[Federal Register: September 24, 2007 (Volume 72, Number 184)]
[Rules and Regulations]
[Page 54212-54214]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr24se07-6]
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DEPARTMENT OF DEFENSE
Office of the Secretary
[DOD-2006-HA-0210]
RIN 0720-AB12
32 CFR Part 199
TRICARE; TRICARE Retiree Dental Program (TRDP) Basic Benefit
Descriptions and Administrative Corrections
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule amends TRICARE Retiree Dental Program (TRDP)
Basic benefit descriptions by replacing specific American Dental
Association (ADA) dental procedure codes and nomenclature with general
benefit categories and descriptions. This revision is necessary to keep
the regulation current, since dental procedure codes are added,
revised, and deleted on a regular basis. This final rule does not
change or eliminate any benefits that are currently available under the
TRDP program. This final rule also revises several incorrect, obsolete,
or historical terms pertaining to the TRICARE program, and removes an
inaccurate statement regarding appeals and grievances.
DATES: Effective Date: October 24, 2007.
ADDRESSES: TRICARE Management Activity, 16401 East Centretech Parkway,
Aurora, CO 80011-9066.
FOR FURTHER INFORMATION CONTACT: Debra Hatzel, Program Requirements
Division, TRICARE Management Activity, telephone (303) 676-3572.
SUPPLEMENTARY INFORMATION:
1. Introduction and Background
A. Provisions of the Rule Regarding Dental Procedure Codes and
Nomenclature. This final rule amends TRICARE Retiree Dental Program
(TRDP) Basic benefit descriptions by removing specific American Dental
Association (ADA) dental procedure codes and nomenclature, and
replacing them with general benefit categories and descriptions from
the most recent Current Dental Terminology (CDT) Manual (CDT-2005).
This action is required because dental procedure codes and nomenclature
are added, revised, and deleted by the ADA every two years; when this
occurs, the regulation must also be revised to reflect the new codes
and nomenclature. Maintaining specific procedure codes and nomenclature
in the regulation is unnecessary, since the TRDP contract and TRDP
marketing materials (available at http://www.tricare.osd.mil/dental/dm2.cfm
) already contain detailed benefit descriptions. Also, the TRDP
contractor and enrollees are notified when the Government directs any
changes to TRDP benefits, limits, or exclusions. The TRDP contract and
TRDP marketing materials will continue to be the primary vehicles for
communicating specific benefit information to the TRDP contractor and
beneficiaries. Removal of specific procedure codes and nomenclature
from this section does not change or eliminate any benefits that are
currently available under the TRDP. The general categories of benefits
that are listed in this final rule will be adjusted periodically to
conform to the current CDT Manual.
Although there are many similarities between the TRDP and the
TRICARE Dental Program (TDP), the benefits are not identical. Also,
there are different dental benefits available under the TRDP Basic
program and the TRDP Enhanced program. The general benefit categories
in this TRDP final rule differ from the TDP benefit categories listed
in 32 CFR Part 199.13. This variance exists because some of the
benefits offered under the TDP are not benefits under the TRDP Basic
program (e.g., prosthodontic and orthodontic services), and because the
TDP benefit categories were derived from an earlier version of the CDT
Manual.
B. Provisions of the Rule Regarding the Administrative Correction
of Incorrect, Obsolete, or Historical Terms and Inaccurate Information.
The proposed rule addressed the revision of several incorrect, obsolete
or historical terms that appear in the regulation. Specifically,
``Director, OCHAMPUS'' was proposed to be amended to ``Director,
TRICARE Management Activity''; ``Assistant Secretary of Defense (Human
Affairs)'' was proposed to be amended to ``Assistant Secretary of
Defense (Health Affairs)''; ``Active Duty Dependents Dental Program''
was proposed to be amended to ``TRICARE Dental Program''; ``CHAMPUS''
was proposed to be amended to ``TRICARE/CHAMPUS''; and ``OCHAMPUS'' was
proposed to be amended to ``TRICARE Management Activity.''
Subsequent to the publication of the proposed rule, TRICARE
Management Activity identified a long-standing error in the regulation
regarding appeals and grievances. Specifically, 32 CFR 199.22(k)(1)
currently states, ``Appeal and hearing procedures. All levels of
appeals and grievances established by the Contractor for internal
review shall be exhausted prior to forwarding to OCHAMPUS for a final
review. Procedures comparable to those established under Sec. 199.13(h)
of this part shall apply.'' The first sentence in this paragraph is
inaccurate. TRDP grievances are written complaints regarding non-
appealable issues involving a perceived failure of a provider or
contractor staff to furnish the expected level or quality of care
(e.g., demeanor or behavior of providers or their staff). The TRDP
contractor is responsible for the investigation and resolution of
grievances; since they are not forwarded to TMA for ``final review'',
the current CFR language is incorrect. Appeals involve decisions
related to TRICARE benefits (e.g., denial of preauthorization for
requested services, or denial of TRICARE payment for services
received). Appeals are initially sent to the TRDP contractor for
reconsideration. If the original denial is upheld (and the amount in
dispute is $50 or more), the beneficiary may
[[Page 54213]]
request a formal review by the TRICARE Management Activity. If the
beneficiary is dissatisfied with the formal review decision (and the
amount in dispute is $300 or more, the beneficiary may request that the
TRICARE Management Activity schedule an independent hearing. Since
there are two possible levels of action for appeals that are forwarded
to the TRICARE Management Activity (not a single ``final review''), the
current CFR language is incorrect. Therefore, the inaccurate sentence
has been deleted in this final rule as an administrative correction.
The current TRDP appeal and hearing procedures are comparable to those
established under Sec. 199.13(h) as required by the regulation, and are
unchanged by this rule.
II. Public Comments
The proposed rule was published in the Federal Register on November
27, 2006. We received no public comments.
III. Regulatory Procedures
Executive Order 12866 directs agencies to assess all costs and
benefits available, regulatory alternatives and, when regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety,
and other advantages; distributive impacts; and equity). The Order
classifies a rule as a significant regulatory action requiring review
by the Office of Management and Budget if it meets any one of a number
of specified conditions, including having an annual effect on the
national economy of $100 million or more, creating a serious
inconsistency or interfering with an action of another agency,
materially altering the budgetary impact of entitlements or the right
of entitlement recipients, or raising novel legal or policy issues. DoD
has examined the economic, legal, and policy implications of this final
rule and has concluded that is not a significant regulatory action. The
changes set forth in the final rule are minor administrative revisions
to the existing regulation which do not change the basic TRDP benefit
structure. This is neither a significant regulatory action under
Executive Order 12866, nor would it have a significant impact on small
entities.
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 major rule under the Congressional Review
Act because its economic impact will be less than $100 million.
Executive Order 13132 requires that each Federal Agency shall
consult with State and local officials and obtain their input if a rule
has federalism implications which have substantial direct effects on
the States, on the relationship between the national government and the
States, or on the distribution of power and responsibilities among the
various levels of government. We have examined the impact of the final
rule under Executive Order 13132 and it does not have policies that
have federalism implications that would have substantial direct effects
on the States, on the relationship between the national government and
the States, or on the distribution of power and responsibilities among
the various levels of government; therefore, consultation with State
and local officials is not required. In addition, this final rule does
not impose new information collection requirements for purposes of the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3511).
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care, Health insurance, Individuals
with disabilities, Military personnel.
0
Accordingly, 32 CFR part 199 is amended as follows:
PART 199--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. Section 199.22 is amended by revising the last sentence of paragraph
(b)(1), paragraph (b)(4), paragraph (c), paragraph (d)(1)(v), the first
sentence of paragraph (d)(4)(ii), paragraph (f) introductory text,
paragraph (f)(1) introductory text, paragraphs (f)(1)(i) through
(f)(1)(vii), the first sentence of paragraph (f)(3), and paragraph (g);
and by removing paragraph (f)(1)(viii), paragraph (f)(1)(ix), and the
first sentence of paragraph (k) to read as follows:
Sec. 199.22 TRICARE Retiree Dental Program (TRDP).
* * * * *
(b) * * *
(1) * * * Additional services comparable to those contained in
paragraph (e)(2) of Sec. 199.13 may be covered pursuant to benefit
policy decisions made by the Director, TRICARE Management Activity, or
designee.
* * * * *
(4) Except as otherwise provided in this section or by the
Assistant Secretary of Defense (Health Affairs) or designee, the TRDP
is administered in a manner similar to the TRICARE Dental Program under
Sec. 199.13 of this part.
* * * * *
(c) Except as may be specifically provided in this section, to the
extent terms defined in Sec. 199.2 and Sec. 199.13(b) are relevant to
the administration of the TRICARE Retiree Dental Program, the
definitions contained in Sec. 199.2 and Sec. 199.13(b) shall apply to
the TRDP as they do to TRICARE/CHAMPUS and the TRICARE Dental Program.
(d) * * *
(1) * * *
(v) The unremarried surviving spouse and eligible child dependents
of a deceased member who died while in status described in paragraph
(d)(1)(i) or paragraph (d)(1)(ii) of this section; the unremarried
surviving spouse and eligible child dependents who receive a surviving
spouse annuity; or the unremarried surviving spouse and eligible child
dependents of a deceased member who died while on active duty for a
period of more than 30 days and whose eligible dependents are not
eligible or no longer for the TRICARE Dental Program.
* * * * *
(4) * * *
(ii) Enrollment period for enhanced benefits. The initial
enrollment period for enhanced benefit coverage described in paragraph
(f)(2) of this section shall be established by the Director, TRICARE
Management Activity, or designee, when such coverage is offered, to be
a period of not less than 12 months and not more than 24 months. * * *
* * * * *
(f) Plan benefits. The Director, TRICARE Management Activity, or
designee, may modify the services covered by the TRDP to the extent
determined appropriate based on developments in common dental care
practices and standard dental programs. In addition, the Director,
TRICARE Management Activity, 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 TRDP.
(1) The minimum TRDP benefit is basic dental care to include
diagnostic services, preventive services, restorative services,
endodontic services, periodontic services, oral surgery
[[Page 54214]]
services, and other general services. The following is the minimum TRDP
covered dental benefit:
(i) Diagnostic services.
(A) Clinical oral examinations.
(B) Radiographs and diagnostic imaging.
(C) Tests and laboratory examinations.
(ii) Preventive services.
(A) Dental prophylaxis.
(B) Topical fluoride treatment (office procedure).
(C) Sealants.
(D) Other preventive services.
(E) Space maintenance.
(iii) Restorative services.
(A) Amalgam restorations.
(B) Resin-based composite restorations.
(C) Other restorative services.
(iv) Endodontic services.
(A) Pulp capping.
(B) Pulpotomy and pulpectomy.
(C) Root canal therapy.
(D) Apexification and recalcification procedures.
(E) Apicoectomy and periradicular services.
(F) Other endodontic procedures.
(v) Periodontic Services.
(A) Surgical services.
(B) Periodontal services.
(vi) Oral surgery.
(A) Extractions.
(B) Surgical extractions.
(C) Alveoloplasty.
(D) Biopsy.
(E) Other surgical procedures.
(vii) Other general services.
(A) Palliative (emergenery) treatment of dental pain.
(B) Therapeutic drug injection.
(C) Other drugs and/or medicaments.
(D) Treatment of postsurgical complications.
* * * * *
(3) Alternative course of treatment policy. The Director, TRICARE
Management Activity, 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 TRDP enrollee select a more expensive service, procedure,
or course of treatement than in customarily provided. * * *
* * * * *
(g) Maximum coverage amounts. Each enrollee is subject to an annual
maximum coverage amount for non-orthodontic dental benefits and, if an
orthodontic benefit is offered, a lifetime maximum coverage amount for
orthodontics as established by the Director, TRICARE Management
Activity, or designee.
* * * * *
Dated: September 14, 2007.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 07-4658 Filed 9-21-07; 8:45 am]
BILLING CODE 5001-06-M