VA Dental Insurance Program, 12517-12522 [2012-4879]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 77, Number 41 (Thursday, March 1, 2012)]
[Proposed Rules]
[Pages 12517-12522]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-4879]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AN99


VA Dental Insurance Program

AGENCY: Department of Veterans Affairs and Department of Defense.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) proposes to amend its 
regulations to establish a pilot program to offer premium-based dental 
insurance to enrolled veterans and certain survivors and dependents of 
veterans. VA would contract with a private insurer through the Federal 
contracting process to offer dental insurance, and the private insurer 
would then be responsible for the administration of the dental 
insurance plan. VA's role would primarily be to form the contract with 
the private insurer and verify the eligibility of veterans, survivors, 
and dependents. The program is authorized, and this rulemaking is 
required, by section 510 of the Caregivers and Veterans Omnibus Health 
Services Act of 2010 (the 2010 Act).

DATES: Comments must be received by VA on or before April 30, 2012.

ADDRESSES: Written comments may be submitted through https://www.regulations.gov; by mail or hand delivery to the Director, 
Regulations Management (02REG), Department of Veterans Affairs, 810 
Vermont Avenue NW., Room 1068, Washington, DC 20420; or by fax to (202) 
273-9026. Comments should indicate that they are submitted in response 
to ``RIN 2900-AN99, VA Dental Insurance Program.'' Copies of comments 
received will be available for public inspection in the Office of 
Regulation Policy and Management, Room 1063B, between the hours of 8 
a.m. and 4:30 p.m., Monday through Friday (except holidays). Please 
call (202) 461-4902 (this is not a toll-free number) for an 
appointment. In addition, during the comment period, comments may be 
viewed online through the Federal Docket Management System at https://www.regulations.gov.

FOR FURTHER INFORMATION CONTACT: Kristin Cunningham, Director, Business 
Policy, Chief Business Office (10NB), Veterans Health Administration, 
Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 
20420; (202) 461-1599. (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION: Pursuant to section 510(a) of the 2010 Act, 
VA ``shall carry out a pilot program to assess the feasibility and 
advisability of providing a dental insurance plan to veterans and 
survivors and dependents of veterans.'' In order to comply with section 
510, VA would contract with a private dental insurer that would offer 
dental coverage to the persons identified in section 510(b) of the 2010 
Act. This proposed rule would establish rules and procedures for the VA 
Dental Insurance Program (VADIP), in accordance with section 510(k) of 
the 2010 Act, which requires VA to prescribe regulations.
    Section 510(c) of the 2010 Act is a ``sunset provision'' that 
authorizes VADIP to run from January 30, 2011, to January 30, 2014. 
Public Law 111-163, Sec.  510(c) (``The pilot program shall be carried 
out during the 3-year program beginning on the date that is 270 days 
after enactment of this Act,'' which was May 5, 2010). However, we 
would not include that date limitation in the proposed rule, as we were 
not able to begin the pilot program on January 30, 2011, due to the 
need to prescribe regulations, a time-intensive process. We nonetheless 
interpret section 510(c) to require that the pilot program be 
administered for no less than three years, and would conduct the 
program for three years once commenced. Our interpretation is further 
supported by the Secretary's duty as stated in section 510(a) of the 
2010 Act, to ``assess the feasibility and advisability of providing a 
dental insurance plan to veterans and survivors and dependants of 
veterans'', and we believe that this assessment would be incomplete 
unless afforded the full duration of the program as prescribed by law. 
We can easily ensure the termination of VADIP through contract if no 
extension is provided and the program is no longer authorized by law. 
If VADIP is not extended, we would remove the rule from the Code of 
Federal Regulations and, in the meantime, would no longer offer the 
benefit.
    Paragraph (a)(1) of proposed Sec.  17.169 would generally establish 
VADIP and explain what the program provides. We would note that 
``[e]nrollment in VADIP does not affect the covered beneficiary's 
eligibility for VA outpatient dental services and treatment, and 
related dental appliances under 38 U.S.C. 1712.'' This reiterates the 
requirement in section 510(j) of the 2010 Act.
    Proposed paragraph (a)(2) would define the terms ``insured'' and 
``participating insurer,'' which are used throughout the proposed rule 
to identify persons enrolled in an insurance plan through VADIP and 
providers of VADIP insurance, respectively. Defining the terms as such 
would help ensure that the proposed rule is easily understood.
    Proposed paragraph (b) would identify the persons who are eligible 
for insurance through VADIP, and would require that a participating 
insurer offer coverage to such persons. These individuals are clearly 
identified by section 510(b) of the 2010 Act, and the proposed rule 
would use language that is virtually identical to the language used in 
section 510(b). We would require that a participating insurer offer 
coverage to all persons identified in the paragraph in order to ensure 
that we have fully assessed the feasibility and advisability of VADIP, 
as required by section 510(a) of the 2010 Act. We note that we would 
not geographically limit coverage by regulation, but would allow the 
participating insurer to incorporate

[[Page 12518]]

such limitations in the contract with VA. Section 510(d) of the 2010 
Act requires that VADIP ``be carried out in such Veterans Integrated 
Services Networks [VISNs] as the Secretary considers appropriate.'' We 
believe that such consideration must be made in the context of the 
Federal contracting process. VA's limitation of this pilot program to 
particular VISNs, as regional groupings, could be detrimental to 
contract formation, as dental services can be provided by insurers 
through national contracts, regional contracts, or partnerships between 
national and regional group practices. We cannot predict at this time 
whether private insurance companies will want to provide limited or 
nationwide coverage through VADIP, but will attempt through the 
contracting process to obtain the widest possible geographic coverage 
for veterans and their survivors and dependents.
    Proposed paragraph (c)(1) would address premiums, coverage, and 
selection of the participating insurer. Premiums and copayments would 
be paid by the insured in accordance with the terms of the insurance 
plan. Responsibility for payment is so mandated by section 510(h)(3) of 
the 2010 Act. The amount of premiums and copayments would be based on 
the contract with the participating insurer. We do not propose to 
require a minimum or maximum amount in the proposed rule, because we 
believe that this matter would be best handled through the contracting 
process, during which factors such as competition between insurers, 
locations where services are provided, and the range of services 
offered would determine the amounts. VA will not know the range of 
amounts for premium and copayment rates until the proposals received 
from insurers are reviewed, and then based on that review and 
subsequent negotiation, the insurers would be selected. Proposed 
paragraph (c)(1) would additionally require annual premium adjustments, 
and also require that insureds be notified of the amount and effective 
date of such adjustments, in accordance with section 510(h)(2). The 
burden of notifying the insureds would be placed on the participating 
insurer, and we would additionally require that such notice be provided 
in writing.
    Proposed paragraph (c)(2) would specify the minimum coverage that 
must be offered by the participating insurer. We believe that the 
described coverage must be provided in order for the dental plan to be 
meaningful, as well as to comply with the minimum requirements 
established in section 510(f) of the 2010 Act, which are that the 
benefits include appropriate ``diagnostic services, preventative 
services, endodontics and other restorative services, surgical 
services, and emergency services.'' We note that a more detailed 
discussion of covered services, and additional services, would be 
established in the actual insurance plan offered by the participating 
insurer, which VA would approve by contract.
    Proposed paragraph (c)(3) would state that VA would use the Federal 
competitive contracting process to select a participating insurer and 
would further provide that the selected insurer would administer the 
program, in accordance with section 510(e) of the 2010 Act, which 
requires that VA contract with a dental insurer to administer the 
dental insurance plan pilot program. Section 510(e) of the 2010 Act 
makes clear that the Secretary's duty is to contract with a dental 
insurer, and that insurer would then administer the dental insurance 
plan as provided under the pilot.
    Proposed paragraph (d)(1) would establish that VA, in connection 
with the participating insurer, would market VADIP through existing VA 
communication channels to notify all eligible persons of their right to 
voluntarily enroll in VADIP. Enrollment must be purely voluntary under 
section 510(g)(1) of the 2010 Act. We would require that further 
procedures associated with voluntary enrollment, beyond notification of 
eligible persons, would be the responsibility of the participating 
insurer. VA would be responsible for verifying eligibility using 
established VA data storage systems. As previously stated, VA is not 
required by section 510 of the 2010 Act to take an active role in the 
administration of the actual dental program, as the law is merely 
designed to facilitate the provision of private insurance to the 
specified VA beneficiaries. Requiring that the private insurer take on 
a majority of responsibility for enrollment procedures would help 
ensure that only minimal VA resources are devoted to VADIP, and that VA 
may optimally manage its resources to provide VA dental benefits to VA 
beneficiaries as applicable. Section 510(j) makes clear that the 
Secretary's responsibilities to provide VA dental benefits under 38 
U.S.C. 1712 shall not be affected by the administration of this pilot, 
and in fact that the Secretary must not allow a veteran's dental care 
under that section to be affected even in instances where that veteran 
is also participating in the pilot.
    Proposed paragraph (d)(2) would require a minimum initial 
enrollment period of 12 calendar months, followed by month-to-month 
enrollment at the option of the insured. We are required to prescribe a 
minimum period of enrollment by section 510(g)(2) of the 2010 Act, and 
we believe that a minimum of one year is required to assess the 
viability of VADIP. Allowing month-to-month enrollment thereafter, as 
long as the enrollee chooses to continue, would help ensure that 
enrollment remains voluntary, as required in section 510(g)(1) of the 
2010 Act.
    Proposed paragraph (d)(3) would require an insurer to continue to 
provide coverage for at least 30 calendar days after an insured ceases 
to be eligible under proposed paragraphs (b)(1) and (2), to ensure the 
completion of any services scheduled but not yet provided. This 
continued coverage is critical for certain services in proposed 
paragraph (c)(2) that typically would be provided in multiple stages, 
such as when an insured would receive a crown. The insured would be 
required to pay any premiums due during this 30-day continued coverage 
period. This 30-day continued coverage period would not be available to 
those insureds who become disenrolled under proposed paragraph (e), but 
only to those who cease to be eligible under proposed paragraphs (b)(1) 
and (2).
    Under proposed paragraph (e), we would include five voluntary bases 
for insureds to disenroll from VADIP, consistent with section 510(i) of 
the 2010 Act, and would also authorize participating insurers to 
disenroll insureds who fail to pay the required premiums. Disenrollment 
for failure to pay premiums would be at the discretion of the 
participating insurer, in accordance with the details of the insurance 
plan. Because insureds are required by section 510(h)(3) of the 2010 
Act to make such payments, we do not believe that VA has any duty to 
regulate disenrollment on this basis, beyond authorizing involuntary 
disenrollment for non-payment. Proposed paragraphs (e)(1)(i) through 
(iii) would set forth the bases for voluntarily disenrollment that are 
established by section 510(i) of the 2010 Act. Under proposed paragraph 
(e)(1)(i), we would require the participating insurer to allow 
disenrollment ``[f]or any reason, during the first 30 days that the 
beneficiary is covered by the plan, if no claims for dental services or 
benefits were filed by the insured.'' We would require that no claims 
were filed because such an action would require the insurer to expend 
resources, and would also

[[Page 12519]]

indicate the insured's desire to participate in the plan, and because 
VA is required by section 510(i)(1)(B) of the Act to ensure that 
disenrollment criteria do not ``jeopardize the fiscal integrity of the 
dental insurance plan.'' Proposed paragraph (e)(1)(ii) would require 
the participating insurer to allow disenrollment if the insured 
relocates to an area outside the jurisdiction of the plan that prevents 
the use of the benefits under the plan, as required by section 
510(i)(2)(A) of the 2010 Act. Proposed paragraph (e)(1)(iii) would 
require the participating insurer to allow disenrollment if the insured 
is prevented by serious medical condition from being able to obtain 
benefits under the plan, as required by section 510(i)(2)(B) of the 
2010 Act.
    Section 510(i)(2)(C) of the 2010 Act also authorizes VA to 
prescribe additional bases for voluntary disenrollment. We propose two 
additional bases in paragraphs (e)(1)(iv) and (e)(1)(v). Proposed 
paragraph (e)(1)(iv) would establish the first additional basis of 
disenrollment to be that the insured could voluntarily disenroll if he 
or she would suffer severe financial hardship by continuing in VADIP. 
Proposed paragraph (e)(1)(v) would establish the second additional 
basis to be that an insured could voluntarily disenroll for any reason 
at any time after the initial 12-month enrollment period. Both these 
bases further support VA's obligation under section 510(g)(1) of the 
2010 Act to ensure that enrollment in the dental insurance plan be 
voluntary. All bases of voluntary disenrollment in proposed paragraphs 
(e)(1)(i) through (v) either reiterate specific Congressional 
requirements in section 510(i) of the 2010 Act, or are additional bases 
to ensure that enrollment remains voluntary, as also mandated in 
section 510(i).
    Proposed paragraph (e)(2) would establish that all insured requests 
for voluntary disenrollment must be submitted to the insurer for 
determination of whether the insured qualifies for disenrollment under 
the criteria in proposed (e)(1)(i)-(v). Requests for disenrollment 
because of a serious medical condition or severe financial hardship 
would include the insured's submission to the insurer of written 
documentation that verifies the existence of a serious medical 
condition or financial hardship. The written documentation submitted to 
the insurer must show that circumstances leading to a serious medical 
condition or financial hardship originated after the effective date 
coverage began, and would prevent the insured's use of benefits. These 
standards obviate the need to define the statutory terms ``serious 
medical condition'' or ``severe financial hardship,'' because under the 
regulation all that would be required is that the insured provide 
written documentation that shows that conditions exist which prevent 
him or her from maintaining the insurance benefits, and which did not 
exist prior to the start of coverage.
    Section 510(i)(3) of the 2010 Act requires VA to ``establish 
procedures for determinations on the permissibility of voluntary 
disenrollments,'' i.e., disenrollment initiated by the insured pursuant 
to proposed paragraphs (e)(1)(i) through (v). Section 510(i)(3) 
requires that ``[s]uch procedures shall ensure timely determinations on 
the permissibility of such disenrollments,'' but section 510 of the 
2010 Act does not require that VA adjudicate or participate in such 
appeals. Moreover, section 510 of the 2010 Act is silent as to VA's 
role in appeals of issues other than disenrollment, such as denials of 
benefits. We propose minimum timeframes for disenrollment appeals and 
subsequent decisions and we propose an appeals process to ensure that 
appropriate notice and an opportunity to respond is provided to 
insureds. VA would not be involved in the appeals process beyond 
establishing these criteria. Particularly, the decisions of the insurer 
with regards to an insured appeal must be final, so that VA does not 
become involved with the adjudication of appeals. In proposed paragraph 
(e)(3), we would require that, when requests for voluntary 
disenrollment are denied because the insured does not meet any 
criterion under proposed paragraphs (e)(1)(i)-(v), the insurer must 
provide notification of the denial and the right to appeal to the 
insured in writing within 30 days after receipt of the insured's 
request to voluntarily disenroll. The form of the appeal would be 
established by the participating insurer, and may include oral appeals 
rather than (or in addition to) written appeals, but the insured must 
be provided at least 30 days to appeal. The participating insurer would 
be required to issue a final decision in writing on such an appeal 
within 30 days after receiving the appeal. We believe that by requiring 
these timeframes we can ensure compliance with requirements in section 
510(i)(3) of the 2010 Act that VA establish procedures for 
determinations of disenrollment and ensure those determinations are 
timely, while ensuring VA is not actively involved in the determination 
process. Participating insurers would be free to provide additional 
rights to insureds, but at a minimum would be required to comply with 
the procedural framework set forth in proposed paragraph (e)(3).
    In proposed paragraph (f), we would state that ``[p]articipating 
insurers will establish and be responsible for determination and 
appeals procedures for all issues other than voluntary disenrollment.'' 
This would allow participating insurers to establish determination 
procedures consistent with the generally accepted administration of 
private insurance plans or with their current practice. We are not 
required by section 510 of the 2010 Act to regulate determination of 
matters other than voluntary disenrollment, and we believe that 
including proposed paragraph (f) would help clarify the narrow scope of 
VA's obligation.

Effect of Rulemaking

    The Code of Federal Regulations, as proposed to be revised by this 
proposed rulemaking, would represent the exclusive legal authority on 
this subject. No contrary rules or procedures are authorized. All VA 
guidance would be read to conform with this proposed rulemaking if 
possible or, if not possible, such guidance would be superseded by this 
rulemaking.

Paperwork Reduction Act

    This proposed rule includes a collection of information under the 
Paperwork Reduction Act (44 U.S.C. 3501-3521) that requires approval by 
the Office of Management and Budget (OMB). Accordingly, under section 
3507(d) of the 2010 Act, VA has submitted a copy of this rulemaking to 
OMB for review. OMB assigns a control number for each collection of 
information it approves. Except for emergency approvals under 44 U.S.C. 
3507(j), VA may not conduct or sponsor, and a person is not required to 
respond to, a collection of information unless it displays a currently 
valid OMB control number. Proposed Sec.  17.169(d) and (e) contain 
collections of information under the Paperwork Reduction Act (44 U.S.C. 
3501-3521). If OMB does not approve the collections of information as 
requested, VA will immediately remove the provisions containing a 
collection of information or take such other action as is directed by 
OMB.
    Comments on the collections of information contained in this 
proposed rule should be submitted to the Office of Management and 
Budget, Attention: Desk Officer for the Department of Veterans Affairs, 
Office of Information and Regulatory Affairs, Washington, DC

[[Page 12520]]

20503, with copies sent by mail or hand delivery to: the Director, 
Office of Regulation Policy and Management (02REG), Department of 
Veterans Affairs, 810 Vermont Ave. NW., Room 1068, Washington, DC 
20420; fax to (202) 273-9026; or through www.Regulations.gov. Comments 
should indicate that they are submitted in response to ``RIN 2900-AN99, 
VA Dental Insurance Program.''
    OMB is required to make a decision concerning the collections of 
information contained in this proposed rule between 30 and 60 days 
after publication of this document in the Federal Register. Therefore, 
a comment to OMB is best assured of having its full effect if OMB 
receives it within 30 days of publication. This does not affect the 
deadline for the public to comment on the proposed rule.
    VA considers comments by the public on proposed collections of 
information in--
     Evaluating whether the proposed collections of information 
are necessary for the proper performance of the functions of VA, 
including whether the information will have practical utility;
     Evaluating the accuracy of VA's estimate of the burden of 
the proposed collections of information, including the validity of the 
methodology and assumptions used;
     Enhancing the quality, usefulness, and clarity of the 
information to be collected; and
     Minimizing the burden of the collections of information on 
those who are to respond, including through the use of appropriate 
automated, electronic, mechanical, or other technological collection 
techniques or other forms of information technology, e.g., permitting 
electronic submission of responses.
    The proposed amendments to title 38 CFR part 17 contain collections 
of information under the Paperwork Reduction Act for which we are 
requesting approval by OMB. These collections of information are 
described immediately following this paragraph, under their respective 
titles.
    Title: VA Dental Insurance Program.
    Summary of collections of information: The proposed rule at Sec.  
17.169(d) would allow an individual to voluntarily apply for dental 
insurance by submitting an application to a participating insurer; the 
application will be made in accordance with the plan requirements 
provided by the private insurer. The proposed rule at Sec.  
17.169(e)(2) would authorize the submission to the participating 
insurer of evidence to support an attempt to disenroll from the 
program. Paragraph (e) would establish procedures for submission of 
requests for voluntary disenrollment and supporting documentation.
    Description of the need for information and proposed use of 
information: Applications are needed so that individuals can 
voluntarily participate in VADIP. Procedures for voluntary 
disenrollment, as well as appeals of disenrollment decisions, are 
needed to ensure that enrollment remain voluntary, and that 
disenrollment determinations are timely.
    Description of likely respondents: Veterans, certain survivors and 
dependents.
    Estimated number of respondents per year: Applications: 101,000-
201,000. Disenrollment requests: 1,000. Appeals of disenrollment 
decisions: 500.
    Estimated frequency of responses per year: 1.
    Estimated burden per response: Applications: 15 min. Disenrollment 
requests: 30 min. Appeals of disenrollment decisions: 30 min.
    Estimated total annual reporting and recordkeeping burden: 26,000-
51,000 hours.

Regulatory Flexibility Act

    The Secretary hereby certifies that this proposed rule would not 
have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act, 5 
U.S.C. 601-612. This proposed rule would not directly affect any small 
entities. Only dental insurers, certain veterans and their survivors 
and dependents, which are not small entities, could be affected. 
Therefore, pursuant to 5 U.S.C. 605(b), this proposed amendment is 
exempt from the initial and final regulatory flexibility analysis 
requirements of sections 603 and 604.

Executive Orders 12866 and 13563

    Executive Orders 12866 and 13563 direct agencies to assess the 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, and other advantages; distributive impacts; 
and equity). Executive Order 13563 (Improving Regulation and Regulatory 
Review) emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility. 
Executive Order 12866 (Regulatory Planning and Review) classifies a 
regulatory action as a ``significant regulatory action,'' requiring 
review by OMB, unless OMB waives such review, if it is a regulatory 
action that is likely to result in a rule that may: (1) Have an annual 
effect on the economy of $100 million or more or adversely affect in a 
material way the economy, a sector of the economy, productivity, 
competition, jobs, the environment, public health or safety, or State, 
local, or tribal governments or communities; (2) create a serious 
inconsistency or otherwise interfere with an action taken or planned by 
another agency; (3) materially alter the budgetary impact of 
entitlements, grants, user fees, or loan programs or the rights and 
obligations of recipients thereof; or (4) raise novel legal or policy 
issues arising out of legal mandates, the President's priorities, or 
the principles set forth in the Executive Order.
    The economic, interagency, budgetary, legal, and policy 
implications of this proposed rule have been examined and it has been 
determined not to be a significant regulatory action under Executive 
Order 12866.

Unfunded Mandates

    The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 
1532, that agencies prepare an assessment of anticipated costs and 
benefits before issuing any rule that may result in expenditure by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $100 million or more (adjusted annually for 
inflation) in any year. This proposed rule would have no such effect on 
State, local, and tribal governments, or on the private sector.

Catalog of Federal Domestic Assistance Numbers

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.009 Veterans Medical Care 
Benefits and 64.011 Veterans Dental Care.

Signing Authority

    The Secretary of Veterans Affairs, or designee, approved this 
document and authorized the undersigned to sign and submit the document 
to the Office of the Federal Register for publication electronically as 
an official document of the Department of Veterans Affairs. John R. 
Gingrich, Chief of Staff, Department of Veterans Affairs, approved this 
document on February 23, 2012, for publication.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Claims, Dental health, 
Health care, Veterans.


[[Page 12521]]


    Dated: February 24, 2012.
William F. Russo,
Deputy Director, Office of Regulation Policy & Management, Office of 
the General Counsel, Department of Veterans Affairs.
    For the reasons stated in the preamble, VA proposes to amend 38 CFR 
part 17 as follows:

PART 17--MEDICAL

    1. The authority citation for part 17 continues to read as follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections.

    2. Add Sec.  17.169 after Sec.  17.166 to read as follows:


Sec.  17.169  VA Dental Insurance Plan program for veterans and 
survivors and dependents of veterans (VADIP).

    (a) General. (1) The VA Dental Insurance Plan Program (VADIP) 
provides premium-based dental insurance coverage through which 
individuals eligible under paragraph (b) of this section may choose to 
obtain dental insurance from a participating insurer. Enrollment in 
VADIP does not affect the insured's eligibility for outpatient dental 
services and treatment, and related dental appliances, under 38 U.S.C. 
1712.
    (2) The following definitions apply to this section:
    Insured means an individual, identified in paragraph (b) of this 
section, who has enrolled in an insurance plan through VADIP.
    Participating insurer means an insurance company that has 
contracted with VA to offer a premium-based dental insurance plan to 
veterans, survivors, and dependents through VADIP. There may be more 
than one participating insurer.
    (b) Covered veterans and survivors and dependents. A participating 
insurer must offer coverage to the following persons:
    (1) Any veteran who is enrolled under 38 U.S.C. 1705 in accordance 
with 38 CFR 17.36.
    (2) Any survivor or dependent of a veteran who is eligible for 
medical care under 38 U.S.C. 1781 and 38 CFR 17.271.
    (c) Premiums, coverage, and selection of participating insurer. (1) 
Premiums. Premiums and copayments will be paid by the insured in 
accordance with the terms of the insurance plan. Premiums and 
copayments will be determined by VA through the contracting process, 
and will be adjusted on an annual basis. The participating insurer will 
notify all insureds in writing of the amount and effective date of such 
adjustment.
    (2) Benefits. Participating insurers must offer, at a minimum, 
coverage for the following dental care and services:
    (i) Diagnostic services.
    (A) Clinical oral examinations.
    (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) Space maintenance.
    (iii) Restorative services.
    (A) Amalgam restorations.
    (B) Resin-based composite restorations.
    (iv) Endodontic services.
    (A) Pulp capping.
    (B) Pulpotomy and pulpectomy.
    (C) Root canal therapy.
    (D) Apexification and recalcification procedures.
    (E) Apicoectomy and periradicular services.
    (v) Periodontic services.
    (A) Surgical services.
    (B) Periodontal services.
    (vi) Oral surgery.
    (A) Extractions.
    (B) Surgical extractions.
    (C) Alveoloplasty.
    (D) Biopsy.
    (vii) Other services.
    (A) Palliative (emergency) treatment of dental pain.
    (B) Therapeutic drug injection.
    (C) Other drugs and/or medications.
    (D) Treatment of postsurgical complications.
    (E) Crowns.
    (F) Bridges.
    (G) Dentures.
    (3) Selection of participating insurer. VA will use the Federal 
competitive contracting process to select a participating insurer, and 
the insurer will be responsible for the administration of VADIP.
    (d) Enrollment. (1) VA, in connection with the participating 
insurer, will market VADIP through existing VA communication channels 
to notify all eligible persons of their right to voluntarily enroll in 
VADIP. The participating insurer will prescribe all further enrollment 
procedures, and VA will be responsible for confirming that a person is 
eligible under paragraph (b) of this section.
    (2) The initial period of enrollment will be for a period of 12 
calendar months, followed by month-to-month enrollment as long as the 
insured remains eligible for coverage under paragraph (b) of this 
section and chooses to continue enrollment, so long as VA continues to 
authorize VADIP.
    (3) The participating insurer will agree to continue to provide 
coverage to an insured who ceases to be eligible under paragraphs 
(b)(1) through (2) of this section for at least 30 calendar days after 
eligibility ceased. The insured must pay any premiums due during this 
30-day period. This 30-day coverage does not apply to an insured who is 
disenrolled under paragraph (e) of this section.
    (e) Disenrollment. (1) Insureds may be involuntarily disenrolled at 
any time for failure to make premium payments. Insureds must be 
permitted to voluntarily disenroll, and will not be required to 
continue to pay any copayments or premiums, under any of the following 
circumstances:
    (i) For any reason, during the first 30 days that the beneficiary 
is covered by the plan, if no claims for dental services or benefits 
were filed by the insured.
    (ii) If the insured relocates to an area outside the jurisdiction 
of the plan that prevents the use of the benefits under the plan.
    (iii) If the insured is prevented by serious medical condition from 
being able to obtain benefits under the plan.
    (iv) If the insured would suffer severe financial hardship by 
continuing in VADIP.
    (v) For any reason during the month-to-month coverage period, after 
the initial 12-month enrollment period.
    (2) All insured requests for voluntary disenrollment must be 
submitted to the insurer for determination of whether the insured 
qualifies for disenrollment under the criteria in paragraphs (e)(1)(i) 
through (v) of this section. Requests for disenrollment due to a 
serious medical condition or financial hardship must include submission 
of written documentation that verifies the existence of a serious 
medical condition or financial hardship. The written documentation 
submitted to the insurer must show that circumstances leading to a 
serious medical condition or financial hardship originated after the 
effective date coverage began, and will prevent the insured from 
maintaining the insurance benefits.
    (3) If the participating insurer denies a request for voluntary 
disenrollment because the insured does not meet any criterion under 
paragraphs (e)(1)(i) through (v) of this section, the participating 
insurer must issue a written decision and notify the insured of the 
basis for the denial and how to appeal. The participating insurer will 
establish the form of such appeals whether orally, in writing, or both. 
The decision and notification of appellate rights must be issued to the 
insured no later than 30 days after the request for

[[Page 12522]]

voluntary disenrollment is received by the participating insurer. The 
appeal will be decided and that decision issued in writing to the 
insured no later than 30 days after the appeal is received by the 
participating insurer. An insurer's decision of an appeal is final.
    (f) Participating insurers will establish and be responsible for 
determination and appeal procedures for all issues other than voluntary 
disenrollment.

(Authority: Sec. 510, Pub. L. 111-163)

[FR Doc. 2012-4879 Filed 2-29-12; 8:45 am]
BILLING CODE 8320-01-P