(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]