[Federal Register Volume 72, Number 185 (Tuesday, September 25, 2007)]
[Rules and Regulations]
[Pages 54353-54355]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 07-4655]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DoD-2007-HA-0026]
RIN 0720-AB14


TRICARE; Changes Included in the John Warner National Defense 
Authorization Act for Fiscal Year 2007; Authorization of Anesthesia and 
Other Costs for Dental Care for Children and Certain Other Patients

AGENCY: Office of the Secretary, Department of Defense.

ACTION: Final rule.

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SUMMARY: This final rule implements section 702 of the John Warner 
National Defense Authorization Act for Fiscal Year 2007, Public Law 
109-364. The rule provides coverage of contracted medical care with 
respect to dental care beyond that care required as a necessary adjunct 
to medical or surgical treatment. The entitlement of institutional and 
anesthesia services is authorized in conjunction with non-covered 
dental treatment for patients with developmental, mental, or physical 
disabilities or for pediatric patients age 5 or under. This final rule 
does not eliminate any contracted medical care that is currently 
covered for spouses and children. The entitlement of anesthesia 
services includes general anesthesia services only. Institutional 
services include institutional benefits associated with both hospital 
and in-out surgery settings. Patients with developmental, mental, or 
physical disabilities are those patients with conditions that prohibit 
dental treatment in a safe and effective manner. Therefore, it is 
medically or psychologically necessary for these patients to require 
general anesthesia for dental treatment.

[[Page 54354]]


EFFECTIVE DATE: This is rule is effective September 25, 2007.

ADDRESSES: TRICARE Management Activity, Skyline 5, Suite 810, 5111 
Leesburg Pike, Falls Church, VA 22041.

FOR FURTHER INFORMATION CONTACT: Col. Gary C. Martin, Office of the 
Assistant Secretary of Defense (Health Affairs), TRICARE Management 
Activity, telephone (703) 681-0039.

SUPPLEMENTARY INFORMATION:

I. Summary of Final Rule Provisions

    This final rule amends the coverage of contracted medical care with 
respect to dental care beyond that care required as a necessary adjunct 
to medical or surgical treatment. The entitlement of institutional and 
anesthesia services is authorized in conjunction with non-covered 
dental treatment for patients with developmental, mental, or physical 
disabilities or for pediatric patients age 5 or under. This final rule 
does not eliminate any contracted medical care that is currently 
covered for spouses and children. The entitlement of anesthesia 
services includes general anesthesia services only. Institutional 
services includes institutional benefits associated with both hospital 
and in-out surgery settings. Patients with developmental, mental, or 
physical disabilities are those patients with conditions that prohibit 
dental treatment in a safe and effective manner. Therefore, it is 
medically or psychologically necessary for these patients to require 
general anesthesia for dental treatment.
    Prior to section 702 of the John Warner National Defense 
Authorization Act for Fiscal Year 2007, general anesthesia and 
institutional services were not covered in conjunction with dental 
treatment for patients with developmental, mental, or physical 
disabilities or for pediatric patients of any age through TRICARE 
medical plan contracts unless it qualified as adjunctive dental care. 
For military families who have children that require extensive dental 
treatment under general anesthesia, the two options available were to 
have the care provided locally at a Department of Defense (DoD) 
facility or a civilian facility. If the care was provided in a DoD 
facility, the total costs to the family are minimal.This option remains 
available. There are, however, locations where this care is not 
available from a DoD facility due to facility constraints (no operating 
room) and/or lack of dental specialists. For dental care provided in a 
civilian facility, families currently enrolled in the TRICARE Dental 
Program (TDP) or TRICARE Retiree Dental Program (TRDP) are provided 
with coverage for dental care with applicable cost-shares. These 
include a 40-percent cost-share for general anesthesia and varying 
cost-shares for dental procedures (fillings, crowns, root canals) 
completed in the operating room setting. There is an annual maximum 
benefit for the TDP and TRDP of $1,200 per enrollee. This means that 
the total payments covered services for each enrolled member will not 
exceed $1,200 in any contract year. In addition, the TRDP has a 
deductible of $50 per patient per year, not to exceed $150 per family 
per year. Frequently, the annual maximum is reached for those pediatric 
patients who require extensive dental treatment under general 
anesthesia. Once the annual maximum is reached, the remainder of the 
billed charges is the enrollee's responsibility. The hospital costs 
(institutional services) are covered by neither the TDP nor the TRDP. 
For families with dental insurance other the TDP or TRDP, their plan 
structure may have defrayed some costs but out-of-pocket costs remained 
significant. Families without any dental insurance incurred the total 
costs of dental, anesthesia, and institutional services.

II. Review of Public Comments

    We provided a 60-day comment period on the proposed rule which was 
published in the Federal Register on March 23, 2007 (72 FR 13721). We 
received one document with joint comments from the American Dental 
Association (ADA) and the American Academy of Pediatric Dentists 
(AAPD). All comments were in support of the proposed rule. The ADA and 
AAPD concurred that the proposed rule accurately interpreted section 
702 of the John Warner National Defense Authorization Act for Fiscal 
Year 2007, Public Law 109-364. They also concurred with the definitions 
and requirements as stated in the proposed rule. A waiver of the 
preauthorization requirement will be provided for beneficiaries 
receiving care in the transition period between October 17, 2006, the 
effective date of the change in the law upon which this final rule is 
based, and the implementation date, by applying the same criteria in a 
post-authorization. The ADA and AAPD recommended that post-
authorization reviews utilize the same criteria as preauthorization 
reviews, and that this transition plan be referenced in the final rule. 
Post authorization review procedures will utilize the same criteria as 
preauthorization reviews; however, post authorization procedures will 
be addressed and outlined in detail in the TRICARE Manuals and are not 
included in this final rule.

III. Regulatory Procedures

    Executive Order 12866 requires that a comprehensive regulatory 
impact analysis be performed on any economically significant regulatory 
action, defined as one that would result in an annual effect of $100 
million or more on the national economy or which would have other 
substantial impacts. The Regulatory Flexibility Act (RFA) requires that 
each Federal agency prepare, and make available for public comment, a 
regulatory flexibility analysis when the agency issues a regulation 
which would have a significant impact on a substantial number of small 
entities. This rule is not an economically significant regulatory 
action and will not have a significant impact on a substantial number 
of small entities for purposes of the RFA, thus this final rule is not 
subject to any of these requirements.
    This rule will not impose additional information collection 
requirements on the public under the Paperwork Reduction Act of 1995 
(44 U.S.C. 3501-3511). We have examined the impact(s) of the final rule 
under Executive Order 13132 and it does not have policies that have 
federalism implications that would have substantial direct effects on 
the States, on the relationship between the national government and the 
States, or on the distribution of power and responsibilities among the 
various levels of government, therefore, consultation with State and 
local officials is not required.

List of Subjects in 32 CFR Part 199

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


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

PART 199--CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED 
SERVICES (CHAMPUS)

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

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


0
2. Section 199.4 is amended by removing the first sentence of paragraph 
(e)(10) introductory text and adding two sentences in its place; 
revising the first sentence of paragraph (e)(10)(iii); and adding 
paragraph (e)(10)(vi) to read as follows:


Sec.  199.4  Basic Program Benefits.

* * * * *

[[Page 54355]]

    (e)* * *
    (10) Dental. TRICARE/CHAMPUS does not include a dental benefit. 
However, in connection with dental treatment for patients with 
developmental, mental, or physical disabilities or for pediatric 
patients age 5 or under, only institutional and anesthesia services may 
be provided as a benefit.* * *
* * * * *
    (iii) Preauthorization required. In order to be covered, adjunctive 
dental care requires preauthorization from the Director, TRICARE 
Management Activity, or a designee, in accordance with paragraph 
(a)(12) of this section.* * *
* * * * *
    (vi) Anesthesia and institutional costs for dental care for 
children and certain other patients. Institutional benefits specified 
in paragraph (b) of this section may be extended for hospital and in-
out surgery settings related to noncovered, nonadjunctive dental care 
when such outpatient care or inpatient stay is in conjunction with 
dental treatment for patients with developmental, mental, or physical 
disabilities or for pediatric patients age 5 or under. For these 
patients, anesthesia services will be limited to the administration of 
general anesthesia only. Patients with developmental, mental, or 
physical disabilities are those patients with conditions that prohibit 
dental treatment in a safe and effective manner. Therefore, it is 
medically or psychologically necessary for these patients to require 
general anesthesia for dental treatment. Patients with physical 
disabilities include those patients having disabilities as defined in 
Sec.  199.2 as a serious physical disability. Preauthorization by the 
Director, TRICARE Management Activity, or a designee, is required for 
such outpatient care or inpatient stays to be covered in the same 
manner as required for adjunctive dental care described in paragraph 
(e)(10)(iii) of this section. Regardless of whether or not the 
preauthorization request for outpatient care or hospital admission is 
approved and thus qualifies for institutional benefits, the 
professional service related to the nonadjunctive dental care is not 
covered, with the exception of coverage for anesthesia services.
* * * * *

    Dated: September 13, 2007.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 07-4655 Filed 9-24-07; 8:45 am]
BILLING CODE 5001-06-M