[Code of Federal Regulations]
[Title 32, Volume 2]
[Revised as of July 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 32CFR199.22]

[Page 347-352]
 
                       TITLE 32--NATIONAL DEFENSE
 
        CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED)
 
PART 199_CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES 
 
Sec. 199.22  TRICARE Retiree Dental Program (TRDP).

    (a) Purpose. The TRDP is a premium based indemnity dental insurance 
coverage program that will be available to retired members of the 
Uniformed Services, their dependents, and certain other beneficiaries, 
as specified in

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paragraph (d) of this section. The TRDP is authorized by 10 U.S.C. 
1076c.
    (b) General provisions. (1) At a minimum, benefits are the 
diagnostic services, preventive services, basic restorative services 
(including endodontics), oral surgery services, and emergency services 
specified in paragraph (f)(1) of this section. 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.
    (2) Premium costs for this coverage will be paid by the enrollee.
    (3) Geographic scope. (i) The TRDP is applicable to authorized 
providers in the 50 United States and the District of Columbia, Canada, 
Puerto Rico, Guam, American Samoa, the Commonwealth of the Northern 
Mariana Islands, and the U.S. Virgin Islands.
    (ii) The Assistant Secretary of Defense (Health Affairs) (ASD (HA)) 
may extend the TRDP to geographic areas other than those specified in 
paragraph (b)(3)(i) of this section. In extending the TRDP overseas, the 
ASD (HA) is authorized to establish program elements, methods of 
administration, and payment rates and procedures that are different from 
those in effect for the areas specified in paragraph (b)(3)(i) of this 
section to the extent the ASD (HA), or designee, determines necessary 
for the effective and efficient operation of the TRDP. These differences 
may include, but are not limited to, specific provisions for 
preauthorization of care, varying licensure and certification 
requirements for foreign providers, and other differences based on 
limitations in the availability and capabilities of the Uniformed 
Services overseas dental treatment facilities and a particular nation's 
civilian sector providers in certain areas. The Director, TRICARE 
Management Activity shall issue guidance, as necessary, to implement the 
provisions of this paragraph. TRDP enrollees residing in overseas 
locations will be eligible for the same benefits as enrollees residing 
in the continental United States, although dental services may not be 
available or accessible in all locations.
    (4) Except as otherwise provided in this section or by the Assistant 
Secretary of Defense (Human Affairs) or designee, the TRDP is 
administered in a manner similar to the Active Duty Dependents Dental 
Plan under Sec. 199.13 of this part.
    (5) The TRDP shall be administered through a contract.
    (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) Eligibility and enrollment.--(1) Eligibility. Enrollment in the 
TRICARE Retiree Dental Program is open to:
    (i) Members of the Uniformed Services who are entitled to retired 
pay, or former members of the armed forces who are Medal of Honor 
recipients and who are not otherwise entitled to dental benefits;
    (ii) Members of the Retired Reserve under the age of 60;
    (iii) Eligible dependents of a member described in paragraph 
(d)(1)(i) or paragraph (d)(1)(ii) of this section who are covered by the 
enrollment of the member;
    (iv) Eligible dependents of a member described in paragraph 
(d)(1)(i) or paragraph (d)(1)(ii) of this section when the member is not 
enrolled in the program and the member meets at least one of the 
conditions in paragraphs (d)(1)(iv)(A) through (C) of this section. 
Already enrolled members must satisfy any remaining enrollment 
commitment prior to enrollment of dependents becoming effective under 
this paragraph, at which time the dependent-only enrollment will 
continue on a voluntary, month-to-month basis as specified in paragraph 
(d)(4) of this section. Members must provide documentation to the TRDP 
contractor giving evidence of compliance with paragraphs (d)(1)(iv)(A), 
(B), or (C) of this section at the time of application for enrollment of 
their dependents under this paragraph.
    (A) The member is enrolled under Section 1705 of Title 38, United 
States

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Code, to receive ongoing, comprehensive dental care from the Department 
of Veterans Affairs pursuant to Section 1712 of Title 38, United States 
Code, and 38 CFR 17.93, 17.161, or 17.166. Authorization of such dental 
care must be confirmed in writing by the Department of Veterans Affairs.
    (B) The member is enrolled in a dental plan that is available to the 
member as a result of employment of the member that is separate from the 
Uniformed Service of the member, and the dental plan is not available to 
dependents of the member as a result of such separate employment by the 
member. Enrollment in this dental plan and the exclusion of dependents 
from enrollment in the plan must be confirmed by documentation from the 
member's employer or the dental plan's administrator.
    (C) The member is prevented by a current and enduring medical or 
dental condition from being able to obtain benefits under the TRDP. The 
specific medical or dental condition and reason for the inability to use 
the program's benefits over time, if not apparent based on the 
condition, must be documented by the member's physician or dentist.
    (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.
    Note to paragraphs (d)(1)(iii), (d)(1)(iv), and (d)(1)(v): Eligible 
dependents of Medal of Honor recipients are described in Sec. 
199.3(b)(2)(i) (except for former spouses) and Sec. 199.3(b)(2)(ii) 
(except for a child placed in legal custody of a Medal of Honor 
recipient under Sec. 199.3(b)(2)(ii)(H)(4)).
    (2) Notification of eligibility. The contractor will notify persons 
eligible to receive dental benefits under the TRICARE Retiree Dental 
Program.
    (3) Election of coverage. In order to initiate dental coverage, 
election to enroll must be made by the member or eligible dependent. 
Enrollment in the TRICARE Retiree Dental Program is voluntary and will 
be accomplished by submission of an application to the TRDP contractor.
    (4) Enrollment periods--(i) Enrollment period for basic benefits. 
The initial enrollment for the basic dental benefits described in 
paragraph (f)(1) of this section shall be for a period of 24 months 
followed by month-to-month enrollment as long as the enrollee remains 
eligible and chooses to continue enrollment. An enrollee's disenrollment 
from the TRDP at any time for any reason, including termination for 
failure to pay premiums, is subject to a lockout period of 12 months. 
After any lockout period, eligible individuals may elect to reenroll and 
are subject to a new initial enrollment period. The enrollment periods 
and conditions stipulated in this paragraph apply only to the basic 
benefit coverage described in paragraph (f)(1) of this section. 
Effective with the implementation of an enhanced benefit program, new 
enrollments for basic coverage will cease. Enrollees in the basic 
program at that time may continue their enrollment for basic coverage, 
subject to the applicable provisions of this section, as long as the 
contract administering that coverage is in effect.
    (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. The initial 
enrollment period shall be followed by renewal periods of up to 12 
months as long as the enrollee chooses to continue enrollment and 
remains eligible. An enrollee's disenrollment from the TRDP during an 
enrollment period for any reason, including termination for failure to 
pay premiums, is subject to a lockout period of 12 months. This lockout 
provision does not apply to disenrollment during an enrollment grace 
period as defined in paragraph (d)(5)(ii) of this section or following 
completion of an initial or

[[Page 350]]

renewal enrollment period. Eligible individuals who elect to reenroll 
following a lockout period or a disenrollment after completion of an 
enrollment period are subject to a new initial enrollment period.
    (5) Termination of coverage--(i) Involuntary termination. TRDP 
coverage is terminated when the member's entitlement to retired pay is 
terminated, the member's status as a member of the Retired Reserve is 
terminated, a dependent child loses eligible child dependent status, or 
a surviving spouse remarries.
    (ii) Voluntary termination. Regardless of the reason, TRDP coverage 
shall be canceled, or otherwise terminated, upon written request from an 
enrollee if the request is received by the TRDP contractor within thirty 
(30) calendar days following the enrollment effective date and there has 
been no use of TRDP benefits by the enrolled member, enrolled spouse, or 
enrolled dependents during that period. If such is the case, the 
enrollment is voided and all premium payments are refunded. However, use 
of benefits during this 30-day enrollment grace period constitutes 
acceptance by the enrollee of the enrollment and the enrollment period 
commitment. In this case, a request for voluntary disenrollment before 
the end of the initial enrollment period will not be honored, and 
premiums will not be refunded.
    (6) Continuation of dependents' enrollment upon death of enrollee. 
Coverage of a dependent in the TRDP under an enrollment of a member or 
surviving spouse who dies during the period of enrollment shall continue 
until the end of that period and may be renewed by (or for) the 
dependent, so long as the premium paid is sufficient to cover 
continuation of the dependent's enrollment. Coverage may be terminated 
when the premiums paid are no longer sufficient to cover continuation of 
the enrollment.
    (e) Premium payments. Persons enrolled in the dental plan will be 
responsible for paying the full cost of the premiums in order to obtain 
the dental insurance.
    (1) Premium payment method. The premium payment may be collected 
pursuant to procedures established by the Assistant Secretary of Defense 
(Health Affairs) or designee.
    (2) Effects of failure to make premium payments. Failure to make 
monthly renewal premium payments will result in the enrollee's 
disenrollment from the TRDP and subject to a lock-out period of 12 
months. Following this period of time, persons eligible will be able to 
reenroll if they so choose.
    (3) Member's payment of premiums. The cost of the TRDP monthly 
premium will be paid by the enrollee. Interested beneficiaries may 
contact the dental contractor-insurer to obtain the enrollee premium 
cost.
    (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 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.

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    (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.
    (2) Enhanced benefits. In addition to the minimum TRDP services in 
paragraph (f)(1) of this section, other services that are comparable to 
those contained in paragraph (e)(2) of Sec. 199.13 may be covered 
pursuant to TRDP benefit policy decisions made by the Director, 
OCHAMPUS, or designee. In general, these include additional diagnostic 
and preventive services, major restorative services, prosthodontics 
(removable and fixed), additional oral surgery services, orthodontics, 
and additional adjunctive general services (including general anesthesia 
and intravenous sedation). Enrollees in the basis plan will be given an 
enrollment option at the time the enhanced plan is implemented.
    (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. The alternative 
course of treatment policy must meet the following conditions:
    (i) The service, procedure, or course of treatment must be 
consistent with sound professional standards of generally accepted 
dental practice for the dental condition concerned.
    (ii) The service, procedure, or course of treatment must be a 
generally accepted alternative for a service or procedure covered by the 
TRDP for the dental condition.
    (iii) 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.
    (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.
    (h) Annual notification of rates. TRDP premiums will be determined 
as part of the competitive contracting process. Information on the 
premium rates will be widely distributed.
    (i) Authorized providers. The TRDP enrollee may seek covered 
services from any provider who is fully licensed and approved to provide 
dental care in the state where the provider is located.
    (j) Benefit payment. Enrollees are not required to utilize the 
special network of dental providers established by the TRDP contractor. 
For enrollees who do use these network providers, however, providers 
shall not balance bill any amount in excess of the maximum payment 
allowable by the TRDP. Enrollees using non-network providers may balance 
billed amounts in excess of allowable charges. The maximum payment 
allowable by the TRDP (minus the appropriate cost-share) will be the 
lesser of:
    (1) Billed charges; or
    (2) Usual, Customary and Reasonable rates, in which the customary 
rate is calculated at the 50th percentile of billed charges in that 
geographic area, as measured in an undiscounted charge profile in 1995 
or later for that geographic area (as defined by three-digit zip code).

[[Page 352]]

    (k) Appeal and hearing procedures. Procedures comparable to those 
established under Sec. 199.13(h) of this part shall apply.
    (l) Preemption of State laws. (1) Pursuant to 10 U.S.C. 1103, the 
Department of Defense has determined that in the administration of 
chapter 55 of title 10, U.S. Code, preemption of State and local laws 
relating to health insurance, prepaid health plans, or other health care 
delivery or financing methods is necessary to achieve important Federal 
interests, including but not limited to the assurance of uniform 
national health programs for military families and the operation of such 
programs at the lowest possible cost to the Department of Defense, 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.
    (2) Based on the determination set forth in paragraph (l)(1) of this 
section, any State or local law or regulation pertaining to health or 
dental insurance, prepaid health or dental plans, or other health or 
dental care delivery, administration, and financing methods is preempted 
and does not apply in connection with the TRICARE Retiree Dental Program 
contract. Any such law, or regulation pursuant to such law, is without 
any force or effect, and State or local governments have no legal 
authority to enforce them in relation to the TRICARE Retiree Dental 
Program contract. (However, the Department of Defense may, by contract, 
establish legal obligations on the part of the TRICARE Retiree Dental 
Program contractor to conform with requirements similar to or identical 
to requirements of State or local laws or regulations).
    (3) The preemption of State and local laws set forth in paragraph 
(l)(2) 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 section 1103. 
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 the 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).
    (m) Administration. The Assistant Secretary of Defense (Health 
Affairs) or designee may establish other rules and procedures for the 
administration of the TRICARE Retiree Dental Program.

[62 FR 66993, Dec. 23, 1997, as amended at 65 FR 48913, Aug. 10, 2000; 
65 FR 49492, Aug. 14, 2000; 66 FR 9658, Feb. 9, 2001; 67 FR 4354, Jan. 
30, 2002; 67 FR 15725, Apr. 3, 2002; 72 FR 54213, Sept. 24, 2007; 72 FR 
64537, Nov. 16, 2007]