(a) Establishment.
The TRDP is
a premium based indemnity dental insurance coverage program that
will be available to certain retirees and their surviving spouses,
their dependents, and certain other beneficiaries, as specified
in paragraph (d) of this section. The TRDP is authorized by 10 U.S.C.
1076c.
(1) The Director will, except
as authorized in paragraph (a)(2) of this section, make available
a premium based indemnity dental insurance plan for eligible TRDP
beneficiaries specified in paragraph (d) of this section consistent
with the provisions of this section.
(2) The
TRDP premium based indemnity dental insurance program under paragraph
(a) of this section may be provided by allowing eligible beneficiaries
specified in paragraph (d) of this section to enroll in an insurance
plan under chapter 89A of title 5, United States Code that provides
benefits similar to those benefits provided under paragraph (f)
of this section. Such enrollment shall be authorized pursuant to
an agreement entered into between the Department of Defense and
the Office of Personnel Management which agreement, in the event
of any inconsistency, shall take precedence over provisions in this
section.
(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
(Health Affairs) or designee, the TRDP is administered in a manner
similar to the TRICARE Dental Program under Sec. 199.13 of this
part.
(5) The TRDP shall be administered through a contract.
(c) Definitions.
Except as may
be specifically provided in this section, to the extent terms defined
in Sec. 199.2 and 199.13(b) are relevant to the administration of
the TRICARE Retiree Dental Program, the definitions contained in
Sec. 199.2 and 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 basis as specified in paragraph
(d)(4) of this section.
(A) The member is enrolled
under Section 1705 of Title 38, United States 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, TMA, or designee, 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 enrollment periods of up to
12 months as long as the enrollee chooses to continue enrollment
and remains eligible. An enrollee who chooses not to continue enrollment
upon completion of an enrollment period may re-enroll at any time.
However, an enrollee who is disenrolled from the TRDP before completion
of an initial or subsequent enrollment period for reasons other
than those in paragraphs in (d)(5)(ii)(A) and (B) of this section
shall incur a lockout period of 12 months before re-enrollment can
occur. Former enrollees who re-enroll following a lockout period
or following a period of disenrollment after completion of an enrollment
period must comply with all provisions that apply to new enrollees,
including a new enrollment commitment.
(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.
All enrollee
requests for termination of TRDP coverage before the completion
of an enrollment period shall be submitted to the TRDP contractor
for determination of whether the enrollee qualifies to be disenrolled
under paragraphs (d)(5)(ii)(A) or (B) of this section.
(A) Enrollment grace
period.
Regardless
of the reason, TRDP coverage shall be cancelled, or otherwise terminated,
upon request from an enrollee if the request is received by the
TRDP contractor within 30 calendar days following the enrollment
effective date and there has been no use of TRDP benefits under
the enrollment 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 termination of enrollment
under paragraph (d)(5)(ii)(A) of this section will not be honored,
and premiums will not be refunded.
(B) Extenuating circumstances.
Under limited
circumstances, TRDP enrollees shall be disenrolled by the contractor
before the completion of an enrollment period commitment upon request
by an enrollee if the enrollee submits written, factual documentation
that independently verifies that one of the following extenuating
circumstances occurred during the enrollment period. In general,
the circumstances must be unforeseen and long-term and must have
originated after the effective date of TRDP coverage.
(1) The enrollee is prevented by a serious
medical condition from being able to utilize TRDP benefits,
(2) The enrollee would suffer severe financial
hardship by continuing TRDP enrollment; or
(3) Any other circumstances which the Secretary
considers appropriate.
(C) Effective date of voluntary termination.
For cases determined
to qualify for disenrollment under the grace period provisions in
paragraph (d)(5)(ii)(A) of this section, enrollment is completely
nullified effective from the beginning date of coverage. For cases
determined to qualify for disenrollment under the extenuating circumstances
provisions in paragraph (d)(5)(ii)(B) of this section, the effective
date of disenrollment is the first of the month following the contractor’s
initial determination on the disenrollment request or the first
of the month following the last use of TRDP benefits under the enrollment,
whichever is later.
(D) Appeal process for denied voluntary enrollment
termination.
An
enrollee has the right to appeal the contractor’s determination
that a disenrollment request does not qualify under paragraphs (d)(5)(ii)(A)
or (B) of this section. The enrollee may appeal that determination
by submitting a written appeal to the TMA, Office of Appeals and
Hearings, with a copy of the contractor’s determination notice and
relevant documentation supporting the disenrollment request. This
appeal must be received by TMA within 60 days of the date on the
contractor’s determination notice. The burden of proof is on the enrollee
to establish affirmatively by substantial evidence that the enrollee
qualifies to be disenrolled under paragraphs (d)(5)(ii)(A) or (B)
of this section. TMA will issue written notification to the enrollee and
the contractor of its appeal determination within 60 days from the
date of receipt of the appeal request. That determination is final.
(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 premium payments will result
in the enrollee’s disenrollment from the TRDP and a lockout period
of 12 months. Following this period of time, eligible individuals
will be able to re-enroll.
(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) Basic benefits.
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 examination.
(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 (emergency) 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 treatment than is 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).
(k) Appeal procedures.
All levels of
appeal established by the contractor shall be exhausted prior to
an appeal being filed with the TMA. Procedures comparable to those
established for appeal of benefit determinations under Sec. 199.10
of this part shall apply together with the procedures for appeal
of voluntary disenrollment determinations described in paragraph
(d)(5)(ii)(D) of this section.
(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 54212, Sep 24, 2007; 72 FR 64537, Nov 16, 2007; 73 FR 59504,
Oct 9, 2008; 82 FR 45458, Sep 29, 2017]