[Federal Register Volume 62, Number 95 (Friday, May 16, 1997)]
[Rules and Regulations]
[Pages 26939-26941]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-12871]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DoD 6010.8-R]
RIN 0720-AA40
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Selected Reserve Dental Program
AGENCY: Office of the Secretary, DoD.
ACTION: Interim final rule.
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SUMMARY: This interim final rule establishes the TRICARE Selected
Reserve Dental Program (TSRDP) to provide dental care to members of the
Selected Reserves of the Ready Reserve. The rule details operation of
the program and seeks comments on our plan to implement the TRSDP.
DATES: This rule is effective August 1, 1997. Public comments must be
received by July 15, 1997.
ADDRESSES: TRICARE Support Office (TSO)/Office of the Civilian Health
and Medical Program of the Uniformed Services (OCHAMPUS), Program
Development Branch; Aurora, Colorado 80045-6900.
FOR FURTHER INFORMATION CONTACT:
Mr. Gunther J. Zimmerman, Office of the Assistant Secretary of Defense
(Health Affairs), (703) 695-3331.
SUPPLEMENTARY INFORMATION:
I. Overview of the Proposed Rule
Implementation of the TRICARE Selected Reserve Dental Program
(TSRDP) was directed by Congress in section 705 of the National Defense
Authorization Act for Fiscal Year 1996, Public Law 104-106, which
amended title 10, United States Code, by adding section 1076b. This law
directed the implementation of a dental program for members of the
Selected Reserve of the Ready Reserve, providing for voluntary
enrollment and premium sharing between DoD and the enrollee.
Section 702 of the 1997 National Defense Authorization Act amended
Title 10, U.S.C., by revising the program's start date, requiring the
program to start during fiscal year 1997 and also to conform to several
operational requirements. The costs of the program will be shared
between the enrollee and the government. The statute directs that a
members enrolling in the program shall pay a share of the premium
charged for the insurance coverage.
Dental coverage under the TSRDP will provide basic dental care, to
include diagnostic services, preventive services, basic restorative
services, and emergency oral examinations.
Under this approach, where possible, reservists may make use of
participating dental providers in their areas and benefit from the
reduced copayments and provider submission of claims and acceptance of
contractor allowances and arrangements. TSRDP eligible beneficiaries
will obtain information concerning the program and the application
process from the contractor.
This interim final rule adopts the statutory preemption authority
of 10 U.S.C., section 1103. This statute broadly authorizes preemption
of state laws in connection with DoD contracts for medical and dental
care. We have made the judgment that preemption is necessary and
appropriate to assure the operation of a consistent, effective, and
efficient federal program. In addition, the enacting legislation for
the TRICARE Selected Reserve Dental Program directs the Department of
Defense to utilize full and open competition in selecting a contractor
and to implement this program during fiscal year 1997. Absent
preemption of certain state and local laws on insurance regulation and
other matters, competition would be severely limited and the process
substantially delayed.
II. Rulemaking Procedures
Executive Order 12866 requires certain regulatory assessments for
any ``significant regulatory action,'' defined as one which would
result in an annual effect on the economy of $100 million or more, or
have other substantial impacts.
The Regulatory Flexibility Act (RFA) requires that each Federal
agency prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation which would
have a significant impact on a substantial number of small entities.
This is not a significant regulatory action under the provisions of
Executive Order 12866, and it would not have a significant impact on a
substantial number of small entities.
The interim final rule will not impose additional information
collection requirements on the public under the Paperwork Reduction Act
of 1995 (44 U.S.C. Chapter 55).
The Department is publishing this rule as an interim final rule in
order to implement the program in a timely manner. Regulations
involving military affairs are exempt from the notice and comment
rulemaking procedures of the Administrative Procedures Act. Because
this rule deals exclusively with a program for the military reserves,
there is a heightened impact on the conduct of affairs peculiar to
military functions of the government, and a significant reduced impact
on the public. Based on this, it is appropriate, as an exemption to our
normal practice of providing an opportunity for prior public comment on
all CHAMPUS regulations, to issue this rule as an interim final rule,
with a subsequent opportunity for public comment. Public comments are
invited. All comments will be carefully considered. A discussion of the
major issues received by public comments will be included with the
issuance of the permanent final rule, anticipated approximately 90 days
after the end of the comment period.
[[Page 26940]]
List of Subjects in 32 CFR Part 199
Claims, Handicapped, Health insurance, Military personnel.
Accordingly, 32 CFR Part 199 is amended as follows:
1. The authority citation for part 199 continues to read as
follows:
Authority: 10 U.S.C., Chapter 55.5 U.S.C. 301.
2. Part 199 is amended by adding Sec. 199.21, as follows:
Sec. 199.21 TRICARE Selected Reserve Dental Program (TSRDP).
(a) Purpose. The TSRDP is a premium based indemnity dental
insurance coverage program that will be available to members of the
Selected Reserve of the Ready Reserve. Dental coverage will be
available only to members of the Selected Reserve, no family coverage
will be offered. Benefits are limited to preventive, restorative and
emergency care. Premium costs for this coverage will be shared by the
enrollee and the government.
(b) General provisions. The TSRDP is authorized by 10 U.S.C. 1076b.
(c) Definitions. Except as may be specifically provided in this
section, to the extent terms defined in Secs. 199.2 and 199.13(b) are
relevant to the administration of the TRICARE Selected Reserved Dental
Program, the definitions contained in those sections shall apply to the
TSRDP as they do to CHAMPUS and the active duty dependents dental plan.
(d) Eligibility and enrollment--(1) Eligibility. Enrollment in the
TRICARE Selected Reserve Dental Program is open to members of the
Selected Reserve of the Ready Reserve.
(2) Notification of eligibility. The contractor will notify persons
eligible to receive dental benefits under the TRICARE Selected Reserve
Dental Program.
(3) Election of Coverage. Following this notification, interested
reservists may elect to enroll. In order to obtain dental coverage,
written election by eligible beneficiary must be made.
(4) Enrollment. Enrollment in the TRICARE Selected Reserve Dental
Program is voluntary and will be accomplished by submission of an
application to the TSRDP contractor.
(5) Period of coverage. TRICARE Selected Reserve Dental Program
coverage is terminated on the last day of the month in which the member
is discharged, transferred to the Individual Ready Reserve, Standby
Reserve, or Retired Reserve, or ordered to active duty for a period of
more than 30 days.
(e) Premium sharing. The Government and the enrollee will share in
the monthly premium cost.
(f) Premium Payments. The enrollee will be responsible for a
monthly premium payment in order to obtain the dental insurance.
(1) Premium payment method. The premium payment may be collected
pursuant to procedures established by the Assistant Secretary of
Defense (Health Affairs).
(2) Effects of failure to make premium payments. Failure to make
monthly renewal premium payments will result in the enrollee being
disenrolled from the TSRDP and subject to lock-out period of 12 months.
Following this period of time, eligible reservists will be able to
enroll if they so choose.
(3) Member's share of premiums. The cost of the TSRDP monthly
premium will be shared between the Government and the enrollee.
Interested eligible reservists may contact the dental contractor to
obtain the enrollee premium cost. The members's share may not exceed
$25 per month.
(g) Plan Benefits. The TSRDP will provide basic dental coverage, to
include diagnostic services, preventive services, basic restorative
services, and emergency oral examinations. The following is the TSRDP
covered dental benefit (using the American Dental Association, The
Council on Dental Care Program's Code On Dental Procedures and
Nomenclature):
(1) Diagnostic: Comprehensive oral examination (00150), and
Periodic oral examination (00120), Intraoral-complete series (including
bitewings) (00210); Intraoral-periapical-first film (00220); Intraoral-
periapical-each additional film (00230); Bitewings-single film (00270);
Bitewings-two films (00272); Bitewings-four films (00274); Panoramic
film (00330; Pulp Vitality Tests (00460).
(2) Preventive: Prophylaxis-adult (limit--two per year) (01110);
Topical application of fluoride (excluding prophylaxis)--adult (01204).
(3) Restorative: Amalgam-one surface, permanent (02140); Amalgam-
two surfaces, permanent (02150); Amalgam-three surfaces; permanent
(02160); Amalgam-four or more surfaces, permanent (02161); Resin-one
surface, anterior (02330); Resin-two surfaces, anterior (02331); Resin-
three surfaces, anterior (02332); Resin-four or more surfaces or
involving incisal angle (anterior) (02335); Pin retention-per tooth, in
addition to restoration (02951).
(4) Oral Surgery: Single tooth (07110); Each additional tooth
(07120); Root removal-exposed roots (07130); Surgical removal of
erupted tooth requiring evaluation of mucoperiosteal flap and removal
of bone and/or section of tooth (07210); Surgical removal of residual
tooth roots (cutting procedure) (07250).
(5) Emergency: Emergency oral examination (00130); Palliative
(emergency) treatment of dental pain-minor procedures (09110).
(h) Maximum Annual Cap. TSRDP enrollees will be subject to a
maximum $1,000.00 of paid allowable charges per year.
(i) Annual Review of Rates. TSRDP premiums will be determined as
part of the competitive contracting process. The contractor will
annually notify eligible reservists of the TSRDP premium rates.
(j) Authorized Providers. The TSRDP enrollee may seek covered
services from any provider who is fully licensed and approved to
provide dental care in the state where the provider is located.
(k) Benefit Payment. Enrollees are not required to utilize the
special network of dental providers established by the TSRDP
contractor. For enrollees who do use this network, however, providers
shall not balance bill any amount in excess of the maximum payment
allowable by the TSRDP. Enrollees using non-network providers may be
balanced billed such as amount. The maximum payment allowable by the
TSRDP (minus the appropriate cost-share) will be the lesser of:
(1) Billed charges; or
(2) Usual, Customary and Reasonable rates, in which the customary
rate is calculated at the 85th percentile of billed charges in that
geographic area, as measured in an undiscounted charge profile in 1995
or later for that geographic area (as defined by three-digit zip code).
(l) Appeal and Hearing Procedures. All levels of appeals and
grievances established by the Contractor for internal review shall be
exhausted prior to forwarding to OCHAMPUS for a final review.
Procedures comparable to those established under Sec. 199.13(h) shall
apply.
(m) Preemption of State Laws. Pursuant to 10 U.S.C. 1103, any state
or local law or regulation relating to health or dental insurance,
prepaid health or dental plans, or other health or dental care
delivery, administration, and financing methods is preempted and does
not apply in connection with the TRICARE Selected Reserve Dental
Program contract. Any such law, or regulation pursuant to such law, is
without any force or effect, and State or local governments have no
legal authority to enforce them in relation to the TRICARE Selected
Reserve Dental Program contract. (However, the Department of Defense
may, by contract, establish legal obligations on the part of the
TRICARE Selected Reserve Dental Program contractor to conform with
requirements similar or identical to
[[Page 26941]]
requirements of State or local laws or regulations.)
(n) Director, OCHAMPUS. The Director, OCHAMPUS, may establish other
rules and procedures for the administration of the TRICARE Selected
Reserve Dental Program.
Dated: May 12, 1997.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 97-12871 Filed 5-15-97; 8:45 am]
BILLING CODE 5000-04-M