarried and meet the

requirements set forth in Sec. 199.3(b)(2)(iv)(A) and

Sec. 199.3(b)(2)(iv)(C).

(ii) Determination of eligibility status and evidence of

eligibility.--(A) Eligibility determination responsibility of the

Uniformed Services. Determination of a person's eligibility for the

TFMDP is the responsibility of the active duty member's Uniformed

Service. For the purpose of program integrity, the appropriate

Uniformed Service shall, upon request of the Director, OCHAMPUS, or

designee, review the eligibility status. In such cases, a report on the

result of the review and any action taken will be submitted to the

Director, OCHAMPUS, or designee.

(B) Procedures for determination of eligibility

ility of the active duty member's Uniformed

Service. For the purpose of program integrity, the appropriate

Uniformed Service shall, upon request of the Director, OCHAMPUS, or

designee, review the eligibility status. In such cases, a report on the

result of the review and any action taken will be submitted to the

Director, OCHAMPUS, or designee.

(B) Procedures for determination of eligibility. Uniformed Services

identification cards do not distinguish eligibility for the TFMDP.

Procedures for the determination of eligibility are identified in

Sec. 199.3(f)(2), except that Uniformed Services identification cards

do not provide evidence of eligibility for the TFMDP. Although OCHAMPUS

and the dental plan contractor must make determinations concerning a

dependent's eligibility in order to ensure proper enrollment and proper

disbursement of appropriated funds, ultimate responsibility for

resolving a dependent's eligibility rests with the Uniformed Services.

(C) Evidence of eligibility required. Eligibility and enrollment in

the TFMDP will be verified through the DEERS. Eligibility and

enrollment information established and maintained in the DEERS file is

the only acceptable evidence of TFMDP eligibility and enrollment. It is

the responsibility of the active duty member or TFMDP beneficiary,

parent, or legal representative, when appropriate, to provide adequate

evidence for entry into the DEERS file to establish eligibility for the

TFMDP, and to ensure that all changes in status that may effect

eligibility are reported immediately to the appropriate Uniformed

Service for action. Ineligibility for benefits is presumed in the

absence of prescribed eligibility evidence in the DEERS file.

t, or legal representative, when appropriate, to provide adequate

evidence for entry into the DEERS file to establish eligibility for the

TFMDP, and to ensure that all changes in status that may effect

eligibility are reported immediately to the appropriate Uniformed

Service for action. Ineligibility for benefits is presumed in the

absence of prescribed eligibility evidence in the DEERS file.

(3) Enrollment--Previous plans--(A) Basic active duty dependents

dental benefit plan. The Basic Active Duty Dependents Dental Plan was

effective from August 1, 1987, up to the date of implementation of the

Expanded Active Duty Dependents Dental Benefit Plan. The Basic Active

Duty Dependents Dental Benefit Plan terminated upon implementation of

the expanded plan.

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

Expanded Active Duty Dependents Dental Benefit Plan was effective from

August 1, 1993, up to the date of implementation of the TFMDP. The

Expanded Active Duty Dependents Dental Benefit Plan terminates upon

implementation of the TFMDP.

(ii) TRICARE Family Member Dental Plan (TFMDP)--(A) Election of

coverage. (1) Except as provided in paragraph (c)(3)(ii)(A) (2) of this

section, active duty members may voluntarily elect to enroll their

eligible dependents following implementation of the TFMDP. In order to

obtain TFMDP coverage, written or telephonic election by the active

duty member must be made and will be accomplished by submission or

telephonic completion of an application to the dental plan contractor.

This election can also be accomplished via electronic means.

(2) Eligible dependents of active duty members enrolled in the

Expanded Active Duty Dependents Dental Benefit Plan at the time of

implementation of TFMDP will automatically be enrolled in TFMDP. No

election to enroll in TFMDP will be required by the active duty member.

(B) Premiums. (1) Enrollment will be by either single or family

premium as defined as follows:

plished via electronic means.

(2) Eligible dependents of active duty members enrolled in the

Expanded Active Duty Dependents Dental Benefit Plan at the time of

implementation of TFMDP will automatically be enrolled in TFMDP. No

election to enroll in TFMDP will be required by the active duty member.

(B) Premiums. (1) Enrollment will be by either single or family

premium as defined as follows:

(i) Single premium. One (1) covered eligible dependent.

(ii) Family premium. Two (2) or more covered eligible dependents.

Under the family premium, all eligible dependents of the active duty

member are enrolled.

(2) Exceptions. (i) An active duty member may elect to enroll only

those eligible dependents residing in one location when the active duty

member has eligible dependents residing in two or more geographically

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

child attending college).

(ii) Instances where a dependent requires a hospital or special

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

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

dependent may be excluded from TFMDP enrollment and may continue to

receive care from a military treatment facility.

(C) Enrollment period--(1) General. Enrollment of beneficiaries is

for a period of one (1) year followed by month-to-month enrollment as

long as the active duty member chooses to continue enrollment. Active

duty members may enroll their family members in the TFMDP provided

there is an intent to remain on active duty for a period of not less

than one (1) year by the active duty member and the parent Uniformed

Service. Family members enrolled in the TFMDP must remain enrolled for

a minimum period of one (1) year unless one of the conditions for

disenrollment specified in paragraph (c)(3)(ii)(E) of this section is

met.

l their family members in the TFMDP provided

there is an intent to remain on active duty for a period of not less

than one (1) year by the active duty member and the parent Uniformed

Service. Family members enrolled in the TFMDP must remain enrolled for

a minimum period of one (1) year unless one of the conditions for

disenrollment specified in paragraph (c)(3)(ii)(E) of this section is

met.

(2) Reserve component members ordered to active duty in support of

contingency operations. The mandatory 12 month enrollment period does

not apply to Reserve component members ordered to active duty (other

than for training) in support of a contingency operation as designated

by the Secretary of Defense. Affected Reserve component members may

enroll in the TFMDP only if their orders specify that they are ordered

to active duty in support of a contingency operation, as defined by 10

U.S.C., for a period of thirty-one (31) days or more. An affected

Reserve component member must elect to enroll in TFMDP and complete the

enrollment application within 30 days following entry on active duty.

following enrollment, family members must remain enrolled, with the

member paying premiums, until the end of the member's active duty

period in support of the contingency operation or 12 months, whichever

occurs first unless one of the conditions for disenrollment specified

in paragraph (c)(3)(ii)(E) of this section is met.

enrollment application within 30 days following entry on active duty.

following enrollment, family members must remain enrolled, with the

member paying premiums, until the end of the member's active duty

period in support of the contingency operation or 12 months, whichever

occurs first unless one of the conditions for disenrollment specified

in paragraph (c)(3)(ii)(E) of this section is met.

(3) Continuation of enrollment from Expanded Active Duty Dependents

Dental Benefit Plan. Beneficiaries enrolled in the Expanded Active Duty

Dependents Dental Benefit Plan at the time when TFMDP coverage begins

must complete their two (2) year enrollment period established under

this former plan except if one of the conditions for disenrollment

specified in paragraph (c)(3)(ii)(E) of this section is met. Once this

original two (2) year enrollment period is met, the active duty member

may continue TFMDP enrollment on a month-to-month basis. A new one (1)

year enrollment period will only be incurred if the active duty member

disenrolls and attempts to re-enroll in the TFMDP at a later date.

(D) Beginning dates of eligibility. The beginning date of

eligibility for TFMDP benefits is the first day of the month following

the month in which the election of enrollment is completed, signed, and

the enrollment and premium is received by the dental plan contractor,

subject to a predetermined and publicized dental plan contractor

monthly cut-off date. This includes any changes between single and

family member premium coverage and coverage of newly eligible or

enrolled dependents.

(E) Changes in and termination of enrollment--(1) Changes in status

of active duty member. When the active duty member is separated,

discharged, or retired, his or her dependents lose eligibility as of

11:59 p.m. on the last day of the month in which the change in status

takes place

nges between single and

family member premium coverage and coverage of newly eligible or

enrolled dependents.

(E) Changes in and termination of enrollment--(1) Changes in status

of active duty member. When the active duty member is separated,

discharged, or retired, his or her dependents lose eligibility as of

11:59 p.m. on the last day of the month in which the change in status

takes place. Eligible dependents of an active duty member serving a

sentence of confinement in conjunction with a sentence of punitive

discharge are still eligible for the TFMDP until such time as the

active duty member's discharge is executed.

(2) Continuation of eligibility for dependents of active duty

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

members who die on or after October 1, 1993, while on active duty for a

period of more than thirty (30) days and who are enrolled in the TFMDP

on the date of the death of the active duty member shall be eligible

for continued enrollment in the TFMDP for up to one (1) year from the

date of the active duty member's death.

(3) Changes in status of dependent.--(i) Divorce. A spouse

separated from an active duty member by a final divorce decree loses

all eligibility based on his or her former marital relationship as of

11:59 p.m. of the last day of the month in which the divorce becomes

final. The eligibility of the active duty member's own children

(including adopted and eligible illegitimate children) is unaffected by

the divorce. An unadopted stepchild, however, loses eligibility with

the termination of the marriage, also as of 11:59 p.m. of the last day

of the month in which the divorce becomes final.

11:59 p.m. of the last day of the month in which the divorce becomes

final. The eligibility of the active duty member's own children

(including adopted and eligible illegitimate children) is unaffected by

the divorce. An unadopted stepchild, however, loses eligibility with

the termination of the marriage, also as of 11:59 p.m. of the last day

of the month in which the divorce becomes final.

(ii) Annulment. A spouse whose marriage to an active duty member is

dissolved by annulment loses eligibility as of 11:59 p.m. of the last

day of the month in which the court grants the annulment order. The

fact that the annulment legally declares the entire marriage void from

its inception does not affect the termination date of eligibility. When

there are children, the eligibility of the active duty member's own

children (including adopted and eligible illegitimate children) is

unaffected by the annulment. An unadopted stepchild, however, loses

eligibility with the annulment of the marriage, also as of 11:59 p.m.

of the last day of the month in which the court grants the annulment

order.

(iii) Adoption. A child of an active duty member who is adopted by

a person, other than a person whose dependents are eligible for TFMDP

benefits while the active duty member is living, thereby severing the

legal relationship between the child and the active duty member, loses

eligibility as of 11:59 p.m. of the last day of the month in which the

adoption becomes final.

the annulment

order.

(iii) Adoption. A child of an active duty member who is adopted by

a person, other than a person whose dependents are eligible for TFMDP

benefits while the active duty member is living, thereby severing the

legal relationship between the child and the active duty member, loses

eligibility as of 11:59 p.m. of the last day of the month in which the

adoption becomes final.

(iv) Marriage of child. A child of an active duty member who

marries a person whose dependents are not eligible for the TFMDP, loses

eligibility as of 11:59 p.m. on the last day of the month in which the

marriage takes place. However, should the marriage be terminated by

death, divorce, or annulment before the child is 21 years old, the

child again becomes eligible for enrollment as a dependent as of 12:00

a.m. of the first day of the month following the month in which the

occurrence takes place that terminates the marriage and continues up to

age 21 if the child does not remarry before that time. If the marriage

terminates after the child's 21st birthday, there is no reinstatement

of eligibility.

(v) Disabling illness or injury of child age 21 or 22 who has

eligibility based on his or her student status. A child 21 or 22 years

old who is pursuing a full-time course of higher education and who,

either during the school year or between semesters, suffers a disabling

illness or injury with resultant inability to resume attendance at the

institution remains eligible for the TFMDP for six (6) months after the

disability is removed or until the student passes his or her 23rd

birthday, whichever occurs first. However, if recovery occurs before

the 23rd birthday and there is resumption of a full-time course of

higher education, the TFMDP can be continued until the 23rd birthday.

The normal vacation periods during an established school year do not

change the eligibility status of a dependent child 21 or 22 years old

in full-time student status

asses his or her 23rd

birthday, whichever occurs first. However, if recovery occurs before

the 23rd birthday and there is resumption of a full-time course of

higher education, the TFMDP can be continued until the 23rd birthday.

The normal vacation periods during an established school year do not

change the eligibility status of a dependent child 21 or 22 years old

in full-time student status. Unless an incapacitating condition existed

before, and at the time of, a dependent child's 21st birthday, a

dependent child 21 or 22 years old in student status does not have

eligibility related to mental or physical incapacity as described in

Sec. 199.3(b)(2)(iv)(C)(2).

(4) Other.--(1) Disenrollment because of no eligible beneficiaries.

When an active duty member ceases to have any eligible beneficiaries,

enrollment is terminated.

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

station. When an active duty member transfers with beneficiaries to a

duty station where space-available dental care for the beneficiaries is

readily available at the local Uniformed Service dental treatment

facility or to locations within the OCONUS service area, the active

duty member may elect, within ninety (90) calendar days of the

transfer, to disenroll from the TFMDP. If the active duty member is

later transferred to a duty station where dental care for the

dependents is not available in the local Uniformed Service dental

treatment facility, the active duty member may re-enroll his or her

dependents in the TFMDP provided the member, as of the date of

reenrollment, otherwise meets the requirements for enrollment,

including the intent to remain on active duty for a period of not less

than one (1) year.

to a duty station where dental care for the

dependents is not available in the local Uniformed Service dental

treatment facility, the active duty member may re-enroll his or her

dependents in the TFMDP provided the member, as of the date of

reenrollment, otherwise meets the requirements for enrollment,

including the intent to remain on active duty for a period of not less

than one (1) year.

(iii) Option to disenroll after an initial one (1) year enrollment.

When an active duty member's enrollment has been in effect for a

continuous period of one (1) year, the active duty member may disenroll

at any time following procedures as set up by the dental plan

contractor. Subsequent to the disenrollment, the active duty member may

reenroll for another minimum period of one (1) year. If, during any one

(1) year enrollment period, the active duty member disenrolls for

reasons other than those listed in this paragraph (c)(3)(ii)(E) or

fails to make premium payments, the active duty member and

beneficiaries will be subject to a lock-out period of twelve (12)

months. Following this period of time, active duty members will be able

to reenroll if they so choose. The twelve (12) month lock-out period

applies to a Reserve component member who disenrolls for reasons other

than those listed in this paragraph (c)(3)(ii)(E) or fails to make

premium payments after the member has enrolled pursuant to paragraph

(c)(3)(ii)(C) of this section.

(d) Premium sharing--(1) General. Active duty members enrolling in

the TFMDP shall be required to pay a

portion of the premium cost for their dependents.

(2) Proportion of active duty member's premium share. The

proportion of premium share to be paid by the active duty member is

established by the ASD (HA), or designee, at not more than forty (40)

percent of the total premium.

(3) Provision for increases in active duty member's premium share.

enrolling in

the TFMDP shall be required to pay a

portion of the premium cost for their dependents.

(2) Proportion of active duty member's premium share. The

proportion of premium share to be paid by the active duty member is

established by the ASD (HA), or designee, at not more than forty (40)

percent of the total premium.

(3) Provision for increases in active duty member's premium share.

(i) Although previously capped at $20 per month, the law has been

amended to authorize the cap on active duty members' premiums to rise,

effective as of January 1 of each year, by the percent equal to the

lesser of:

(A) The percent by which the rates of basic pay of active duty

members are increased on such date; or

(B) The sum of one-half percent and the percent computed under 5

U.S.C. 5303(a) for the increase in rates of basic pay for statutory pay

systems for pay periods beginning on or after such date.

(ii) Under the legislation authorizing an increase in the monthly

premium cap, the methodology for determining the active duty member's

TFMDP premium will be applied as if the methodology had been in

continuous use since December 31, 1993.

(4) Reduction of premium share or cost-shares for enlisted members.

For enlisted members in pay grades E-1 through E-4, the ASD (HA) or

designee, may reduce the monthly premium and/or cost-shares these

active duty members pay for selected benefits as specified in paragraph

e duty member's

TFMDP premium will be applied as if the methodology had been in

continuous use since December 31, 1993.

(4) Reduction of premium share or cost-shares for enlisted members.

For enlisted members in pay grades E-1 through E-4, the ASD (HA) or

designee, may reduce the monthly premium and/or cost-shares these

active duty members pay for selected benefits as specified in paragraph

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

(5) Premium payment method. The active duty member's premium share

shall be deducted from the active duty member's basic pay, if

sufficient pay is available. For dependents who are otherwise eligible

for TFMDP benefits and whose sponsors do not receive such pay, or if

sufficient pay is available, the premium payment may be collected

pursuant to procedures established by the Director, OCHAMPUS, or

designee.

(6) Annual notification of premium rates. TFMDP premium rates will

be determined as part of the competitive contracting process.

Information on the premium rates will be widely distributed by the

dental plan contractor and the Government.

(e) Plan benefits.--(1) General.--(i) Scope of benefits. The TFMDP

provides coverage for diagnostic and preventive services, sealants,

restorative services, endodontics, periodontics, prosthodontics,

orthodontics and oral and maxillofacial surgery.

(ii) Authority to act for the plan. The authority to make benefit

determinations and authorize plan payments under the TFMDP rests

primarily with the insurance, service plan, or prepayment dental plan

contractor, subject to compliance with Federal law and regulation and

Government contract provisions. The Director, OCHAMPUS, or designee,

provides required benefit policy decisions resulting from changes in

Federal law and regulation and appeal decisions. No other persons or

agents (such as dentists or Uniformed Services HBAs) have such

authority.

ce, service plan, or prepayment dental plan

contractor, subject to compliance with Federal law and regulation and

Government contract provisions. The Director, OCHAMPUS, or designee,

provides required benefit policy decisions resulting from changes in

Federal law and regulation and appeal decisions. No other persons or

agents (such as dentists or Uniformed Services HBAs) have such

authority.

(iii) Dental benefits brochure.--(A) Content. The Director,

OCHAMPUS, or designee, shall establish a comprehensive dental benefits

brochure explaining the benefits of the plan in common lay terminology.

The brochure shall include the limitations and exclusions and other

benefit determination rules for administering the benefits in

accordance with the law and this part. The brochure shall include the

rules for adjudication and payment of claims, appealable issues, and

appeal procedures in sufficient detail to serve as a common basis for

interpretation and understanding of the rules by providers,

beneficiaries, claims examiners, correspondence specialists, employees

and representatives of other Government bodies, HBAs, and other

interested parties. Any conflict, which may occur between the dental

benefits brochure and law or regulation, shall be resolved in favor of

law and regulation.

(b) Distribution. The dental benefits brochure will be available

through the dental plan contractor and will be distributed with the

assistance of the Uniformed Service HBAs and major personnel centers at

Uniformed Service installations to all members enrolling their

dependents.

DP's exclusions, limitations, and benefit determination rules

approved by OCHAMPUS) using the American Dental Association's Council

on Dental Care Program's Code on Dental Procedures and Nomenclature.

The Director, OCHAMPUS, or designee, may modify these services, to the

extent determined appropriate based on developments in common dental

care practices and standard dental insurance programs.

(i) Diagnostic and preventive services. Benefits may be extended

for those dental services described as oral examination, diagnostic,

and preventive services defined as traditional prophylaxis (i.e.,

scaling deposits from teeth, polishing teeth, and topical application

of fluoride to teeth) when performed directly by dentists and dental

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

include the following categories of service:

(A) Diagnostic services. (1) Clinical oral examinations.

(2) Radiographs and diagnostic imaging.

(3) Tests and laboratory examinations.

(B) Preventive services. (1) Dental prophylaxis.

(2) Topical fluoride treatment (office procedure).

(3) Other preventive services.

(4) Space maintenance (passive appliances).

(ii) General services and services ``by report''. The following

categories of services are authorized when performed directly by

dentists or dental hygienists, as authorized under paragraph (f) of

this section, only in unusual circumstances requiring justification of

exceptional conditions directly related to otherwise authorized

procedures. Use of the procedures may not result in the fragmentation

of services normally included in a single procedure. The dental plan

contractor may recognize a ``by report'' condition by providing

additional allowance to the primary covered procedure instead of

recognizing or permitting a distinct billing for the ``by report''

service. These include the following categories of general services:

(A) Unclassified treatment.

(B) Anesthesia.

e fragmentation

of services normally included in a single procedure. The dental plan

contractor may recognize a ``by report'' condition by providing

additional allowance to the primary covered procedure instead of

recognizing or permitting a distinct billing for the ``by report''

service. These include the following categories of general services:

(A) Unclassified treatment.

(B) Anesthesia.

(C) Professional consultation.

(D) Professional visits.

(E) Drugs.

(F) Miscellaneous services.

(iii) Restorative services. Benefits may be extended for

restorative services when performed directly by dentists or dental

hygienists, or under orders and supervision by dentists, as authorized

under paragraph (f) of this section. These include the following

categories of restorative services:

(A) Amalgam restorations.

(B) Resin restorations.

(C) Inlay and onlay restorations.

(D) Crowns.

(E) Other restorative services.

(iv) Endodontic services. Benefits may be extended for those dental

services involved in treatment of diseases and injuries affecting the

dental pulp, tooth root, and periapical tissue when performed directly

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

include the following categories of endodontic services:

(A) Pulp capping.

(B) Pulpotomy and pulpectomy.

(C) Endodontic therapy.

(D) Apexification and recalcification procedures.

(E) Apicoectomy and periradicular services.

(F) Other endodontic procedures.

tal pulp, tooth root, and periapical tissue when performed directly

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

include the following categories of endodontic services:

(A) Pulp capping.

(B) Pulpotomy and pulpectomy.

(C) Endodontic therapy.

(D) Apexification and recalcification procedures.

(E) Apicoectomy and periradicular services.

(F) Other endodontic procedures.

(v) Periodontic services. Benefits may be extended for those dental

services involved in prevention and treatment of diseases affecting the

supporting structures of the teeth to include periodontal prophylaxis,

gingivectomy or gingivoplasty, gingival curettage, etc., when performed

directly by dentists as authorized under paragraph (f) of this section.

These include the following categories of periodontic services:

(A) Surgical services.

(B) Periodontal services.

(C) Other periodontal services.

(vi) Prosthodontic services. Benefits may be extended for those

dental services involved in fabrication, insertion, adjustment,

relinement, and repair of artificial teeth and associated tissues to

include removal of complete and partial dentures, fixed crowns and

bridges when performed directly by dentists as authorized under

paragraph (f) of this section. These include the following categories

of prosthodontic services:

(A) Prosthodontics (removable).

(1) Complete and partial dentures.

(2) Adjustment to dentures.

(3) Repairs to complete and partial dentures.

(4) Denture rebase procedures.

(5) Denture reline procedures.

(6) Other removable prosthetic services.

(B) Prosthodontics (fixed).

(1) Fixed partial denture pontics.

(2) Fixed partial denture retainers.

llowing categories

of prosthodontic services:

(A) Prosthodontics (removable).

(1) Complete and partial dentures.

(2) Adjustment to dentures.

(3) Repairs to complete and partial dentures.

(4) Denture rebase procedures.

(5) Denture reline procedures.

(6) Other removable prosthetic services.

(B) Prosthodontics (fixed).

(1) Fixed partial denture pontics.

(2) Fixed partial denture retainers.

(3) Other partial denture services.

(vii) Orthodontic services. Benefits may be extended for the

supervision, guidance, and correction of growing or mature dentofacial

structures, including those conditions that require movement of teeth

or correction of malrelationships and malformations through the use of

orthodontic procedures and devices when performed directly by dentists

as authorized under paragraph (f) of this section to include in-process

orthodontics. These include the following categories of orthodontic

services:

(A) Limited orthodontic treatment.

(B) Minor treatment to control harmful habits.

(C) Interceptive orthodontic treatment.

(D) Comprehensive orthodontic treatment.

(E) Other orthodontic services.

(viii) Oral and maxillofacial surgery services. Benefits may be

extended for basic surgical procedure of the extraction,

reimplantation, stabilization and repositioning of teeth,

alveoloplasties, incision and drainage of abscesses, suturing of

wounds, biopsies, etc., when performed directly by dentists as

authorized under paragraph (f) of this section. These include the

following categories of oral and maxillofacial surgery services:

(A) Extractions.

(B) Surgical extractions.

(C) Other surgical procedures.

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

(E) Surgical incision.

(F) Repair of traumatic wounds.

(G) Complicated suturing.

(H) Other repair procedures.

y dentists as

authorized under paragraph (f) of this section. These include the

following categories of oral and maxillofacial surgery services:

(A) Extractions.

(B) Surgical extractions.

(C) Other surgical procedures.

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

(E) Surgical incision.

(F) Repair of traumatic wounds.

(G) Complicated suturing.

(H) Other repair procedures.

(ix) Exclusion of adjunctive dental care. Adjunctive dental care

benefits are excluded under the TFMP. For further information on

adjunctive dental care benefits under TRICARE/CAMPUS, see

Sec. 199.4(e)(10).

(x) Benefit limitations and exclusions. The Director, OCHAMPUS, or

designee, may establish such exclusions and limitations as are

consistent with those established by dental insurance and prepayment

plans to control utilization and quality of care for the services and

items covered by the TFMDP.

(xi) Limitation on reduction of benefits. If a reduction in

benefits is planned, the Secretary of Defense, or designee, may not

reduce TFMDP benefits without notifying the appropriate Congressional

committees. If a reduction is approved, the Secretary of Defense, or

designee, must wait one year from the date of notice before a benefit

reduction can be implemented.

(3) Cost-shares, liability and maximum coverage. (i) Cost-shares.

The following table lists maximum active duty member cost shares for

covered services for participating and nonparticipating providers of

care. These are percentages of the dental plan contractor's determined

allowable amount that the active duty member or beneficiary must pay to

these providers:

reduction can be implemented.

(3) Cost-shares, liability and maximum coverage. (i) Cost-shares.

The following table lists maximum active duty member cost shares for

covered services for participating and nonparticipating providers of

care. These are percentages of the dental plan contractor's determined

allowable amount that the active duty member or beneficiary must pay to

these providers:

[In percent]

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

Cost-share for

pay grades E- Cost-share for

Covered services 1, E-2, E-3 all other pay

and E-4 grades

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

Diagnostic.............................. 0 0

Preventive, except Sealants............. 0 0

Emergency Services...................... 0 0

Sealants................................ 20 20

Professional Consultations.............. 20 20

Professional Visits..................... 20 20

Post Surgical Services.................. 20 20

Basic Restorative (example: amalgams, 20 20

resins, stainless steel crowns)........

Endodontic.............................. 30 40

Periodontic............................. 30 40

Oral and Maxillofacial Surgery.......... 30 40

General Anesthesia...................... 40 40

Intravenous Sedation.................... 50 50

Other Restorative (example: crowns, 50 50

onlays, casts).........................

Prostodontic............................ 50 50

Medications............................. 50 50

Orthodontic............................. 50 50

Miscellaneous Services.................. 50 50

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

40 40

Intravenous Sedation.................... 50 50

Other Restorative (example: crowns, 50 50

onlays, casts).........................

Prostodontic............................ 50 50

Medications............................. 50 50

Orthodontic............................. 50 50

Miscellaneous Services.................. 50 50

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

(ii) Dental plan contractor liability. Where the dental program

contractor is unable to identify a participating provider of care

(i.e., a general dentist) within thirty five (35) miles of the

beneficiary's place of residence with appointment availability within

twenty one (21) calendar days, the dental program contractor will

reimburse the beneficiary, or active duty member, or the

nonparticipating provider selected by the beneficiary within thirty

five (35) miles of the beneficiary's place of residence at the level of

the provider's usual fees less the applicable beneficiary cost share,

if any.

(iii) Maximum coverage amounts. Beneficiaries are subject to an

annual maximum coverage amount for non-orthodontic dental benefits and

a lifetime maximum coverage amount for orthodontics as established by

the ASD (HA) or designee.

(f) Authorized providers--(1) General. Enrolled beneficiaries may

seek covered services from any provider who is fully licensed and

approved to provide dental care or covered anesthesia benefits in the

state where the provider is located. This includes licensed dental

hygienists, practicing within the scope of their licensure, subject to

any restriction a state licensure or legislative body imposes regarding

their status as independent providers of care.

y

seek covered services from any provider who is fully licensed and

approved to provide dental care or covered anesthesia benefits in the

state where the provider is located. This includes licensed dental

hygienists, practicing within the scope of their licensure, subject to

any restriction a state licensure or legislative body imposes regarding

their status as independent providers of care.

(2) Authorized provider status does not guarantee payment of

benefits. The fact that a provider is ``authorized'' is not to be

construed to mean that the TFMDP will automatically pay a claim for

services or supplies provided by such a provider. The Director,

OCHAMPUS, or designee, also must determine if the patient is an

eligible beneficiary, whether the services or supplies billed are

authorized and medically necessary, and whether any of the authorized

exclusions of otherwise qualified providers presented in this section

apply.

(3) Utlization review and quality assurance. Services and supplies

furnished by providers of care shall be subject to utilization review

and quality assurance standards, norms, and criteria established under

the TFMDP. Utilization review and quality assurance assessments shall

be performed under the TFMDP. Utilization review and quality assurance

assessments shall be performed under the TFMDP consistent with the

nature and level of benefits of the plan, and shall include analysis of

the data and findings by the dental plan contractor from other dental

accounts.

(4) Provider required. In order to be considered benefits, all

services and supplies shall be rendered by, prescribed by, or furnished

at the direction of, or on the order of a TFMDP authorized provide

practicing within the scope of his or her license.

level of benefits of the plan, and shall include analysis of

the data and findings by the dental plan contractor from other dental

accounts.

(4) Provider required. In order to be considered benefits, all

services and supplies shall be rendered by, prescribed by, or furnished

at the direction of, or on the order of a TFMDP authorized provide

practicing within the scope of his or her license.

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

participate for all TFMDP beneficiaries and accept the fee or charge

determinations as established and made known to the provider by the

dental plan contractor. The fee or charge determinations are binding

upon the provider in accordance with the dental plan contractor's

procedures for participation. The authorized provider may not

participate on a claim-by-claim basis. The participating provider must

agree to accept, within one day of a request for appointment,

beneficiaries in need of emergency palliative treatment. Payment to the

participating provider is based on the lower of the actual charge or

the dental plan contractor's determination of the allowable charge;

however, payments to participating providers shall be in accordance

with the methodology specified in paragraph (g)(2)(ii) of this section.

Payment is made directly to the participating provider, and the

participating provider may only charge the beneficiary the percent

cost-share of the dental plan contractor's allowable charge for those

benefit categories as specified in paragraph (e) of this section, in

addition to the full charges for any services not authorized as

benefits.

specified in paragraph (g)(2)(ii) of this section.

Payment is made directly to the participating provider, and the

participating provider may only charge the beneficiary the percent

cost-share of the dental plan contractor's allowable charge for those

benefit categories as specified in paragraph (e) of this section, in

addition to the full charges for any services not authorized as

benefits.

(6) Nonparticipating provider. An authorized provider may elect to

not participate for all TFMDP beneficiaries and request the beneficiary

or active duty member to pay any amount of the provider's billed charge

in excess of the dental plan contractor's determination of allowable

charges (to include the appropriate cost share). Neither the Government

nor the dental plan contractor shall have any responsibility for any

amounts over the allowable charges as determined by the dental plan

contractor, except where the dental plan contractor is unable to

identify a participating provider of care within thirty five (35) miles

of the beneficiary's place of residence with appointment availabiltiy

within twenty one (21) calendar days. In such instances of the

nonavailability of a participating provider, the nonparticipating

provider located within thirty five (35) miles of the beneficiary's

place of residence shall be paid his or her usual fees (either by the

beneficiary or the dental plan contractor if the beneficiary elected

assignment of benefits), less the percent cost-share as specified in

paragraph (e)(i) of this section.

h instances of the

nonavailability of a participating provider, the nonparticipating

provider located within thirty five (35) miles of the beneficiary's

place of residence shall be paid his or her usual fees (either by the

beneficiary or the dental plan contractor if the beneficiary elected

assignment of benefits), less the percent cost-share as specified in

paragraph (e)(i) of this section.

(i) Assignment of benefits. A nonparticipating provider may accept

assignment of benefits for claims (for beneficiaries certifying their

wilingness to make such assignment of benefits) by filing the claims

completed with the assistance of the beneficiary or active duty member

for direct payment by the dental plan contractor to the provider.

(ii) No assignment of benefits. A nonparticipating provider for all

beneficiaries may request that the beneficiary or active duty member

file the claim directly with the dental plan contractor, making

arrangements with the beneficiary or active duty member for direct

payment by the beneficiary or active duty member.

(7) Alternative delivery system--(i) General. Alternative delivery

systems may be established by the Director, OCHAMPUS, or designee, as

authorized providers. Only dentists, dental hygienists and licensed

anesthetists shall be authorized to provide or direct the provision of

authorized services and supplies in an approved alternative delivery

system.

(ii) Defined. An alternative delivery system may be any approved

arrangement for a preferred provider organization, capitation plan,

dental health maintenance or clinic organization, or other contracted

arrangement which is approved by OCHAMPUS in accordance with

requirements and guidelines.

(iii) Elective or exclusive arrangement. Alternative delivery

systems may be established by contract or other arrangement on either

and elective or exclusive basis for beneficiary selection of

participating and authorized providers in accordance with contractual

requirements and guidelines.

contracted

arrangement which is approved by OCHAMPUS in accordance with

requirements and guidelines.

(iii) Elective or exclusive arrangement. Alternative delivery

systems may be established by contract or other arrangement on either

and elective or exclusive basis for beneficiary selection of

participating and authorized providers in accordance with contractual

requirements and guidelines.

(iv) Provider election of participation. Otherwise authorized

providers must be provided with the opportunity of applying for

participation in an alternative delivery system and of achieving

participation status based on reasonable criteria for timeliness of

application, quality of care, cost containment, geographic location,

patient availability, and acceptance of reimbursement allowance.

(v) Limitation on authorized providers. Where exclusive alternative

delivery systems are established, only providers participating in the

alternative delivery system are authorized providers of care. In such

instances, the TFMDP shall continue to pay beneficiary claims for

services rendered by otherwise authorized providers in accordance with

established rules for reimbursement of nonparticipating providers where

the beneficiary has established a patient relationship with the

nonparticipating provider prior to the TFMDP's proposal to subcontract

with the alternative delivery system.

(vi) Charge agreements. Where the alternative delivery system

employs a discounted fee-for-service reimbursement methodology or

schedule of charges or rates which includes all or most dental services

and procedures recognized by the American Dental Association's Council

on Dental Care Program's Code on Dental Procedures and Nomenclature,

the discounts or schedule of charges or rates for all dental services

and procedures shall be extended by its participating providers to

beneficiaries of the TFMDP as and incentive for beneficiary

participation in the alternative delivery system.

ervices

and procedures recognized by the American Dental Association's Council

on Dental Care Program's Code on Dental Procedures and Nomenclature,

the discounts or schedule of charges or rates for all dental services

and procedures shall be extended by its participating providers to

beneficiaries of the TFMDP as and incentive for beneficiary

participation in the alternative delivery system.

(g) Benefit payment.--(1) General. TFMDP benefit payments are made

either directly to the provider or to the beneficiary or active duty

member, depending on the manner in which the claim is submitted or the

terms of the subcontract of an alternative delivery system with the

dental plan contractor.

(2) Benefit payment. Beneficiaries are not required to utilize

participating providers. For beneficiaries who do use these

participating providers, however, these providers shall not balance

bill any amount in excess of the maximum payment allowed by the dental

plan contractor for covered services. Beneficiaries using

nonparticipating providers may be balance-billed amounts in excess of

allowable charges. The following general requirements for the TFMDP

benefit payment methodology shall be met, subject to modifications and

exceptions approved by the Director, OCHAMPUS, or designee:

(i) Nonparticipating providers (or the beneficiaries or active duty

members of unassigned claims) shall be reimbursed at the equivalent of

not less than the 50th percentile of prevailing charges made for

similar services in the same locality (region) or state, or the

provider's actual charge, whichever is lower, subject to the exception

listed in paragraph (e)(3)(ii) of this section, less any cost-share

amount due for authorized services.

ries or active duty

members of unassigned claims) shall be reimbursed at the equivalent of

not less than the 50th percentile of prevailing charges made for

similar services in the same locality (region) or state, or the

provider's actual charge, whichever is lower, subject to the exception

listed in paragraph (e)(3)(ii) of this section, less any cost-share

amount due for authorized services.

(ii) Participating providers shall be reimbursed at the equivalent

of a percentile of prevailing charges sufficiently above the 50th

percentile of prevailing charges made for similar services in the same

locality (region) or state as to constitute a significant financial

incentive for participation, or the provider's actual charge, whichever

is lower, less any cost-share amount due for authorized services.

(3) Fraud, abuse, and conflict of interest. The provisions of

Sec. 199.9 shall apply except for Sec. 199.9(e). All references to

``CHAMPUS contractors'', ``CHAMPUS beneficiaries'' and ``CHAMPUS

providers'' in Sec. 199.9 shall be construed to mean the ``dental plan

contractor'', ``TFDP beneficiaries'' and ``TFMDP providers''

respectively for the purposes of this section. Examples of fraud

include situations in which ineligible persons not enrolled in the

TFMDP obtain care and file claims for benefits under the name and

identification of an enrolled beneficiary; or when providers submit

claims for services and supplies not rendered to beneficiaries; or when

a participating provider bills the beneficiary for amounts over the

dental plan contractors's determination of allowable charges; or when a

provider fails to collect the specified patient cost-share amount.

and file claims for benefits under the name and

identification of an enrolled beneficiary; or when providers submit

claims for services and supplies not rendered to beneficiaries; or when

a participating provider bills the beneficiary for amounts over the

dental plan contractors's determination of allowable charges; or when a

provider fails to collect the specified patient cost-share amount.

(h) Appeal and hearing procedures. The provisions of Sec. 199.10

shall apply except where noted in this section. All references to

``CHAMPUS contractors'', ``CHAMPUS beneficiaries'', ``CHAMPUS

participating providers'' and ``CHAMPUS Explanation of Benefits'' in

Sec. 199.10 shall be construed to mean the ``dental plan contractor'',

``TFMDP beneficiaries'', ``TFMDP participating providers'' and ``Dental

Explanation of Benefits of DEOB'' respectively for the purposes of this

section. References to ``OCAMPUSEUR'' in Sec. 199.10 are not applicable

to the TFMDP or this section.

(1) General. See Sec. 199.10(a).

(i) Initial determination--(A) Notice of initial determination and

right to appeal. See Sec. 199.10(a)(1)(i).

(B) Effect of initial determination. See Sec. 199.10(a)(1)(ii).

(B) Participation in an appeal. Participating in an appeal is

limited to any party to the initial determination, including OCHAMPUS,

the dental plan contractor, and authorized representatives of the

parties. Any party to the initial determination, except OCHAMPUS and

the dental plan contractor, may appeal an adverse determination. The

appealing party is the party who actually files the appeal.

(A) Parties to the initial determination. See Sec. 199.10(a)(2)(i)

and Sec. 199.10(a)(2)(i)(A), (B), (C) and (E). In addition, a third

party other than the dental plan contractor, such as an insurance

company, is not a party to the initial determination and is not

entitled to appeal, even though it may have an indirect interest in the

initial determination.

(B) Representative. See Sec. 199.10(a)(2)(ii).

to the initial determination. See Sec. 199.10(a)(2)(i)

and Sec. 199.10(a)(2)(i)(A), (B), (C) and (E). In addition, a third

party other than the dental plan contractor, such as an insurance

company, is not a party to the initial determination and is not

entitled to appeal, even though it may have an indirect interest in the

initial determination.

(B) Representative. See Sec. 199.10(a)(2)(ii).

(iii) Burden of proof. See Sec. 199.10(a)(3).

(iv) Evidence in appeal and hearing cases. See Sec. 199.10(a)(4).

(v) Late filing. If a request for reconsideration, formal review,

or hearing is filed after the time permitted in this section, written

notice shall be issued denying the request. Late filing may be

permitted only if the appealing party reasonably can demonstrate to the

satisfaction of the dental plan contractor, or the Director, OCHAMPUS,

or designee, that timely filing of the request was not feasible due to

extraordinary circumstances over which the appealing party had no

practical control. Each request for an exception to the filing

requirement will be considered on its own merits. The decision of the

Director, OCHAMPUS, or a designee, on the request for an exception to

the filing requirement shall be final.

(vi) Appealable issue. See Sec. 199.10(a)(6), Sec. 199.10(a)(6)(i),

Sec. 199.10(a)(6)(iv), including Sec. 199.10(a)(6)(iv) (A) and (C), and

Sec. 199.10(a)(6)(v) for an explanation and examples of nonappealable

issues.

Other examples of issues that are not appealable under this section

include:

(A) The amount of the dental plan contractor-determined allowable

charge since the methodology constitutes a limitation on benefits under

the provisions of this section.

(B) Certain other issues on the basis that the authority for the

initial determination is not vested in OCHAMPUS. Such issues include

but are not limited to the following examples:

not appealable under this section

include:

(A) The amount of the dental plan contractor-determined allowable

charge since the methodology constitutes a limitation on benefits under

the provisions of this section.

(B) Certain other issues on the basis that the authority for the

initial determination is not vested in OCHAMPUS. Such issues include

but are not limited to the following examples:

(1) A determination of a person's enrollment in the TFMDP is the

responsibility of the dental plan contractor and ultimate

responsibility for resolving a beneficiary's enrollment rests with the

dental plan contractor. Accordingly, a disputed question of fact

concerning a beneficiary's enrollment will not be considered an

appealable issue under the provisions of this section, but shall be

resolved in accordance with paragraph (c) of this section and the

dental plan contractor's enrollment policies and procedures.

(2) Decisions relating to the issuance of a nonavailability

statement (NAS) in each case are made by the Uniformed Services.

Disputes over the need for an NAS or a refusal to issue an NAS are not

appealable under this section. The one exception is when a dispute

arises over whether the facts of the case demonstrate a dental

emergency for which an NAS is not required. Denial of payment in this

one situation is an appealable issue.

(3) Any decision or action on the part of the dental plan

contractor to include a provider in their network or to designate a

provider as participating is not appealable under this section.

Similarly, any decision or action on the part of the dental plan

contractor to exclude a provider from their network or to deny

participating provider status is not appealable under this section.

e issue.

(3) Any decision or action on the part of the dental plan

contractor to include a provider in their network or to designate a

provider as participating is not appealable under this section.

Similarly, any decision or action on the part of the dental plan

contractor to exclude a provider from their network or to deny

participating provider status is not appealable under this section.

(vii) Amount in dispute. (A) General. An amount in dispute is

required for an adverse determination to be appealed under the

provisions of this section, except as set forth or further explained in

Sec. 199.10(a)(7)(ii), (iii) and (iv).

(B) Calculated amount. The amount in dispute is calculated as the

amount of money the dental plan contractor would pay if the services

involved in the dispute were determined to be authorized benefits of

the TFMDP. Examples of amounts of money that are excluded by this

section from payments for authorized benefits include, but are not

limited to:

(1) Amounts in excess of the dental plan contractor's-determined

allowable charge.

(2) The beneficiary's cost-share amounts.

(3) Amounts that the beneficiary, or parent, guardian, or other

responsible person has no legal obligation to pay.

(4) Amounts excluded under the provisions of Sec. 199.8 of this

part.

(viii) Levels of appeal. See Sec. 199.10(a)(8)(i). Initials

determinations involving the sanctioning (exclusion, suspension, or

termination) of TFMDP providers shall be appealed directly to the

hearing level.

(ix) Appeal decision. See Sec. 199.10(a)(9).

(2) Reconsideration. See Sec. 199.10(b).

(3) Formal review. See Sec. 199.10(c).

excluded under the provisions of Sec. 199.8 of this

part.

(viii) Levels of appeal. See Sec. 199.10(a)(8)(i). Initials

determinations involving the sanctioning (exclusion, suspension, or

termination) of TFMDP providers shall be appealed directly to the

hearing level.

(ix) Appeal decision. See Sec. 199.10(a)(9).

(2) Reconsideration. See Sec. 199.10(b).

(3) Formal review. See Sec. 199.10(c).

(4) Hearing.--(i) General. See Sec. 199.10(d) and Sec. 199.10(d)(1)

through (d)(5) and (d)(7) through (d)(12) for information on the

hearing process.

(ii) Authority of the hearing officer. The hearing officer, in

exercising the authority to conduct a hearing under this part, will be

bound by 10 U.S.C., chapter 55, and this part. The hearing officer in

addressing substantive, appealable issues shall be bound by the dental

benefits brochure, policies, procedures, instructions and other

guidelines issued by the ASD(HA), or a designee, or by the Director,

OCHAMPUS, or a designee, in effect for the period in which the matter

in dispute arose. A hearing officer may not establish or amend the

dental benefits brochure, policy, procedures, instructions, or

guidelines. However, the hearing officer may recommend reconsideration

of the policy, procedures, instructions or guidelines by the ASD(HA),

or a designee, when the final decision is issued in the case.

(5) Final decision. See Sec. 199.10(e)(1) and Sec. 199.10(e)(1)(i)

for information on final decisions in the appeal and hearing process,

with the exception that no recommended decision shall be referred for

review by ASD(HA).

Dated: November 12, 1999.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 99-30072 Filed 11-23-99; 8:45 am]

BILLING CODE 5001-10-M