(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]