Civilian health and medical program of uniformed services (CHAMPUS): TRICARE program — Dental Program; John Warner National Defense Authorization Act changes,

[Federal Register: March 23, 2007 (Volume 72, Number 56)]

[Proposed Rules]

[Page 13721-13722]

From the Federal Register Online via GPO Access [wais.access.gpo.gov]

[DOCID:fr23mr07-23]

DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD-2007-HA-0026]

RIN 0720-AB14

TRICARE; Changes Included in the John Warner National Defense Authorization Act for Fiscal Year 2007; Authorization of Anesthesia and Other Costs for Dental Care for Children and Certain Other Patients

AGENCY: Office of the Secretary, DoD.

ACTION: Proposed rule.

SUMMARY: This proposed rule will implement section 702 of the John Warner National Defense Authorization Act for Fiscal Year 2007 (NDAA for FY 2007), Pubic Law 109-364. Specifically, that legislation amends the coverage of contracted medical care with respect to dental care beyond that care required as a necessary adjunct to medical or surgical treatment. The entitlement of institutional and anesthesia services is authorized in conjunction with non-covered dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under. This proposed rule will not eliminate any contracted medical care that is currently covered for spouses and children. The entitlement of anesthesia services will include general anesthesia services only. Institutional services will include institutional benefits associated with both hospital and in-out surgery settings. Patients with developmental, mental, or physical disabilities are those patients with conditions that prohibit dental treatment in a safe and effective manner. Therefore, it is medically or psychologically necessary for these patients to require general anesthesia for dental treatment.

DATES: Written comments received at the address indicated below by May 22, 2007 will be accepted.

ADDRESSES: You may submit comments, identified by docket number and/or RIN number and title, by any of the following methods:

Federal eRulemaking Portal: http://www.regulations.gov.

Follow the instructions for submitting comments.

Mail: Federal Docket Management System Office, 1160 Defense Pentagon, Washington, DC 20301-1160.

Instructions: All submissions received must include the agency name and docket number of Regulatory Information Number (RIN) for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at http://regulations.gov

as they are received without change, including any personal identifies or contact information.

FOR FURTHER INFORMATION CONTACT: Col. Gary C. Martin, Office of the Assistant Secretary of Defense (Health Affairs), TRICARE Management Activity, telephone (703) 681-0039.

SUPPLEMENTARY INFORMATION:

1. Background

   This proposed rule will amend the coverage of contracted medical care with respect to dental care beyond that care required as necessary adjunct to medical or surgical treatment. The entitlement of institutional and anesthesia services will be authorized in conjunction with non-covered dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under. This proposed rule will not eliminate any contracted medical care that is currently covered for spouses and children. The entitlement of anesthesia services will include general anesthesia services only. Institutional services will include institutional benefits associated with both hospital and in-out surgery settings. Patients with developmental, mental, or physical disabilities are those patients with conditions that prohibit dental treatment in a safe and effective manner. Therefore, it is medically or psychologically necessary for these patients to require general anesthesia for dental treatment.

   Currently, general anesthesia and institutional services are not covered in conjunction with dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients of any age through TRICARE medical plan contracts. For military families who have children that require extensive dental treatment under general anesthesia, the two options available are to have the care provided locally at a Department of Defense (DoD) facility or a civilian facility. If the care is provided in a DoD facility, the total costs to the family are minimal. There are locations where this care is not available from a DoD facility due to facility constraints (no operating room) and/or lack of dental specialists. For dental care provided in a civilian facility, families currently enrolled in the TRICARE Dental Program (TDP) or TRICARE Retiree Dental Program (TRDP) are provided with coverage for dental care with applicable cost-shares. These include a 40% cost-share for

   [[Page 13722]]

   general anesthesia and varying cost-shares for dental procedures (fillings, crowns, root canals) completed in the operating room setting. There is an annual maximum benefit for the TDP and TRDP of $1,200 per enrollee. This means that the total payments for covered services for each enrolled member will not exceed $1,200 in any contract year. In addition, the TRDP has a deductible of $50 per patient per year, not to exceed $150 per family per year. Frequently, the annual maximum is reached for those pediatric patients who require extensive dental treatment under general anesthesia. Once the annual maximum is reached, the remainder of the billed charges is the enrollee's responsibility. The hospital costs (institutional services) are covered by neither the TDP nor TRDP. For families with dental insurance other than TDP or TRDP, their plan structure will defray some costs but out-of-pocket costs will remain significant. Currently, families without any dental insurance will incur the total costs of dental, anesthesia, and institutional services.

2. Regulatory Procedures

   Executive Order 12866 requires that a comprehensive regulatory impact analysis be performed on any economically significant regulatory action, defined as one that would result in an annual effect of $100 million or more on the national economy or which would have other substantial impacts. The Regulatory Flexibility Act (RFA) requires that each Federal agency prepare, and make available for public comment, a regulatory flexibility analysis when the agency issues a regulation which would have a significant impact on a substantial number of small entities. This rule is not an economically significant regulatory action and will not have a significant impact on a substantial number of small entities for purposes of the RFA, thus this proposed rule is not subject to any of these requirements.

   This rule will not impose additional information collection requirements on the public under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3511).

   We have examined the impact(s) of the proposed rule under Executive Order 13132 and it does not have policies that have federalism implications that would have substantial direct effects on the States, on the relationship between the national government and the States, or on the distribution of power and responsibilities among the various levels of government, therefore, consultation with State and local officials is not required.

   List of Subjects in 32 CFR Part 199

   Claims, Dental health, Health care, Health insurance, Individuals with disabilities, Military personnel.

   Accordingly, 32 CFR part 199 is proposed to be amended as follows:

   PART 199--CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS)

   1. The authority citation for part 199 continues to read as follows:

      Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.

   2. Section 199.4 is amended by removing the first sentence of paragraph (e)(10) introductory text and adding two sentences in its place; revising the first sentence of paragraph (e)(10)(iii); and adding paragraph (e)(10)(vi) to read as follows:

      Sec. 199.4 Basic program benefits.

      * * * * *

      (e) * * *

      (10) Dental. TRICARE/CHAMPUS does not include a dental benefit. However, in connection with dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under, only institutional and anesthesia services may be provided as a benefit. * * * * * * * *

      (iii) Preauthorization required. In order to be covered, adjunctive dental care requires preauthorization from the Director, TRICARE Management Activity, or a designee, in accordance with paragraph (a)(12) of this section. * * * * * * * *

      (vi) Anesthesia and institutional costs for dental care for children and certain other patients. Institutional benefits specified in paragraph (b) of this section may be extended for hospital and in- out surgery settings related to noncovered, nonadjunctive dental care when such outpatient care or inpatient stay is in conjunction with dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under. For these patients, anesthesia services will be limited to the administration of general anesthesia only. Patients with developmental, mental, or physical disabilities are those patients with conditions that prohibit dental treatment in a safe and effective manner. Therefore, it is medically or psychologically necessary for these patients to require general anesthesia for dental treatment. Patients with physical disabilities include those patients having disabilities as defined in Sec. 199.2 as serious physical disability. Preauthorization by the Director, TRICARE Management Activity, or a designee, is required for such outpatient care or inpatient stays to be covered in the same manner as required for adjunctive dental care described in paragraph (e)(10)(iii) of this section. Regardless of whether or not the preauthorization request for outpatient care or hospital admission is approved and thus qualifies for institutional benefits, the professional service related to the nonadjunctive dental care is not covered with the exception of coverage for anesthesia services. * * * * *

      Dated: March 15, 2007. L.M. Bynum, Alternate OSD Federal Register Liaison Officer, Department of Defense.

      [FR Doc. 07-1375 Filed 3-22-07; 8:45 am]

      BILLING CODE 5001-06-M