(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”, Sec. 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 co-payments)
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 pre-authorization 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, services incidental
to noncovered services, and services provided under paragraph (a)(2)(iv),
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 from military dental care facilities subject to the provisions
for space available care.
(iv) Exception to
the exclusion of services performed in military dental care facilities.
(A) Dependents who
are 12 years of age or younger and are covered by a dental plan
established under this section may be treated by postgraduate dental
residents in a dental treatment facility of the uniformed services under
a graduate dental education program accredited by the American Dental
Association if
(1) Treatment of pediatric dental patients
is necessary in order to satisfy an accreditation standard of the
American Dental Association that is applicable to such program,
or training in pediatric dental care is necessary for the residents
to be professionally qualified to provide dental care for dependent children
accompanying members of the uniformed services outside the United
States; and
(2) The number of pediatric patients at such
facility is insufficient to support satisfaction of the accreditation
or professional requirements in pediatric dental care that apply
to such programs or students.
(B) The total number
of dependents treated in all facilities of the uniformed services
under paragraph (a)(2)(iv) in a fiscal year may not exceed 2,000.
(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 Sec. 199.1. Any guidelines or policy necessary for implementation
of this Sec. 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 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 the 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
including cost-sharing amounts or any amount above the network maximum
allowable charge 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.
(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 pre-determination,
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 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 in the contractor’s network
and accept reimbursement in accordance with the contractor’s network
agreement. 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 participate in the contractor’s
network and accept reimbursement in accordance with the contractor’s
network agreement 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 well as other dental
services authorized 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.
(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 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.
(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 as a network provider in the dental
plan contractor’s network and any such election will apply to all
TDP beneficiaries. The authorized provider may not participate on
a claim-by-claim basis. The participating provide 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 methodology specified in paragraph (g)(2)(ii)
of this section. The fee or charge determinations are binding upon
the provider in accordance with the dental plan contractor’s procedures
for participation in the network. Payment is made directly to the
participating provider, and the participating provider may only
charge the beneficiary the applicable 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 twenty-one (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 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 lesser of the provider’s actual charge: Or
the network maximum allowable charge for similar services for that
same locality (region) or state, 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. The network maximum
allowable charge is the maximum negotiated fee between the dental
contractor and any TDP participating provider for similar services
covered by the dental plan in that same locality (region) or state.
(ii) Participating
providers shall be reimbursed in accordance with the contractor’s
network agreements, less any cost-share amount due for authorized
services.
(3) Fraud, abuse, and conflict of interest.
The provisions
of Sec. 199.9 shall apply except for Sec. 199.9(e). All references
to “CHAMPUS contractors”, “CHAMPUS beneficiaries” and “CHAMPUS providers” in
Sec. 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 cost-share
amount.
[66
FR 12860, Mar 1, 2001; 66 FR 16400, Mar 26, 2001, as amended at
68 FR 65174, Nov 19, 2003; 69 FR 55359, Sep 14, 2004; 70 FR 55252,
Sep 21, 2005; 71 FR 1696, Jan 11, 2006; 71 FR 31943, Jun 2, 2006;
71 FR 66872, Nov 17, 2006; 72 FR 53685, Sep 20, 2007; 76 FR 57643,
Sep 16, 2011; 76 FR 81367, Dec 28, 2011; 80 FR 55254, Sep 15, 2015;
81 FR 11667, Mar 7, 2016]