Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12855

Background Check System Regulation’’

published in the Federal Register on

January 22, 2001, at 66 FR 6470. The

temporary 60-day delay in effective date

is necessary to give Department of

Justice officials the opportunity for

further review and consideration of new

regulations, consistent with the

Assistant to the President’s

memorandum of January 20, 2001.

DATES: The effective date of the final

rule amending 28 CFR Part 25 published

in the Federal Register on Janaury 22,

2001, at 66 FR 6470, is delayed for 60

days, from March 5, 2001, until May 4,

2001.

FOR FURTHER INFORMATION CONTACT:

Fanny Haslebacher, Attorney-Advisor,

Federal Bureau of Investigation, Module

A–3, 1000 Custer Hollow Road,

Clarksburg, West Virginia 26306–0147,

(304) 625–2000.

SUPPLEMENTARY INFORMATION: To the

extent that 5 U.S.C. section 553 applies

to this action, it is exempt from notice

and comment because it constitutes a

rule of procedure under 5 U.S.C. section

553(b)(A). Alternatively, the Department

of Justice’s implementation of this

action without opportunity for public

comment, effective immediately upon

publication today in the Federal

Register, is based on the good cause

exceptions in 5 U.S.C. section 553(b)(B)

and 553(d)(3). Seeking public comment

is impracticable, unnecessary, and

contrary to the public interest. The

temporary 60-day delay in effective date

is necessary to give Department of

Justice officials the opportunity for

further review and consideration of new

regulations, consistent with the

Assistant to the President’s

memorandum of January 20, 2001.

Given the imminence of the effective

date, seeking prior public comment on

this temporary delay would have been

impractical, as well as contrary to the

public interest in the orderly

promulgation and implementation of

regulations. The imminence of the

effective date is also good cause for

making this action effective

immediately upon publication.

Dated: February 23, 2001.

John Ashcroft,

Attorney General.

[FR Doc. 01–4979 Filed 2–28–01; 8:45 am]

BILLING CODE 4410–06–M

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

RIN 0720–AA53

Civilian Health and Medical Program of

the Uniformed Services (CHAMPUS);

TRICARE Dental Program

AGENCY: Office of the Secretary, DoD.

ACTION: Final rule.

SUMMARY: On October 23, 2000 (65 FR

63202), the Department of Defense

published a final rule on TRICARE

Family Member Dental Plan. The rule

had an effective date that began during

the Presidential Moratium on Rules,

therefore, this rule is republished to

change the effective date to April 1,

2001. This rule is published exactly as

previously published. No changes have

been made. It revises the comprehensive

CHAMPUS regulation pertaining to the

Expanded Active Duty Dependents

Benefit Plan, or more commonly

referred to as the TRICARE Family

Member Dental Plan (TFMDP). The

TFMDP limited eligibility to eligible

dependents of active duty members

(under a call or order that does not

specify a period of thirty (30) day or

less). Concurrent with the timeframe of

the publication of the proposed rule, the

Defense Authorization Act for Fiscal

Year 2000 (Pub. L. 106–65, sec. 711) was

signed into law and its provisions have

been incorporated into this final rule.

The Act authorized a new plan, titled

the TRICARE dental program (TDP),

which allows the Secretary of Defense to

offer a comprehensive premium based

indemnity dental insurance coverage

plan to eligible dependents of active

duty members (under a call or order that

does not specify a period of thirty (30)

days or less), eligible dependents of

members of the Selected Reserve and

Individual Ready Reserve, and eligible

members of the Selected Reserve and

Individual Ready Reserve. The Act also

struck section 1076b (Selected Reserve

dental insurance), or Chapter 55 of title

10, United States Code, since the

affected population and the authority

for that particular dental insurance plan

has been incorporated in 10 U.S.C.

1076a. Consistent with the proposed

rule and the provisions of the Defense

Authorization Act for Fiscal Year 2000,

the final rule places the responsibility

for TDP enrollment and a large portion

of the appeals program on the dental

plan contractor; allows the dental plan

contractor to bill beneficiaries for plan

premiums in certain circumstances;

reduces the former TFMDP enrollment

period from twenty-four (24) to twelve

(12) months; excludes Reserve

component members ordered to active

duty in support of a contingency

operation from the mandatory twelve

(12) month enrollment; clarifies dental

plan requirements for different

beneficiary populations; simplifies

enrollment types and exceptions;

reduces cost-shares for certain enlisted

grades; adds anesthesia as a covered

benefit; provides clarification on the

Department’s use of the Congressional

waiver for surviving dependents;

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 members and

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.

The proposed rule was titled the

‘‘TRICARE Family Member Dental

Plan’’.

DATES: This rule is effective April 1,

2001.

FOR FURTHER INFORMATION CONTACT:

Major Brian K. Witt, TRICARE

Management Activity, 303–676–3496.

SUPPLEMENTARY INFORMATION:

I. Background and Legislative Changes

The Basic Active Duty Dependents

Dental Benefits Plan was implemented

on August 1, 1987, allowing Uniformed

Service personnel, on active duty for

periods of greater than thirty (30) days,

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 Uniformed Service 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

For Fiscal Year 1993, Pub. L. 102–484,

sec. 701). The provisions of this Act

specified the expanded benefit

structure, as well as maximum monthly

premiums for enrollees. Cost-sharing

12856 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

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 (1) year of continued

dental coverage for enrolled dependents

of service members who die while on

active duty (The Defense Authorization

Act For Fiscal Year 1995, Pub. L. 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 For Fiscal Year 1998,

Pub. L. 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

servicemembers 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 (1) year, after notification, before

any benefits could be reduced (The

Defense Authorization Act For Fiscal

Year 1999, Pub. L. 105–261, sec. 701).

In Fiscal Year 2000, the Congress

authorized the establishment of the

TRICARE dental program (TDP), by

striking 10 U.S.C. 1076a (Dependents’

dental program) and 10 U.S.C. 1076b

(Selected Reserve dental insurance) and

inserting a revised section 1076a,

TRICARE dental program (The Defense

Authorization Act For Fiscal Year 2000,

Pub. L. 106–65, sec. 711). Language in

this revision directed the Secretary of

Defense to establish a voluntary

enrollment dental insurance plan for

members of the Selected Reserve of the

Ready Reserve (the former Selected

Reserve dental insurance plan or more

commonly referred to as the TRICARE

Selected Reserve Dental Program or

TSRDP) and for members of the

Individual Ready Reserve described in

10 U.S.C. 10144(b). It also provided

authorizing language to allow the

Secretary of Defense to establish a

dental insurance plan for eligible

dependents of Uniformed Service

members who are on active duty for

periods of greater than thirty (30) days

(the former Dependents’ dental plan or

more commonly referred to as the

TRICARE Family Member Dental Plan

or TFMDP), members of the Individual

Ready Reserve as described in 10 U.S.C.

10144(a), and eligible dependents of

members of the Ready Reserve of the

Reserve components who are not on

active duty for more than thirty (30)

days. Essentially, the authorizing

language combined the eligible

populations of the TFMDP and TSRDP

and added, as eligibles, members of the

Individual Ready Reserve and

dependents of members of the Selected

Reserve and Individual Ready Reserve.

Additionally, the Congress directed that

the insurance plans for the dependents

of active duty members and for the

members of the Selected Reserve and

Individual Ready Reserve (as described

in 10 U.S.C. 10144(b)) would be

premium sharing plans between the

enrollee and the Government.

Beneficiaries eligible to enroll in the

remaining insurance plans would be

required to pay the full premium as a

condition of enrollment. To allow for

greater participation in the TDP, the

Congress allowed the member’s share of

the premium to be paid from their basic

or reserve pay accounts or, for those

who do not receive such pay, through

payment procedures as specified by the

Department. The Congress also

authorized waiver of dental plan

requirements for surviving dependents

of members of the Ready Reserve if the

dependent was enrolled in the dental

plan on the date of death of the member.

This revised the previous waiver

authority that applied only to enrolled

surviving dependents of active duty

members.

These legislative provisions have been

codified in 10 U.S.C. 1076a, TRICARE

dental program, and are reflected in the

regulatory provisions of this final rule.

By striking 10 U.S.C. 1076b, its

implementing regulation, 32 CFR

199.21, TRICARE Selected Reserve

Dental Program (TSRDP), is also

removed and reserved.

II. Programmatic Improvements

The below programmatic

improvements will be effective once the

follow-on TDP 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. Expansion of Eligible Populations

With the authorizing legislation (The

National Defense Authorization Act for

Fiscal Year 2000), the final rule extends

TDP coverage to newly eligible

populations. This is an important step

towards improving Reserve member’s

dental readiness and in promoting

proper oral health across the beneficiary

population. Designed to be a uniform

benefit across all enrollees, the TDP

offers a comprehensive benefit package

with a strong focus on preventive and

diagnostic services as well as pediatric

and adolescent oral health. By

extending coverage to the members of

the Individual Ready Reserve and the

dependents of the Selected Reserve and

the Individual Ready Reserve and by

offering a comprehensive dental benefit

to the members of the Selected Reserve

(versus the limited benefit previously

available under the TSRDP), the

Department and the Reserve

components continue on the path

towards parity with dental insurance

plans historically extended only to

dependents of the Active component.

This final rule also addresses several

administrative clarifications that

distinguish dental plan requirements for

the different beneficiary populations.

B. Contractor Enrollment

Since the TFMDP (and its earlier

versions) began, the Uniformed Services

have administered the TFMDP 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 service members to contact

one (1) organization to enroll, disenroll,

reenroll and discuss other TDP 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 supporting the TFMDP does not

allow an active duty member from one

(1) Service to enroll his or her family

members 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

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12857

local level. In addition, it maintains a

stable, trained work force at the front

end of the TDP and greatly improves

customer service.

An added benefit to contractor

enrollment will be the elimination of

the current required TFMDP 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 TSRDP and the TRICARE Retiree

Dental Program (TRDP). The Uniformed

Services will continue, as with the

former dental plans 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).

C. Contractor Direct Billing

The current TFMDP 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

deduced 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 or 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.

With the authorizing legislation (The

National Defense Authorization Act for

Fiscal Year 2000), 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. The

provision of contractor direct billing is

also extended to those Reserve

component members and family

members who are in similar situations.

D. Reduction in Mandatory Enrollment

Period

A mandatory enrollment period is an

essential factor behind Government and

contractor actuarial estimates in

developing the TDP premium and

provides a guarantee to the contracting

community that they will collect a

certain amount of premiums for the

potential benefit payout. The final rule

reduces the previous longstanding

TFMDP twenty-four (24) month

mandatory enrollment period to twelve

(12) months under the TDP since this

twenty-four (24) month period

precluded numerous, otherwise eligible,

active duty dependents from enrolling

in the dental plan. These eligible

dependents include newly eligible

dependents of active duty members who

are near the end of their active service,

dependents of enlisted service members

who are outside of their re-enlistment

window of opportunity, and dependents

of Reserve/Guard personnel called to

active duty for less than twenty-four

(24) months (such as Reserve/Guard

personnel on active duty for training

and special assignments). Reduction to

a twelve (12) month enrollment period

for the TDP has a precedent with other

TRICARE plans, to include the

TRICARE Managed Care Prime option

and the TSRDP. By introducing this

more liberal enrollment period, the

regulation also calls for a twelve (12)

month ‘‘lock-out’’ if the beneficiary

disenrolls before completing the twelve

(12) month enrollment period for any

unauthorized reason or if the

beneficiary fails to pay their premiums.

A twelve (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 as provided in paragraph

(c)(3)(ii)(C)(2) of this final rule. This

‘‘lock-out’’ period has a precedent with

other commercial dental insurance

plans as well as the TRICARE Managed

Care Prime option, the TSRDP and the

TRDP. ‘‘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

twelve (12) months’ worth of premiums.

Beneficiaries enrolled in the TFMDP

and TSRDP at the time when TDP

coverage begins must complete their

respective two (2) and one (1) year

enrollment periods established under

those superseded plans except if one of

the conditions for valid disenrollment

applies. Once these original enrollment

periods are met, the beneficiary may

continue TDP enrollment on month-tomonth basis. A new one (1) year

enrollment period will only be incurred

if the beneficiary disenrolls and

attempts to reenroll in the TDP at a later

date.

E. Enrollment Period for Certain Reserve

Component Sponsors

The regulations provides that the

twelve (12) month enrollment period

shall not apply to eligible dependents of

Reserve component sponsors ordered to

active duty for more than thirty (30)

days but less than twelve (12) months

(other than for training) in support of a

contingency operation as defined in 10

U.S.C. 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 desperate

treatment for certain Reserve component

members is necessary because of the

involuntary nature of their call to active

duty and statutory limitations on their

period of active duty.

By contrast, active duty members are

enlisted, reenlisted or commissioned for

periods of active duty longer than one

(1) 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 twelve (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 (1) year; therefore

they will have the option to enroll

family members at any time other than

in the last twelve (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 nine (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 eighteen (18)

months; if serving for more than thirty

(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 twelve (12) month

enrollment period for TDP, 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

12858 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

exclusion to the twelve (12) month

enrollment period is therefore necessary

to preclude such prejudicial treatment

of Reserve component members ordered

to active duty for less than twelve (12)

months to support a contingency

operation. In its place, a separate

enrollment period is created for the

Reserve component member as provided

in paragraph (c)(3)(ii)(C)(2) if this final

rule.

F. 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 costshare. To allow greater participation and

dental benefit utilization among our

younger enlisted families, this

regulation would have a two-tiered

maximum cost-share dependent on the

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]

Covered services

Cost-share for

pay grades E-1,

E-2, E-3 and E-4

Cost-share for all

other pay 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, resins, stainless steel crowns)........ ............................................... 20 20

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

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

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

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

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

Other Restorative (example: crowns, onlays, casts)......................... .............................................................. 50 50

Prosthodontics.......................... ....................................................................................................................... 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 sixty (60)

percent of the total premium for

dependents of active duty members and

members of the Selected Reserve and

the Individual Ready Reserve (as

described in 10 U.S.C. 10144(b)). As

such, the greatest effect on participation

and utilization can best be achieved

through a reduction in cost-shares.

G. Simplification of Enrollment Options

Under the final rule, previous TFMDP

enrollment options have been simplified

to assist the beneficiary, Government,

provider of care and the dental plan

contractor. Under the TFMDP (and

previous plans), dependents were asked

to choose from several different

enrollment options depending on

whether they had children under the

age of four (4). With the advance in

pediatric dentistry (pedodontics), dental

care for children between the ages of

one (1) and four (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 one (1) year of

age or older. Although there will

continue to be two (2) separate

premiums, a ‘‘single’’ premium for one

(1) covered life, and a ‘‘family’’

premium for more than one (1) 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. A

discussion of these enrollment policies

and options will be found in the TDP

contractor’s benefit booklet.

H. 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 regulation allows the

Department to add other types of

anesthesia services to the TDP benefit

package.

I. Congressional Waiver for Surviving

Dependents

This final rule provides clarification

on the Department’s use of the

Congressional waiver for surviving

dependents. Since 1993, the Department

has used the waiver authority to provide

one (1) year of continued TFMDP

enrollment at Government expense to

eligible dependents of active duty

members who die while on active duty

for a period of thirty-one (31) days or

more. To receive the continued

enrollment at Government expense, the

eligible dependents must have been

enrolled in the TFMDP at the time of the

active duty member’s death. With the

authority in the National Defense

Authorization Act for Fiscal Year 2000,

the final rule clarifies how the waiver

will be used and extends use of the

waiver to enrolled dependents of

deceased members of the Selected

Reserve and the Individual Ready

Reserve (as described in 10 U.S.C.

10144(b)).

J. Appeals Plan

Under the TDP, the Department

wishes to procure a responsive, simple,

and two (or greater) tiered appeals

program within the dental plan

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12859

contractor’s operation. We have had

similar success with this approach

under the TSRDP and the TRDP, where

the contractors administer the first two

(2) levels of the appeals program, which

are termed the initial determination and

the reconsideration. Under the TDP, 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 levels 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.

K. Plan Transition

The programmatic improvements are

scheduled to take effect when the

follow-on TDP contract to the current

TFMDP contact is awarded and the

performance period begins. Operations

under the current TSRDP contract will

also cease at that time. Considering the

magnitude of the planned

improvements, the Department plans to

‘‘phase-out’’ operations under the

former contractors and methods 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 ‘‘phaseout’’ schedule will be jointly

determined between the Department

and the outgoing and incoming dental

plan contractors.

III. Administrative Changes

The final rule 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

TDP.

The final rule 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’’,

‘‘TRICARE Family Member Dental

Plan’’, ‘‘TRICARE Selected Reserve

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. Public Comments

The proposed rule was published in

the Federal Register on Wednesday,

November 24, 1999, (64 FR 66126). We

received one (1) comment letter. We

thank the commenter and their

organization; items raised by the

commenter and our analysis of the

comments are summarized below.

1. Enrollment

The commenter recognized that there

were numerous problems in the current

enrollment and eligibility system that

supports the TFMDP. They believe

though that the Department should

totally absorb any increased costs

related to the contractor’s enrollment

function under the TDP.

Response: Under the law, 10 U.S.C.

1076a, the Congress authorized that the

dental plans offered will be ‘‘premium

sharing plans’’ and ‘‘full premium

plans’’. As such, the Department must

share in the cost of all programmatic

improvements, to include contractor

enrollment, for the majority of the

enrollees.

2. Enrollment

The commenter suggested that, if

problems persist with enrollment and

eligibility processing under the TDP and

which cannot be swiftly handled by the

dental contractor, consideration should

be given to establishing some form of

beneficiary counselor that would act on

behalf of the beneficiary.

Response: As with the current

contracts, the Department is committed

to assisting TDP beneficiaries if

problems occur. Representatives from

the Uniformed Services (to include

Health Benefits Advisors), the Finance

Centers, the Defense Manpower Data

Center and the TRICARE Management

Activity will all be available to act on

our beneficiaries’ behalf, if needed.

3. Enrollment

The commenter asked if there are any

provisions in the TDP to assist deployed

service members with enrollment

issues.

Response: Numerous options exist

under the TDP to assist deployed

service members. These include webbased and electronic mail capabilities,

additional toll-free lines, extended

hours of operation, and use of

commercial business practices that

allow representatives of the sponsor to

act on enrollment issues during the

sponsor’s absence.

4. Enrollment

The commenter requested that

enrollees be offered the option to enroll

their children who reach the age of four

(4) stating that the increase in premium

by moving to a family premium will

result in more junior service members

opting out of the plan.

Response: Under the current TFMDP,

when a child reaches four (4) years old,

they are automatically enrolled. This

has not been a cause of concern with

current enrollees nor has it led to

measurable disenrollments. Continuing

this in the TDP is in keeping with the

accepted standards and direction of

pediatric and adolescent dentistry,

which recommends early preventive

and diagnostic intervention and distinct

care at set age intervals.

5. Survivor Benefit

The commenter requested that the

final rule contain specific language that

the Government will pay premiums for

enrolled survivors for the one (1) year

period following the sponsor’s death.

Response: We appreciate the

comment and have clarified this in the

final rule.

6. Eligibility

The commenter questioned eligibility

language regarding a child who becomes

a re-eligible for TDP benefits because

the child’s marriage ends before the

child is twenty-one (21) years of age and

who loses eligibility at twenty-one (21)

years of age. The commenter stated that

this language was inconsistent with

12860 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

eligibility up to age twenty-three (23) if

the child is a full-time student.

Response: Full-time student eligibility

for the TDP up to age twenty-three (23)

is listed in the final rule by crossreference to 32 CFR 199.3(b)(2)(iv)(C).

7. Alternative Delivery Systems

The commenter was opposed to

language regarding the provision of

alternative delivery systems and

potential implementation of these

systems under the TDP. Their concern

was that alternative delivery systems

would limit beneficiaries to a dental

health maintenance organization,

preclude beneficiary choice of dental

providers, allow such entities as Morale,

Welfare and Recreation and Exchange

organizations the opportunity for

increased profits if they were designated

as alternative delivery systems, and that

both quality and cost could be

compromised by the implementation of

a closed system.

Response: The alternative delivery

system language has been in this

regulation since 1988. To date, this

provision has not been utilized as the

Department supports a traditional

network-oriented dental indemnity

insurance plan over other forms of

managed care. The principle of provider

choice is an important element of this

regulation as well as the TDP contract

and the Department has no immediate

plans to engage in ‘‘closed’’ systems.

The Department does reserve the right

to explore alternative delivery systems

in the form of demonstrations or pilot

programs if the Congress believes this

would be in the beneficiary’s best

interest.

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 final rule is not a significant

regulatory action under Executive Order

12866. The changes set forth in this

final rule are minor revisions to the

existing regulation. Since this final 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:

§ 199.13 TRICARE Dental Program.

(a) General provisions—(1) Purpose.

This section prescribes guidelines and

policies for the delivery and

administration of the TRICARE Dental

Program (TDP) of the Uniformed

Services 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 National Oceanic and Atmospheric

Administration (NOAA) Corps. The TDP

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 (7) 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 TDP

is authorized by 10 U.S.C. 1076a,

TRICARE dental program, and this

section was previously titled the

‘‘Active Duty Dependents Dental Plan’’.

The TDP incorporates the former 10

U.S.C. 1076b, Selected Reserve dental

insurance, and the section previously

titled the ‘‘TRICARE Selected Reserve

Dental Program’’, § 199.21.

(2) Applicability.—(i) Geographic

scope. (A) The TDP is applicable

geographically within the fifty (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 TDP 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 TDP to areas

other than those areas specified in

paragraph (a)(2)(i)(A) of this section for

the eligible members and eligible

dependents of 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

TDP 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 TDP. 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 copayments) and other portions of a

provider’s billed charges for certain

beneficiary categories. Other differences

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 preauthorization 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 paragraph (a)(2)(i)(B). Beneficiaries

will be eligible for the same TDP

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,

dependents of active duty, Selected

Reserve and Individual Ready Reserve

members enrolled in the TDP may not

obtain those services that are benefits of

the TDP in military dental care

facilities, as long as those covered

benefits are available for cost-sharing

under the TDP. Enrolled dependents of

active duty, Selected Reserve and

Individual Ready Reserve members may

continue to obtain noncovered services

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12861

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 authorized

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 TDP.

(B) Administration. 10 U.S.C. 1073

authorizes the Secretary of Defense to

administer the TDP for the Army, Navy,

Air Force, and Marine Corps under DoD

jurisdiction, the Secretary of

Transportation to administer the TDP

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

TDP for the Commissioned Corps of the

USPHS and the NOAA Corps.

(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 § 199.1. Any

guidelines or policy necessary for

implementation of this § 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 TDP.

(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 Uniformed Service

beneficiaries 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 TDP

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 TDP

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 TDP 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

beneficiaries.

(ii) Disposition of funds. TDP 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 TDP 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.

(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 TDP. 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 TDP’s policies and procedures and

has no authority to make benefit

determinations or obligate the TDP’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 TDP. 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

12862 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

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,

Selected Reserve or individual Ready

Reserve 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 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

from 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 TDP 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 Sec. 199.2. The

following definitions apply only to this

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,

Selected Reserve or Individual Ready

Reserve member for any remaining

amount of the fees for services which

exceeds the prevailing fee allowance of

the insurer.

(2) Authorized provider. A dentist,

dental hygienist, or certified and

licensed anesthetist specifically

authorized to provide benefits under the

TDP in paragraph (f) of this section.

(3) Beneficiary. A dependent of an

active duty, Selected Reserve or

Individual Ready Reserve member, or a

member of the Selected Reserve or

Individual Ready Reserve, who has been

enrolled in the TDP, 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 TDP, 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 TDP, 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, Selected Reserve or Individual

Ready Reserve 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 (2) phases:

(i) Enrolling all active duty, Reserve

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 TDP.

(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 TDP and further

defined in paragraph (e) of the 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 TDP claim, a

request for TDP benefit predetermination, 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 TDP. Rejection of a

claim or pre-determination, or of a

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12863

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 TDP

benefits are not initial determinations.

(14) Nonparticipating provider. A

dentist or dental hygienist that

furnished dental services to a TDP

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, Selected

Reserve or Individual Ready Reserve

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,

Selected Reserve or Individual Ready

Reserve 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,

Selected Reserve or Individual Ready

Reserve member) or any cost-share for

covered services.

(18) Party to the initial determination.

Includes the TDP, a beneficiary of the

TDP and a participating provider of

services whose interests have been

adjudicated by the initial determination.

In addition, provider who has been

denied approval as an authorized TDP

provider is a party to the initial

determination, as is a provider who is

suspended, excluded or terminated as

an authorized provider, unless the

provider is excluded or suspended by

another agency of the Federal

Government, a state, or a local licensing

authority.

(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,

refinement, 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, dental

hygienist, or certified and licensed

anesthetist 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.

(c) Eligibility and enrollment—(1)

General. 10 U.S.C. 1076a, 1072(2)(A),

(D), or (I), 1072(6), 10143 and 10144 set

forth those persons who are eligible for

voluntary enrollment in the TDP. 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) Persons eligible.

Eligibility for the TDP is continuous in

situations where the sponsor or member

changes status between any of these

eligible categories and there is no break

in service or transfer to a non-eligible

status.

(A) 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

or less) or a member of the Selected

Reserve (as specified in 10 U.S.C.

10143) or Individual Ready Reserve (as

specified in 10 U.S.C. 10144):

(1) Spouse. A lawful husband or wife,

regardless of whether or not dependent

upon the active duty, Selected Reserve

or Individual Ready Reserve member.

(2) Child. To be eligible, the child

must be unmarried and meet the

requirements set forth in

§§ 199.3(b)(2)(iv)(A) and

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

(B) A member of the Selected Reserve

of the Ready Reserve (as specified in 10

U.S.C. 10143).

(C) A member of the Individual Ready

Reserve of the Ready Reserve (as

specified in 10 U.S.C. 10144(b)) who is

subject to being ordered to active duty

involuntarily in accordance with 10

U.S.C. 12304.

(D) All other members of the

Individual Ready Reserve of the Ready

Reserve (as specified in 10 U.S.C.

10144(a)).

(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 TDP is the responsibility of the

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 of a specified person when

there is reason to question 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 Service

identification cards do not distinguish

eligibility for the TDP. Procedures for

the determination of eligibility are

identified in § 199.3(f)(2), except that

Uniformed Service identification cards

do not provide evidence of eligibility for

the TDP. Although OCHAMPUS and the

dental plan contractor must make

determinations concerning a member or

dependent’s eligibility in order to

ensure proper enrollment and proper

disbursement of appropriated funds,

ultimate responsibility for resolving a

member or dependent’s eligibility rests

with the Uniformed Services.

(C) Evidence of eligibility required.

Eligibility and enrollment in the TDP

will be verified through the DEERS.

Eligibility and enrollment information

established and maintained in the

DEERS file is the only acceptable

evidence of TDP eligibility and

enrollment. It is the responsibility of the

active duty, Selected Reserve or

Individual Ready Reserve member or

TDP beneficiary, parent, or legal

12864 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

representative, when appropriate, to

provide adequate evidence for entry into

the DEERS file to establish eligibility for

the TDP, and to ensure that all changes

in status that may affect 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.—(i) 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 (also known as the TRICARE

Family Member Dental Plan) was

effective from August 1, 1993, up to the

date of implementation of the TDP. The

Expanded Active Duty Dependents

Dental Benefit Plan terminates upon

implementation of the TDP.

(ii) TRICARE Dental Program (TDP).—

(A) Election of coverage. (1) Except as

provided in paragraph (c)(3)(ii)(A)(2) of

this section, active duty, Selected

Reserve and Individual Ready Reserve

service members may voluntarily elect

to enroll their eligible dependents and

members of the Selected Reserve and

Individual Ready Reserve may

voluntarily elect to enroll themselves

following implementation of the TDP. In

order to obtain TDP coverage, written or

telephonic election by the active duty,

Selected Reserve or Individual Ready

Reserve 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

the TDP will automatically be enrolled

in the TDP. Eligible members of the

Selected Reserve enrolled in the

TRICARE Selected Reserve Dental

Program at the time of implementation

of the TDP will automatically be

enrolled in the TDP. No election to

enroll in the TDP will be required by the

active duty or Selected Reserve 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 or one (1) covered

eligible Selected Reserve or Individual

Ready Reserve member.

(ii) Family premium. Two (2) or more

covered eligible dependents. Under the

family premium, all eligible dependents

of the active duty, Selected Reserve or

Individual Ready Reserve member are

enrolled.

(2) Exceptions. (i) An active duty,

Selected Reserve or Individual Ready

Reserve member may elect to enroll

only those eligible dependents residing

in one (1) location when the active duty,

Selected Reserve or Individual Ready

Reserve 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 of an

active duty member requires a hospital

or special treatment environment (due

to a medical, physical handicap, or

mental condition) for dental care

otherwise covered by the TDP, the

dependent may be excluded from TDP

enrollment and may continue to receive

care from a military treatment facility.

(iii) A member of the Selected Reserve

or Individual Ready Reserve may enroll

separately from his or her eligible

dependents. A member of the Selected

Reserve or Individual Ready Reserve

does not have to be enrolled in order for

his or her eligible dependents to enroll

under the TDP.

(C) Enrollment period.—(1) General.

Enrollment of eligible dependents or

members is for a period of one (1) year

followed by month-to-month enrollment

as long as the active duty, Selected

Reserve or Individual Ready Reserve

member chooses to continue

enrollment. Active duty members may

enroll their eligible dependents and

eligible members of the Selected

Reserve or Individual Ready Reserve

may enroll themselves or their eligible

dependents in the TDP provided there

is an intent to remain on active duty or

as a member of the Selected Reserve or

Individual Ready Reserve (or any

combination thereof without a break in

service or transfer to a non-eligible

status) for a period of not less than one

(1) year by the service member and their

parent Uniformed Service. Beneficiaries

enrolled in the TDP 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) Special enrollment period for

Reserve component members ordered to

active duty in support of contingency

operations. The mandatory twelve (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 TDP 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 the TDP and

complete the enrollment application

within thirty (30) days following entry

on active duty or within sixty (60) days

following implementation of the TDP.

Following enrollment, beneficiaries

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 twelve

(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 TDP 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 TDP 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 reenroll in

the TDP at a later date.

(4) Continuation of enrollment from

TRICARE Selected Reserve Dental

Program. Beneficiaries enrolled in the

TRICARE Selected Reserve Dental

Program at the time when TDP coverage

begins must complete their one (1) year

enrollment period established under

this former program except if one of the

conditions for disenrollment specified

in paragraph (c)(3)(ii)(E) of this section

is met. Once this original one (1) year

enrollment period is met, the Selected

Reserve member may continue TDP

enrollment on a month-to-month basis.

A new one (1) year enrollment period

will only be incurred if the Selected

Reserve member disenrolls and attempts

to reenroll in the TDP at a later date.

(D) Beginning dates of eligibility. The

beginning date of eligibility for TDP

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

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12865

monthly cut-off date, except that the

date of eligibility shall not be earlier

than the first day of the month in which

the TDP is implemented. This includes

any changes between single and family

member premium coverage and

coverage of newly eligible or enrolled

dependents or members.

(E) Changes in and termination of

enrollment. (1) Changes in status of

active duty, Selected Reserve or

Individual Ready Reserve member.

When the active duty, Selected Reserve

or Individual Ready Reserve member is

separated, discharged, retired,

transferred to the Standby or Retired

Reserve, his or her enrolled dependents

and/or the enrolled Selected Reserve or

Individual Ready Reserve member lose

eligibility and enrollment as of 11:59

p.m. on the last day of the month in

which the change in status takes place.

When the Selected Reserve or

Individual Ready Reserve member is

ordered to active duty for a period of

thirty-one (31) days or more without a

break in service, the member loses their

eligibility and is disenrolled, if they

were previously enrolled; however,

their enrolled dependents maintain

their eligibility and previous enrollment

subject to eligibility, enrollment and

disenrollment provisions described in

this section and in the TDP contract.

When the previously enrolled active

duty member is transferred back to the

Selected Reserve or Individual Ready

Reserve without a break in service, the

member regains eligibility and is

reenrolled; however, their enrolled

dependents maintain their eligibility

and previous enrollment subject to

eligibility, enrollment and

disenrollment provisions described in

this section and in the TDP contract.

Eligible dependents of an active duty,

Selected Reserve or Individual Ready

Reserve member serving a sentence of

confinement in conjunction with a

sentence of punitive discharge are still

eligible for the TDP until such time as

the active duty, Selected Reserve or

Individual Ready Reserve member’s

discharge is executed.

(2) Continuation of eligibility for

dependents of service members who die

while on active duty or while a member

of the Selected Reserve or Individual

Ready Reserve. Eligible dependents of

active duty members while on active

duty for a period of thirty-one (31) days

or more and eligible dependents of

Selected Reserve or Individual Ready

Reserve members, as specified in 10

U.S.C. 10143 and 10144(b) respectively,

who die on or after the implementation

date of the TDP, and whose dependents

are enrolled in the TDP on the date of

the death of the active duty, Selected

Reserve or Individual Ready Reserve

member shall be eligible for continued

enrollment in the TDP for up to one (1)

year from the date of the active duty,

Selected Reserve or Individual Ready

Reserve member’s death. This continued

enrollment is not contingent on the

Selected Reserve or Individual Ready

Reserve member’s own enrollment in

the TDP. During the one (1) year period

of continuous enrollment, the

Government will pay both the

Government and the beneficiary’s

portion of the premium share.

(3) Changes in status of dependent.—

(i) Divorce. A spouse separated from an

active duty, Selected Reserve or

Individual Ready Reserve 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, Selected Reserve or

Individual Ready Reserve 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, Selected

Reserve or Individual Ready Reserve

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, Selected

Reserve or Individual Ready Reserve

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, Selected Reserve or Individual

Ready Reserve member who is adopted

by a person, other than a person whose

dependents are eligible for TDP benefits

while the active duty, Selected Reserve

or Individual Ready Reserve member is

living, thereby severing the legal

relationship between the child and the

active duty, Selected Reserve or

Individual Ready Reserve 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, Selected Reserve or

Individual Ready Reserve member who

marries a person whose dependents are

not eligible for the TDP, 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 twentyone (21) years old, the child again

become 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 twenty-one (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

twenty-one (21) or twenty-two (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 TDP 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 TDP 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 twenty-one (21) or

twenty-two (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 twenty-one (21) or

twenty-two (22) years old in student

status does not have eligibility related to

mental or physical incapacity as

described in § 199.3(b)(2)(iv)(C)(2).

(4 ) Other.—(i) Disenrollment because

of no eligible beneficiaries. When an

active duty, Selected Reserve or

Individual Ready Reserve member

ceases to have any eligible beneficiaries,

enrollment is terminated for those

enrolled dependents.

(ii) Option to disenroll as a result of

a change in active duty station. When

an active duty member transfers with

enrolled dependents to a duty station

where space-available dental care for

the enrolled dependents is readily

available at the local Uniformed Service

dental treatment facility, the active duty

member may elect, within ninety (90)

calendar days of the transfer, to

12866 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

disenroll their dependents from the

TDP. 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 reenroll their eligible

dependents in the TDP 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. This

disenrollment provision does not apply

to enrolled dependents of members of

the Selected Reserve or Individual

Ready Reserve or to enrolled members

of the Selected Reserve or Individual

Ready Reserve.

(iii) Option to disenroll due to transfer

to OCONUS service area. When an

enrolled dependent of an active duty,

Selected Reserve or Individual Ready

Reserve member or an enrolled Selected

Reserve or Individual Ready Reserve

member relocates to locations within

the OCONUS service area, the active

duty, Selected Reserve or Individual

Ready Reserve member may elect,

within ninety (90) calendar days of the

relocation, to disenroll their dependents

from the TDP, or in the case of enrolled

members of the Selected Reserve or

Individual Ready Reserve, to disenroll

themselves from the TDP. The active

duty, Selected Reserve or Individual

Ready Reserve member may reenroll

their eligible dependents, or in the case

of members of the Selected Reserve or

Individual Ready Reserve, may reenroll

themselves in the TDP provided the

member, as of the date of reenrollment,

otherwise meets the requirements for

enrollment, including the intent to

remain on active duty or as a member

of the Selected Reserve or Individual

Ready Reserve (or any combination

thereof without a break in service or

transfer to a non-eligible status) for a

period of not less than one (1) year.

(iv) Option to disenroll after an initial

one (1) year enrollment. When a

dependent’s enrollment under an active

duty, Selected Reserve or Individual

Ready Reserve member or a Selected

Reserve or Individual Ready Reserve

member’s own enrollment has been in

effect for a continuous period of one (1)

year, the active duty, Selected Reserve

or Individual Ready Reserve member

may disenroll their dependents, or in

the case of enrolled members of the

Selected Reserve or Individual Ready

Reserve may disenroll themselves at any

time following procedures as set up by

the dental plan contractor. Subsequent

to the disenrollment, the active duty,

Selected Reserve or Individual Ready

Reserve member may reenroll their

eligible dependents, or in the case of

members of the Selected Reserve or

Individual Ready Reserve may reenroll

themselves, for another minimum

period of one (1) year. If, during any one

(1) year enrollment period, the active

duty, Selected Reserve or Individual

Ready Reserve member disenrolls their

dependents, or in the case of members

of the Selected Reserve or Individual

Ready Reserve disenrolls themselves,

for reasons other than those listed in

this paragraph (c)(3)(ii)(E) or fails to

make premium payments, dependents

enrolled under the active duty, Selected

Reserve or Individual Ready Reserve

member, or enrolled members of the

Selected Reserve and Individual Ready

Reserve, will be subject to a lock-out

period of twelve (12) months. Following

this period of time, active duty, Selected

Reserve or Individual Ready Reserve

members will be able to reenroll their

eligible dependents, or members of the

Selected Reserve or Individual Ready

Reserve will be able to reenroll

themselves, if they so choose. The

twelve (12) month lock-out period

applies to enrolled dependents of 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, Selected Reserve or

Individual Ready Reserve members

enrolling their eligible dependents, or

members of the Selected Reserve or

Individual Ready Reserve enrolling

themselves, in the TDP shall be required

to pay all or a portion of the premium

cost depending on their status.

(i) Members required to pay a portion

of the premium cost. This premium

category includes active duty members

(under a call or order to active duty that

does not specify a period of thirty (30)

days or less) on behalf of their enrolled

dependents. It also includes members of

the Selected Reserve (as specified in 10

U.S.C. 10143) and the Individual Ready

Reserve (as specified in 10 U.S.C.

10144(b)) enrolled on their own behalf.

(ii) Members required to pay the full

premium cost. This premium category

includes members of the Selected

Reserve (as specified in 10 U.S.C.

10143), and the Individual Ready

Reserve (as specified in 10 U.S.C.

10144), on behalf of their enrolled

dependents. It also includes members of

the Individual Ready Reserve (as

specified in 10 U.S.C. 10144(a)) enrolled

on their own behalf.

(2) Proportion of premium share. The

proportion of premium share to be paid

by the active duty, Selected Reserve and

Individual Reserve member pursuant to

paragraph (d)(1)(i) of this section is

established by the ASD(HA), or

designee, at not more than forty (40)

percent of the total premium. The

proportion of premium share to be paid

by the Selected Reserve and Individual

Reserve member pursuant to paragraph

(d)(1)(ii) of this section is established by

the ASD(HA), or designee, at one

hundred (100) percent of the total

premium.

(3) Provision for increases in active

duty, Selected Reserve and Individual

Ready Reserve member’s premium

share. (i) Although previously capped at

$20 per month, the law has been

amended to authorize the cap on active

duty, Selected Reserve and Individual

Ready Reserve member’s premiums

pursuant to paragraph (d)(1)(i) of this

section 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 members of the Uniformed

Services 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, Selected Reserve and

Individual Ready Reserve member’s

TDP premium pursuant to paragraph

(d)(1)(i) of this section will be applied

as if the methodology had been in

continuous use since December 31,

1993.

(4) Reduction of premium share for

enlisted members. For enlisted members

in pay grades E–1 through E–4, the

ASD(HA) or designee, may reduce the

monthly premium these active duty,

Selected Reserve and Individual Ready

Reserve members pay pursuant to

paragraph (d)(1)(i) of this section.

(5) Reduction of cost-shares for

enlisted members. For enlisted members

in pay grades E–1 through E–4, the

ASD(HA) or designee, may reduce the

cost-shares that active duty, Selected

Reserve and Individual Ready Reserve

members pay on behalf of their enrolled

dependents and that members of the

Selected Reserve and Individual Ready

Reserve pay on their own behalf for

selected benefits as specified in

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

(6) Premium payment method. The

active duty, Selected Reserve and

Individual Ready Reserve member’s

premium share may be deducted from

the active duty, Selected Reserve or

Individual Ready Reserve member’s

basic pay or compensation paid under

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12867

37 U.S.C. 206, if sufficient pay is

available. For members who are

otherwise eligible for TDP benefits and

who do not receive such pay and

dependents who are otherwise eligible

for TDP benefits and whose sponsors do

not receive such pay, or if insufficient

pay is available, the premium payment

may be collected pursuant to procedures

established by the Director,

OCHAMPUS, or designee.

(7) Annual notification of premium

rates. TDP 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 TDP 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 TDP 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.

(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 Services HBAs and major

personnel centers at Uniformed Service

installations and headquarters to all

members enrolling themselves or their

eligible dependents.

(iv) Alternative course of treatment

policy. The Director, OCHAMPUS, or

designee, may establish, in accordance

with generally accepted dental benefit

practices, an alternative course of

treatment policy which provides

reimbursement in instances where the

dentist and beneficiary select a more

expensive service, procedure, or course

of treatment than is customarily

provided. The alternative course of

treatment policy must meet following

conditions:

(A) The service, procedure, or course

of treatment must be consistent with

sound professional standards of dental

practice for the dental condition

concerned.

(B) The service, procedure, or course

of treatment must be a generally

accepted alternative for a service or

procedure covered by the TDP for the

dental condition.

(C) Payment for the alternative service

or procedure may not exceed the lower

of the prevailing limits for the

alternative procedure, the prevailing

limits or dental plan contractor’s

scheduled allowance for the otherwise

authorized benefit procedure for which

the alternative is substituted, or the

actual charge for the alternative

procedure.

(2) Benefits. The following benefits

are defined (subject to the TDP’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.

(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.

(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

12868 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

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 removable complete

and partial dentures, fixed crowns and

bridges when performed directly by

dentists as authorized under paragraph

(f)(4) of this section. These include the

following categories of prosthodontic

services:

(A) Prosthodontics (removable).

(1) Complete and partial dentures.

(2) Adjustments 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.

(ix) Exclusion of adjunctive dental

care. Adjunctive dental care benefits are

excluded under the TDP. For further

information on adjunctive dental care

benefits under TRICARE/CHAMPUS,

see § 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 TDP.

(xi) Limitation on reduction of

benefits. If a reduction in benefits is

planned, the Secretary of Defense, or

designee, may not reduce TDP benefits

without notifying the appropriate

Congressional committees. If a

reduction is approved, the Secretary of

Defense, or designee, must wait one (1)

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, Selected Reserve and

Individual Ready Reserve member and

dependent cost-shares for covered

services for participating and

nonparticipating providers of care (see

paragraph (f)(6) of this section for

additional active duty, Selected Reserve

and Individual Ready Reserve costs).

These are percentages of the dental plan

contractor’s determined allowable

amount that the active duty, Selected

Reserve and Individual Ready Reserve

member or beneficiary must pay to these

providers. For care received in the

OCONUS service area, the ASD(HA), or

designee, may pay certain cost-shares

and other portions of a provider’s billed

charge for enrolled dependents of active

duty members (under a call or order that

does not specify a period of thirty (30)

days or less), and for members of the

Selected Reserve (as specified in 10

U.S.C. 10143) and Individual Ready

Reserve (as specified in 10 U.S.C.

10144(b)) enrolled on their own behalf.

[In percent]

Covered services

Cost-share for

pay grades E-1,

E-2, E-3 and E-4

Cost-share for all

other pay 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, resins, stainless steel crowns) ....................................................... 20 20

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

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

Oral and Maxilllofacial Surgery ........................................................................................................................ 30 40

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

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

Other Restorative (example: crowns, onlays, casts) ....................................................................................... 50 50

Prosthodontics ................................................................................................................................................. 50 50

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

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

Miscellaneous .................................................................................................................................................. 50 50

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12869

(ii) Dental plan contractor liability.

When more than twenty-five (25)

percent or more than two hundred (200)

enrollees in a specific five (5) digit zip

code area are unable to obtain a periodic

or initial (non-emergency) dentistry

appointment with a network provider

within twenty-one (21) calendar days

and within thirty-five (35) miles of the

enrollee’s place of residence, then the

TRICARE Management Activity (TMA)

will designate that area as ‘‘noncompliant with the access standard.’’

Once so designated, the dental program

contractor will reimburse the

beneficiary, or active duty, Selected

Reserve or Individual Ready Reserve

member, or the nonparticipating

provider selected by enrollees in that

area (or a subset of the area or nearby

zip codes in other five (5) digit zip code

areas as determined by TMA) at the

level of the provider’s usual fees less the

applicable enrollee cost-share, if any.

TMA shall determine when such area

becomes compliant with the access

standards. This access standard and

associated liability does not apply to

care received in the OCONUS service

area.

(iii) Maximum coverage amounts.

Beneficiaries are subject to an annual

maximum coverage amount for nonorthodontic dental benefits and a

lifetime maximum coverage amount for

orthodontics as established by the ASD

(HA) or designee.

(f) Authorized providers—(1) General.

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 restrictions 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

TDP 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) Utilization 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 TDP. Utilization

review and quality assurance

assessments shall be performed under

the TDP 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 TDP

authorized provider practicing within

the scope of his or her license.

(5) Participating provider. An

authorized provider may elect to

participate for all TDP 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 (1) 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.

(6) Nonparticipating provider. An

authorized provider may elect to not

participate for all TDP beneficiaries and

request the beneficiary or active duty,

Selected Reserve or Individual Ready

Reserve 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 availability within twentyone (21) calendar days. In such

instances of the nonavailability of a

participating provider and in

accordance with the provisions of the

dental contract, 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)(3)(i) of this section.

(i) Assignment of benefits. A

nonparticipating provider may accept

assignment of benefits for claims (for

beneficiaries certifying their willingness

to make such assignment of benefits) by

filing the claims completed with the

assistance of the beneficiary or active

duty, Selected Reserve or Individual

Ready Reserve 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, Selected

Reserve or Individual Ready Reserve

member file the claim directly with the

dental plan contractor, making

arrangements with the beneficiary or

active duty, Selected Reserve or

Individual Ready Reserve member for

direct payment by the beneficiary or

active duty, Selected Reserve or

Individual Ready Reserve 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 an 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

12870 Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations

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

TDP 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 TDP’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 TDP as

an incentive for beneficiary

participation in the alternative delivery

system.

(g) Benefit payment—(1) General. TDP

benefits payments are made either

directly to the provider or to the

beneficiary or active duty, Selected

Reserve or Individual Ready Reserve

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 the dental plan

contractor’s determination of allowable

charges. The following general

requirements for the TDP 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, Selected

Reserve or Individual Ready Reserve

members for 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 § 199.9 shall

apply except for § 199.9(e). All

references to ‘‘CHAMPUS contractors’’,

‘‘CHAMPUS beneficiaries’’ and

‘‘CHAMPUS providers’’ in § 199.9 shall

be construed to mean the ‘‘dental plan

contractor’’, ‘‘TDP beneficiaries’’ and

‘‘TPD providers’’ respectively for the

purposes of this section. Examples of

fraud include situations in which

ineligible persons not enrolled in the

TDP obtain care and file claims for

benefits under the name and

identification of a 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 contractor’s determination

of allowable charges; or when a provider

fails to collect the specified patient costshare amount.

(h) Appeal and hearing procedures.

The provisions of § 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

§ 199.10 shall be construed to mean the

‘‘dental plan contractor’’, ‘‘TDP

beneficiaries’’, ‘‘TDP participating

providers’’ and ‘‘Dental Explanation of

Benefits or DEOB’’ respectively for the

purposes of this section. References to

‘‘OCHAMPUSEUR’’ in § 199.10 are not

applicable to the TDP or this section.

(1) General. See § 199.10(a).

(i) Initial determination.—(A) Notice

of initial determination and right to

appeal. See § 199.10(a)(1)(i).

(B) Effect of initial determination. See

§ 199.10(a)(1)(ii).

(ii) Participation in an appeal.

Participation 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 §§ 199.10(a)(2)(i)

and 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

§ 199.10(a)(2)(ii).

(iii) Burden of proof. See

§ 199.10(a)(3).

(iv) Evidence in appeal and hearing

cases. See § 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

§§ 199.10(a)(6), 199.10(a)(6)(i),

199.10(a)(6)(iv), including

§§ 199.10(a)(6)(iv) (A) and (C), and

199.10(a)(6)(v) for an explanation and

examples of non-appealable 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:

(1) A determination of a person’s

enrollment in the TDP is the

responsibility of the dental plan

contractor and ultimate responsibility

for resolving a beneficiary’s enrollment

rests with the dental plan contractor.

Federal Register / Vol. 66, No. 41 / Thursday, March 1, 2001 / Rules and Regulations 12871

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.

(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 § 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 TDP.

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 § 199.8 of this part.

(viii) Levels of appeal. See

§ 199.10(a)(8)(i). Initial determinations

involving the sanctioning (exclusion,

suspension, or termination) of TDP

providers shall be appealed directly to

the hearing level.

(ix) Appeal decision. See

§ 199.10(a)(9).

(2) Reconsideration. See § 199.10(b).

(3) Formal review. See § 199.10(c).

(4) Hearing.—(i) General. See

§§ 1.99.10(d) and 199.10(d)(1) through

(d)(5) and (d0(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 applicable for

the date(s) of service, 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 decisions is issued in the case.

(5) Final decision. See §§ 199.10(e)(1)

and 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).

§ 199.21 [Removed and Reserved]

3. Section 199.21 is removed and

reserved.

Dated: February 13, 2001.

L.M. Bynum,

Alternate OSD Federal Register Liaison

Officer, Department of Defense.

[FR Doc. 01–4047 Filed 2–28–01; 8:45 am]

BILLING CODE 5001–10–P

ENVIRONMENTAL PROTECTION

AGENCY

40 CFR Part 60

[TN–2001–01; FRL–6941–7]

New Stationary Sources; Supplemental

Delegation of Authority to Knox

County, TN

AGENCY: Environmental Protection

Agency (EPA).

ACTION: Delegation of authority.

SUMMARY: The Knox County Department

of Air Quality Management located in

Knoxville, Tennessee has requested that

EPA delegate authority for

implementation and enforcement of

existing New Source Performance

Standards (NSPS) which have been

previously adopted by the Knox County

Department of Air Quality Management

(KCDAQM or local agency) but have

remained undelegated by EPA, and to

approve the mechanism for delegation

(adopt-by-reference) of future NSPS.

The purpose of the local agency request

for approval of its delegation

mechanism is to streamline existing

administrative procedures by

eliminating any unnecessary steps

involved in the federal delegation

process. With this NSPS delegation

mechanism in place, a new or revised

NSPS promulgated by EPA will become

effective in Knox County on the date the

NSPS is adopted if the local agency

adopts the NSPS without change. No

further local agency requests for

delegation will be necessary. Likewise,

no further Federal Register notices will

be published. EPA reserves the right to

implement the federal NSPS directly

and continues to retain concurrent

enforcement authority. The EPA’s

review of the local agency’s pertinent

laws, rules, and regulations indicate that

adequate and effective procedures are in

place for the implementation and

enforcement of these Federal standards.

This document was written to inform

the public of delegations that were made

to KCDAQM for which a Federal

Register notice was not previously

written and to inform the public of the

local agency’s new mechanism for

delegation of future NSPS.

EFFECTIVE DATE: The effective date is

March 1, 2001.

ADDRESSES: Copies of the request for

delegation of authority and EPA’s letter

of delegation are available for public

inspection during normal business

hours at the following locations:

Environmental Protection Agency,

Region 4, Air and Radiation Technology

Branch, 61 Forsyth Street, SW., Atlanta,

Georgia 30303.

Knox County Department of Air

Quality Management, City/County

Building, Suite 459, 400 West Main

Street, Knoxville, Tennessee 37902–

2405.

Effective March 1, 2001, all requests,

applications, reports and other

correspondence required pursuant to

the delegated standards should not be

submitted to the Region 4 office, but

should instead be submitted to the

following address:

Knox County Department of Air

Quality Management, City/County

Building, Suite 459, 400 West Main

Street, Knoxville, Tennessee 37902–

2405.

FOR FURTHER INFORMATION CONTACT: Katy

Forney, Air and Radiation Technology

Branch, Environmental Protection

Agency, Region 4, 61 Forsyth St. SW.,

Atlanta, Georgia 30303, 404–562–9130.

E-mail: reeves.kathleen@epa.gov