(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]