TRICARE; Revision of Nonparticipating Providers Reimbursement Rate; Removal of Cost Share for Dental Sealants; TRICARE Dental Program, 11665-11668 [2016-04983]
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Federal Register / Vol. 81, No. 44 / Monday, March 7, 2016 / Rules and Regulations
governments, in the aggregate, or by the
private sector, of $100 million (adjusted
annually for inflation) in any one year.’’
The current threshold after adjustment
for inflation is $144 million, using the
most current (2014) Implicit Price
Deflator for the Gross Domestic Product.
This final rule would not result in any
1-year expenditure that meets or
exceeds this amount.
FDA proposed the removal of § 558.15
on August 8, 2003, because it was
obsolete or redundant. The original
purpose of § 558.15 was to require the
submission of the results of studies on
the long-term administration of thenmarketed antimicrobial drugs in animal
feed on the occurrence of multiple drugresistant bacteria associated with these
animals. FDA determined that this
section was obsolete as FDA had a new
strategy and concept for assessing the
safety of antimicrobial new animal
drugs, including subtherapeutic use of
antimicrobials in animal feed, with
regard to their microbiological effects on
bacteria of human health concern. This
final rule removes the only remaining
animal drug use listed in § 558.15(g),
which is obsolete since approval of its
NADA is now listed elsewhere in part
558.
Only one set of comments to the
proposal was received by FDA. Since
these comments did not question the
benefits as described in the proposed
rule, we retain the benefits for the final
rule. This final rule is expected to
provide greater clarity in the regulations
for new animal drugs for use in animal
feeds by deleting obsolete provisions in
§ 558.15. We do not expect this final
rule to result in any direct human or
animal health benefit. Rather, this final
rule would remove regulations that are
no longer necessary.
We do not expect the final rule that
revokes the remaining portions of
§ 558.15 to have a substantive effect on
any approved new animal drug or to
cause any approved new animal drug to
lose its marketing ability or experience
a loss of sales.
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III. Analysis of Environmental Impact
We have determined under 21 CFR
25.30(h) that this action is of a type that
does not individually or cumulatively
have a significant effect on the human
environment. Therefore, neither an
environmental assessment nor an
environmental impact statement is
required.
IV. Paperwork Reduction Act
This final rule contains no collection
of information. Therefore, clearance by
the Office of Management and Budget
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under the Paperwork Reduction Act of
1995 is not required.
List of Subjects in 21 CFR Part 558
Animal drugs, Animal feeds.
Therefore, under the Federal Food,
Drug, and Cosmetic Act and under
authority delegated to the Commissioner
of Food and Drugs, 21 CFR part 558 is
amended as follows:
PART 558—NEW ANIMAL DRUGS FOR
USE IN ANIMAL FEEDS
1. The authority citation for 21 CFR
part 558 continues to read as follows:
■
Authority: 21 U.S.C. 354, 360b, 360ccc,
360ccc–1, 371.
§ 558.4
[Amended]
2. In paragraph (c) of § 558.4, remove
‘‘and in § 558.15 of this chapter’’.
■
§ 558.15
■
[Removed]
3. Remove § 558.15.
Dated: March 1, 2016.
Leslie Kux,
Associate Commissioner for Policy.
[FR Doc. 2016–04945 Filed 3–4–16; 8:45 am]
BILLING CODE 4164–01–P
DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DOD–2014–HA–0133]
RIN 0720–AB62
TRICARE; Revision of Nonparticipating
Providers Reimbursement Rate;
Removal of Cost Share for Dental
Sealants; TRICARE Dental Program
Office of the Secretary, DoD.
Final rule.
AGENCY:
ACTION:
This final rule revises the
benefit payment provision for
nonparticipating providers to more
closely mirror industry practices by
requiring TDP nonparticipating
providers to be reimbursed (minus the
appropriate cost-share) at the lesser of
billed charges or the network maximum
allowable charge for similar services in
that same locality (region) or state. This
rule also updates the regulatory
provisions regarding dental sealants to
clearly categorize them as a preventive
service and, consequently, eliminate the
current 20 percent cost-share applicable
to sealants to conform with the language
in the regulation to the statute.
DATES:
Effective date: The final rule is
effective April 6, 2016.
SUMMARY:
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11665
Applicability date: The programmatic
improvements in this final rule are
scheduled to take effect as soon as the
Director, Defense Health Agency can
effectively and efficiently implement
through award of a new TRICARE
Dental Program contract. No change will
be negotiated for existing contracts to
implement this rule. Implementation
through the new contract will be
effective with the start of care delivery
under the new contract (currently
anticipated to start February 1, 2017).
FOR FURTHER INFORMATION CONTACT: Col
James Honey, Defense Health Agency,
telephone (703) 681–0039.
SUPPLEMENTARY INFORMATION:
I. Executive Summary
1. Purpose of Regulatory Actions
a. Need for Regulatory Actions
(1) Revision of Nonparticipating
Providers’ Reimbursement Rate
Prior to 2006, TRICARE Dental
Program (TDP) participating and
nonparticipating providers were
reimbursed at the equivalent of not less
than the 50th percentile of prevailing
charges made for similar services in the
same locality (region) or state, or the
provider’s actual charge, whichever is
lower, less any cost-share amount due
for authorized services. This provision
was included in the regulation to
constitute a significant financial
incentive for participation of providers
in the contractor’s network and to
ensure a network of quality providers
through use of a higher reimbursement
rate. Over time, the Department
discovered that this provision placed an
unnecessary burden on contractors with
already established, high quality
provider networks with reimbursement
rates below the 50th percentile that
were of sufficient size to meet the access
requirements of the TDP. Consequently,
the Department of Defense published a
final rule in the Federal Register on
January 11, 2006 (71 FR 1695), revising
the participating provider’s
reimbursement rate for the TDP that has
resulted in significant cost savings to
the TDP enrollees and the Government.
Since over 80 percent of all TDP care
was provided by network dentists, the
need to also change the reimbursement
rate for nonparticipating dentists was
overlooked and not included in the
2006 rule change. However, over the
past eight years this has created an
incentive for some network providers to
leave the TDP network and for other
providers not to become network
providers. As the rule is currently
written, depending on the geographic
location, some non-network providers
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Federal Register / Vol. 81, No. 44 / Monday, March 7, 2016 / Rules and Regulations
are actually reimbursed at a higher
amount than they would have been had
they been a participating provider and
receiving the negotiated network rate.
Specifically, the final rule will require
TDP nonparticipating providers to be
reimbursed (minus the appropriate costshare) at the lesser of (1) billed charges;
(2) the network maximum allowable
charge for similar services in that same
locality (region) or state. This revision
will increase the number of network
providers and provide cost savings to
enrollees and the Government.
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(2) Removal of Cost-Share for Dental
Sealants
Sealants are currently separately
defined in the TDP regulation at 32 CFR
199.13(b)(24), and specifically identified
as a covered non-preventive service
subject to a 20 percent cost-share. The
cost-share for dental sealants was
originally put in place when there was
minimal evidence as to the effectiveness
of dental sealants preventing tooth
decay. The scientific evidence is now
overwhelming that dental sealants are
effective in preventing tooth decay and
the vast majority of commercial dental
insurance plans cover this procedure
with no cost shares. Further, the
American Dental Association’s Council
on Dental Care Programs Code on Dental
Procedures and Nomenclature classifies
dental sealants as a preventive
procedure. Additionally, the
Department currently recognizes
sealants as a preventive service under
the TRICARE Retiree Dental Program
per 32 CFR 199.22(f)(1)(ii)(C). The
regulatory revisions regarding dental
sealants will delete the separate
definition of dental sealants, specifically
include sealants as a category of
preventive service under 32 CFR
199.13(e)(2)(i)(B), delete any possible
inconsistency in the definition of
preventive service in 32 CFR
199.13(b)(20) and (e)(2)(i), and update
the cost-share table in 32 CFR
199.13(e)(3)(i) to delete the specific line
item reference to sealants being subject
to a 20 percent cost-share in order to
conform with the requirement in 10
U.S.C. 1076a(e)(1)(A) that TDP enrollees
pay no charge for preventive services.
b. Legal Authority for the Regulatory
Action
This regulation is finalized under the
authority of 10 U.S.C. 1076a which
authorizes the Secretary of Defense to
establish a voluntary enrollment dental
plan for eligible dependents of members
of the uniformed services who are on
active duty for a period of more than 30
days, members of the Selected Reserve
of the Ready Reserve, members of the
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Individual Ready Reserve, and eligible
dependents of members of the Ready
Reserve of the reserve components who
are not on active duty for more than 30
days.
2. Summary of the Final Rule
In this final rule, the regulatory
language changes nonparticipating
provider (e.g. non-network or out-ofnetwork) reimbursement at 32 CFR
199.13(g)(2)(i) to be on an equivalent
basis with network reimbursement, in
order to serve as an incentive for both
providers to participate in the network
and for beneficiaries to utilize network
providers in order to avoid additional
out-of-pocket costs for balance billing.
The final rule includes several technical
revisions for clarification and
consistency sake in defining beneficiary
liability, nonparticipating provider and
participating provider in the context of
the TDP. The final rule also amends
several provisions within 32 CFR 199.13
to eliminate the separate definition of
sealants, specifically include sealants as
a covered preventive service, and
remove beneficiary cost sharing by
covering sealants at 100 percent of
allowable charge as authorized by law.
3. Summary of the Costs and Benefits
This final rule is not anticipated to
have an annual effect on the economy
of $100 million or more, making it a
substantive, non-significant rule under
the Executive Order and the
Congressional Review Act. The
amendment to transition
nonparticipating provider
reimbursement to be on an equivalent
basis with network reimbursement, will
result in (1) a lower allowed-to-billed
ratio and a decrease in TDP claim
payments, (2) premium decreases for
beneficiaries; (3) a corresponding
increase in enrollment by eligible
beneficiaries as a result of these
premium changes; (4) resultant cost
savings to the government through
reduced premium subsidies; and (5)
increased out-of-pocket costs for
beneficiaries who opt to use a
nonparticipating provider who may
balance bill for the difference in
contractor payment at the current rates
and the new, lower network agreement
rates. While the requirements for sealant
coverage will not change, the removal of
beneficiary cost sharing for sealants will
result in (1) a marginal increase in
sealant utilization, as we anticipate
most beneficiaries requiring sealants are
currently receiving these services since
they remain a relatively inexpensive
procedure and are typically viewed as
beneficial; (2) a minimal premium
increase for beneficiaries; and (3) an
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increase in government costs as a result
of both the direct effect of the waived
cost sharing on current sealant services
and the full cost of the additional
utilization. We estimate that the net
effects of the TDP provisions that would
be implemented by this rule would
result in a net premium decrease for
TDP beneficiaries and corresponding
cost savings to the government over $17
million per year as well as an
anticipated increase in the number of
participating network providers.
II. Background
1 . Statutory and Regulatory
Background
The TRICARE Dental Program (TDP)
allows the Secretary of Defense to offer
comprehensive premium based
indemnity dental insurance coverage to
qualified individuals. The funds used
by the TDP are appropriated funds
furnished by Congress through annual
appropriation acts and funds collected
as premium shares from beneficiaries.
TDP is delivered through a
competitively procured contract
awarded by the Director, Defense Health
Agency, or designee. TDP enrollees are
required to pay all or a portion of the
premium cost depending on their status.
For those eligible for premium sharing,
including active duty dependents and
certain Selected Reserve and Individual
Reserve members, the portion of
premium share to be paid by them is no
more than forty (40) percent of the total
premium. For those entitled to premium
sharing, the Government pays the
remaining sixty (60) percent of the
premium. Additional information
regarding the TDP is available at
www.tricare.mil/tdp.
Because the amendments to 32 CFR
199.13 will result in changes to the TDP
voluntary enrollment dental insurance
plan which is administered through a
competitively procured contract, these
amendments will be incorporated into
the next TDP contract and are scheduled
to take effect with the start of health
care delivery under the next awarded
TDP contract (currently anticipated to
start February 1, 2017).
2. Summary of the Proposed Rule
We proposed several amendments to
the TRICARE Dental Program (TDP)
regulation. Specifically, we proposed
revising the benefit payment provision
for nonparticipating providers to more
closely mirror industry practices by
requiring TDP nonparticipating
providers to be reimbursed (minus the
appropriate cost-share) at the lesser of
(1) billed charges: Or (2) the network
maximum allowable charge for similar
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Federal Register / Vol. 81, No. 44 / Monday, March 7, 2016 / Rules and Regulations
services in that same locality (region) or
state. This rule also proposed updates to
the regulatory provisions regarding
dental sealants to clearly categorize
them as a preventive service and,
consequently, eliminate the current 20
percent cost-share applicable to sealants
to conform the language in the
regulation to the statute.
3. Summary of the Final Rulemaking
The final rule changes the
nonparticipating provider (e.g. nonnetwork or out-of-network)
reimbursement at 32 CFR 199.13(g)(2)(i)
to be on an equivalent basis with
network reimbursement, in order to
serve as an incentive for both providers
to participate in the network and for
beneficiaries to utilize network
providers in order to avoid additional
out-of-pocket costs for balance billing.
The final rule also eliminates the
separate definition of sealants found at
32 CFR 199.13(b)(24) in favor of
including it as a category of preventive
service under 32 CFR 199.13(e)(2)(i)(B).
Also, as a result of clearly classifying
dental sealants as a preventive service,
the final rule eliminates the current 20
percent cost-share to conform with the
requirement in 10 U.S.C. 1076a(e)(1)(A)
that TDP enrollees pay no charge for
preventive services.
III. Summary of and Response to Public
Comments
The proposed rule was published in
the Federal Register (79 FR 78362)
December 30, 2014, for a 60-day
comment period. We received only one
comment on the proposed rule
applauding the proposed change to
remove the 20 percent cost share for
dental sealants. Because the comment
supported the proposed changes, we are
finalizing the proposed rule with no
changes.
IV. Regulatory Procedures
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Executive Order 12866, ‘‘Regulatory
Planning and Review’’ and E.O. 13563,
‘‘Improving Regulation and Regulatory
Review’’
It has been determined that his final
rule is not a significant regulatory
action. This rule does not:
(1) Have an annual effect on the
economy of $100 million or more or
adversely affect in a material way the
economy; a section of the economy;
productivity; completion; jobs; the
environment; public health or safety; or
State, local, or tribunal governments or
communities;
(2) Create a serious inconsistency or
otherwise interfere with an action taken
or planned by another agency;
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(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 Orders.
Unfunded Mandates Reform Act (Sec.
202, Pub. L. 104–4)
It has been determined that this final
rule does not contain a Federal mandate
that may result in the expenditure by
State, local and tribal governments, in
aggregate, or by the private sector, of
$100 million or more in any one year.
Public Law 96–354, ‘‘Regulatory
Flexibility Act’’ (5 U.S.C. 601)
It has been certified that this final rule
is not subject to the Regulatory
Flexibility Act (5 U.S.C. 601) because it
would not, if promulgated, have a
significant economic impact on a
substantial number of small entities. Set
forth in the final rule are minor
revisions to the existing regulation. The
DoD does not anticipate a significant
impact on the Program.
Public Law 96–511, ‘‘Paperwork
Reduction Act’’ (44 U.S.C. Chapter 35)
It has been determined that this final
rule will not impose additional
reporting or recordkeeping requirements
under the Paperwork Act of 1995.
Existing information collections
requirements of the TRICARE and
Medicare programs will be utilized.
Executive Order 13132, Federalism
It has been determined that this final
rule does not have federalism
implications, as set forth in Executive
Order 13132. This rule does not have
substantial direct effects on:
(1) The States;
(2) The relationship between the
National Government and the States; or
The distribution of power and
responsibilities among the various
levels of Government.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care,
Health insurance, Dental sealants,
Military personnel.
Accordingly, 32 CFR part 199 is
amended as follows:
PART 199—[AMENDED]
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 199.13 is amended by:
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11667
a. Revising paragraphs (b)(4), (14),
(17), and (20).
■ b. Removing paragraph (b)(24).
■ c. Revising paragraph (e)(2)(i)
introductory text.
■ d. Adding paragraph (e)(2)(i)(B)(5).
■ e. Removing the entry entitled
‘‘Sealants’’ from the table following
paragraph (e)(3)(i).
■ f. Revising paragraphs (f)(5) and
(g)(2)(i).
The revisions and additions read as
follows:
■
§ 199.13
TRICARE Dental Program.
*
*
*
*
*
(b) * * *
(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.
*
*
*
*
*
(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.
*
*
*
*
*
(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
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Reserve or Individual Ready Reserve
member) or any cost-share for covered
services.
*
*
*
*
*
(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.
*
*
*
*
*
(e) * * *
(2) * * *
(i) Diagnostic and preventive services.
Benefits may be extended for those
dental services described as oral
examination, diagnostic, and preventive
services when performed directly by
dentists and dental hygienists as
authorized under paragraph (f) of this
section. These include the following
categories of service:
*
*
*
*
*
(B) * * *
(5) Sealants.
*
*
*
*
*
(f) * * *
(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.
*
*
*
*
*
(g) * * *
(2) * * *
(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
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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.
*
*
*
*
*
Dated: March 2, 2016.
Morgan E. Park,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2016–04983 Filed 3–4–16; 8:45 am]
BILLING CODE 5001–06–P
DEPARTMENT OF HOMELAND
SECURITY
Coast Guard
33 CFR Part 117
[Docket No. USCG–2016–0150]
Drawbridge Operation Regulation;
Hackensack River, Jersey City, NJ
Coast Guard, DHS.
Notice of deviation from
drawbridge regulation.
AGENCY:
ACTION:
The Coast Guard has issued a
temporary deviation from the operating
schedule that governs the PATH Bridge
across the Hackensack River, mile 3.0, at
Jersey City, New Jersey. This deviation
is necessary to allow the bridge owner
to replace rails and ties at the bridge.
This deviation allows the bridge to
remain closed on Saturdays through
Mondays for twenty-six consecutive
weekends.
SUMMARY:
This deviation is effective from
12:01 a.m. on March 19, 2016 to 12:01
a.m. on September 12, 2016.
ADDRESSES: The docket for this
deviation, [USCG–2016–0150] is
available at https://www.regulations.gov.
Type the docket number in the
‘‘SEARCH’’ box and click ‘‘SEARCH’’.
Click on Open Docket Folder on the line
associated with this deviation.
FOR FURTHER INFORMATION CONTACT: If
you have questions on this temporary
deviation, call or email Joe M. Arca,
Project Officer, First Coast Guard
District, telephone (212) 514–4336,
email joe.m.arca@uscg.mil.
SUPPLEMENTARY INFORMATION: The PATH
railroad bridge across the Hackensack
River, mile 3.0, at Jersey City, New
Jersey, has a vertical clearance in the
closed position of 40 feet at mean high
water and 45 feet at mean low water.
The existing bridge operating
regulations are found at 33 CFR 117.723.
The waterway is transited by seasonal
recreational vessels and commercial
vessels of various sizes.
The bridge owner, Port Authority
Trans-Hudson (PATH), requested a
temporary deviation from the normal
operating schedule to facilitate
replacement of the rails and ties at the
bridge.
Under this temporary deviation, the
PATH railroad bridge may remain in the
closed position for twenty-six
weekends, between 12:01 a.m. on
Saturdays through 12:01 a.m. on
Mondays from March 19, 2016 through
September 12, 2016.
Vessels able to pass under the bridge
in the closed position may do so at
anytime. The bridge will not be able to
open for emergencies and there is no
immediate alternate route for vessels to
pass.
The Coast Guard will inform the users
of the waterways through our Local
Notice and Broadcast to Mariners of the
change in operating schedule for the
bridge so that vessel operations can
arrange their transits to minimize any
impact caused by the temporary
deviation.
In accordance with 33 CFR 117.35(e),
the drawbridge must return to its regular
operating schedule immediately at the
end of the effective period of this
temporary deviation. This deviation
from the operating regulations is
authorized under 33 CFR 117.35.
Dated: March 2, 2016.
C.J. Bisignano,
Supervisory Bridge Management Specialist,
First Coast Guard District.
[FR Doc. 2016–04994 Filed 3–4–16; 8:45 am]
BILLING CODE 9110–04–P
DATES:
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ENVIRONMENTAL PROTECTION
AGENCY
40 CFR Part 52
[EPA–R05–OAR–2015–0592; FRL–9943–15–
Region 5]
Air Plan Approval; Minnesota;
Revision to Visibility Federal
Implementation Plan
Environmental Protection
Agency (EPA).
ACTION: Final rule.
AGENCY:
The Environmental Protection
Agency (EPA) is revising the Minnesota
Federal implementation plan (FIP) for
visibility, to establish emission limits
for Northern States Power Company’s
(NSP’s) Sherburne County Generating
Station (Sherco), pursuant to a
settlement agreement. The settlement
SUMMARY:
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]]>Agencies
[Federal Register Volume 81, Number 44 (Monday, March 7, 2016)]
[Rules and Regulations]
[Pages 11665-11668]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-04983]
=======================================================================
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[DOD-2014-HA-0133]
RIN 0720-AB62
TRICARE; Revision of Nonparticipating Providers Reimbursement
Rate; Removal of Cost Share for Dental Sealants; TRICARE Dental Program
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule revises the benefit payment provision for
nonparticipating providers to more closely mirror industry practices by
requiring TDP nonparticipating providers to be reimbursed (minus the
appropriate cost-share) at the lesser of billed charges or the network
maximum allowable charge for similar services in that same locality
(region) or state. This rule also updates the regulatory provisions
regarding dental sealants to clearly categorize them as a preventive
service and, consequently, eliminate the current 20 percent cost-share
applicable to sealants to conform with the language in the regulation
to the statute.
DATES:
Effective date: The final rule is effective April 6, 2016.
Applicability date: The programmatic improvements in this final
rule are scheduled to take effect as soon as the Director, Defense
Health Agency can effectively and efficiently implement through award
of a new TRICARE Dental Program contract. No change will be negotiated
for existing contracts to implement this rule. Implementation through
the new contract will be effective with the start of care delivery
under the new contract (currently anticipated to start February 1,
2017).
FOR FURTHER INFORMATION CONTACT: Col James Honey, Defense Health
Agency, telephone (703) 681-0039.
SUPPLEMENTARY INFORMATION:
I. Executive Summary
1. Purpose of Regulatory Actions
a. Need for Regulatory Actions
(1) Revision of Nonparticipating Providers' Reimbursement Rate
Prior to 2006, TRICARE Dental Program (TDP) participating and
nonparticipating providers were reimbursed at the equivalent of not
less than the 50th percentile of prevailing charges made for similar
services in the same locality (region) or state, or the provider's
actual charge, whichever is lower, less any cost-share amount due for
authorized services. This provision was included in the regulation to
constitute a significant financial incentive for participation of
providers in the contractor's network and to ensure a network of
quality providers through use of a higher reimbursement rate. Over
time, the Department discovered that this provision placed an
unnecessary burden on contractors with already established, high
quality provider networks with reimbursement rates below the 50th
percentile that were of sufficient size to meet the access requirements
of the TDP. Consequently, the Department of Defense published a final
rule in the Federal Register on January 11, 2006 (71 FR 1695), revising
the participating provider's reimbursement rate for the TDP that has
resulted in significant cost savings to the TDP enrollees and the
Government. Since over 80 percent of all TDP care was provided by
network dentists, the need to also change the reimbursement rate for
nonparticipating dentists was overlooked and not included in the 2006
rule change. However, over the past eight years this has created an
incentive for some network providers to leave the TDP network and for
other providers not to become network providers. As the rule is
currently written, depending on the geographic location, some non-
network providers
[[Page 11666]]
are actually reimbursed at a higher amount than they would have been
had they been a participating provider and receiving the negotiated
network rate. Specifically, the final rule will require TDP
nonparticipating providers to be reimbursed (minus the appropriate
cost-share) at the lesser of (1) billed charges; (2) the network
maximum allowable charge for similar services in that same locality
(region) or state. This revision will increase the number of network
providers and provide cost savings to enrollees and the Government.
(2) Removal of Cost-Share for Dental Sealants
Sealants are currently separately defined in the TDP regulation at
32 CFR 199.13(b)(24), and specifically identified as a covered non-
preventive service subject to a 20 percent cost-share. The cost-share
for dental sealants was originally put in place when there was minimal
evidence as to the effectiveness of dental sealants preventing tooth
decay. The scientific evidence is now overwhelming that dental sealants
are effective in preventing tooth decay and the vast majority of
commercial dental insurance plans cover this procedure with no cost
shares. Further, the American Dental Association's Council on Dental
Care Programs Code on Dental Procedures and Nomenclature classifies
dental sealants as a preventive procedure. Additionally, the Department
currently recognizes sealants as a preventive service under the TRICARE
Retiree Dental Program per 32 CFR 199.22(f)(1)(ii)(C). The regulatory
revisions regarding dental sealants will delete the separate definition
of dental sealants, specifically include sealants as a category of
preventive service under 32 CFR 199.13(e)(2)(i)(B), delete any possible
inconsistency in the definition of preventive service in 32 CFR
199.13(b)(20) and (e)(2)(i), and update the cost-share table in 32 CFR
199.13(e)(3)(i) to delete the specific line item reference to sealants
being subject to a 20 percent cost-share in order to conform with the
requirement in 10 U.S.C. 1076a(e)(1)(A) that TDP enrollees pay no
charge for preventive services.
b. Legal Authority for the Regulatory Action
This regulation is finalized under the authority of 10 U.S.C. 1076a
which authorizes the Secretary of Defense to establish a voluntary
enrollment dental plan for eligible dependents of members of the
uniformed services who are on active duty for a period of more than 30
days, members of the Selected Reserve of the Ready Reserve, members of
the Individual Ready Reserve, and eligible dependents of members of the
Ready Reserve of the reserve components who are not on active duty for
more than 30 days.
2. Summary of the Final Rule
In this final rule, the regulatory language changes
nonparticipating provider (e.g. non-network or out-of-network)
reimbursement at 32 CFR 199.13(g)(2)(i) to be on an equivalent basis
with network reimbursement, in order to serve as an incentive for both
providers to participate in the network and for beneficiaries to
utilize network providers in order to avoid additional out-of-pocket
costs for balance billing. The final rule includes several technical
revisions for clarification and consistency sake in defining
beneficiary liability, nonparticipating provider and participating
provider in the context of the TDP. The final rule also amends several
provisions within 32 CFR 199.13 to eliminate the separate definition of
sealants, specifically include sealants as a covered preventive
service, and remove beneficiary cost sharing by covering sealants at
100 percent of allowable charge as authorized by law.
3. Summary of the Costs and Benefits
This final rule is not anticipated to have an annual effect on the
economy of $100 million or more, making it a substantive, non-
significant rule under the Executive Order and the Congressional Review
Act. The amendment to transition nonparticipating provider
reimbursement to be on an equivalent basis with network reimbursement,
will result in (1) a lower allowed-to-billed ratio and a decrease in
TDP claim payments, (2) premium decreases for beneficiaries; (3) a
corresponding increase in enrollment by eligible beneficiaries as a
result of these premium changes; (4) resultant cost savings to the
government through reduced premium subsidies; and (5) increased out-of-
pocket costs for beneficiaries who opt to use a nonparticipating
provider who may balance bill for the difference in contractor payment
at the current rates and the new, lower network agreement rates. While
the requirements for sealant coverage will not change, the removal of
beneficiary cost sharing for sealants will result in (1) a marginal
increase in sealant utilization, as we anticipate most beneficiaries
requiring sealants are currently receiving these services since they
remain a relatively inexpensive procedure and are typically viewed as
beneficial; (2) a minimal premium increase for beneficiaries; and (3)
an increase in government costs as a result of both the direct effect
of the waived cost sharing on current sealant services and the full
cost of the additional utilization. We estimate that the net effects of
the TDP provisions that would be implemented by this rule would result
in a net premium decrease for TDP beneficiaries and corresponding cost
savings to the government over $17 million per year as well as an
anticipated increase in the number of participating network providers.
II. Background
1 . Statutory and Regulatory Background
The TRICARE Dental Program (TDP) allows the Secretary of Defense to
offer comprehensive premium based indemnity dental insurance coverage
to qualified individuals. The funds used by the TDP are appropriated
funds furnished by Congress through annual appropriation acts and funds
collected as premium shares from beneficiaries. TDP is delivered
through a competitively procured contract awarded by the Director,
Defense Health Agency, or designee. TDP enrollees are required to pay
all or a portion of the premium cost depending on their status. For
those eligible for premium sharing, including active duty dependents
and certain Selected Reserve and Individual Reserve members, the
portion of premium share to be paid by them is no more than forty (40)
percent of the total premium. For those entitled to premium sharing,
the Government pays the remaining sixty (60) percent of the premium.
Additional information regarding the TDP is available at
www.tricare.mil/tdp.
Because the amendments to 32 CFR 199.13 will result in changes to
the TDP voluntary enrollment dental insurance plan which is
administered through a competitively procured contract, these
amendments will be incorporated into the next TDP contract and are
scheduled to take effect with the start of health care delivery under
the next awarded TDP contract (currently anticipated to start February
1, 2017).
2. Summary of the Proposed Rule
We proposed several amendments to the TRICARE Dental Program (TDP)
regulation. Specifically, we proposed revising the benefit payment
provision for nonparticipating providers to more closely mirror
industry practices by requiring TDP nonparticipating providers to be
reimbursed (minus the appropriate cost-share) at the lesser of (1)
billed charges: Or (2) the network maximum allowable charge for similar
[[Page 11667]]
services in that same locality (region) or state. This rule also
proposed updates to the regulatory provisions regarding dental sealants
to clearly categorize them as a preventive service and, consequently,
eliminate the current 20 percent cost-share applicable to sealants to
conform the language in the regulation to the statute.
3. Summary of the Final Rulemaking
The final rule changes the nonparticipating provider (e.g. non-
network or out-of-network) reimbursement at 32 CFR 199.13(g)(2)(i) to
be on an equivalent basis with network reimbursement, in order to serve
as an incentive for both providers to participate in the network and
for beneficiaries to utilize network providers in order to avoid
additional out-of-pocket costs for balance billing. The final rule also
eliminates the separate definition of sealants found at 32 CFR
199.13(b)(24) in favor of including it as a category of preventive
service under 32 CFR 199.13(e)(2)(i)(B). Also, as a result of clearly
classifying dental sealants as a preventive service, the final rule
eliminates the current 20 percent cost-share to conform with the
requirement in 10 U.S.C. 1076a(e)(1)(A) that TDP enrollees pay no
charge for preventive services.
III. Summary of and Response to Public Comments
The proposed rule was published in the Federal Register (79 FR
78362) December 30, 2014, for a 60-day comment period. We received only
one comment on the proposed rule applauding the proposed change to
remove the 20 percent cost share for dental sealants. Because the
comment supported the proposed changes, we are finalizing the proposed
rule with no changes.
IV. Regulatory Procedures
Executive Order 12866, ``Regulatory Planning and Review'' and E.O.
13563, ``Improving Regulation and Regulatory Review''
It has been determined that his final rule is not a significant
regulatory action. This rule does not:
(1) Have an annual effect on the economy of $100 million or more or
adversely affect in a material way the economy; a section of the
economy; productivity; completion; jobs; the environment; public health
or safety; or State, local, or tribunal 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 Orders.
Unfunded Mandates Reform Act (Sec. 202, Pub. L. 104-4)
It has been determined that this final rule does not contain a
Federal mandate that may result in the expenditure by State, local and
tribal governments, in aggregate, or by the private sector, of $100
million or more in any one year.
Public Law 96-354, ``Regulatory Flexibility Act'' (5 U.S.C. 601)
It has been certified that this final rule is not subject to the
Regulatory Flexibility Act (5 U.S.C. 601) because it would not, if
promulgated, have a significant economic impact on a substantial number
of small entities. Set forth in the final rule are minor revisions to
the existing regulation. The DoD does not anticipate a significant
impact on the Program.
Public Law 96-511, ``Paperwork Reduction Act'' (44 U.S.C. Chapter 35)
It has been determined that this final rule will not impose
additional reporting or recordkeeping requirements under the Paperwork
Act of 1995. Existing information collections requirements of the
TRICARE and Medicare programs will be utilized.
Executive Order 13132, Federalism
It has been determined that this final rule does not have
federalism implications, as set forth in Executive Order 13132. This
rule does not have substantial direct effects on:
(1) The States;
(2) The relationship between the National Government and the
States; or
The distribution of power and responsibilities among the various
levels of Government.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care, Health insurance, Dental
sealants, Military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
PART 199--[AMENDED]
0
1. The authority citation for part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
0
2. Section 199.13 is amended by:
0
a. Revising paragraphs (b)(4), (14), (17), and (20).
0
b. Removing paragraph (b)(24).
0
c. Revising paragraph (e)(2)(i) introductory text.
0
d. Adding paragraph (e)(2)(i)(B)(5).
0
e. Removing the entry entitled ``Sealants'' from the table following
paragraph (e)(3)(i).
0
f. Revising paragraphs (f)(5) and (g)(2)(i).
The revisions and additions read as follows:
Sec. 199.13 TRICARE Dental Program.
* * * * *
(b) * * *
(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.
* * * * *
(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.
* * * * *
(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
[[Page 11668]]
Reserve or Individual Ready Reserve member) or any cost-share for
covered services.
* * * * *
(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.
* * * * *
(e) * * *
(2) * * *
(i) Diagnostic and preventive services. Benefits may be extended
for those dental services described as oral examination, diagnostic,
and preventive services when performed directly by dentists and dental
hygienists as authorized under paragraph (f) of this section. These
include the following categories of service:
* * * * *
(B) * * *
(5) Sealants.
* * * * *
(f) * * *
(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.
* * * * *
(g) * * *
(2) * * *
(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.
* * * * *
Dated: March 2, 2016.
Morgan E. Park,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2016-04983 Filed 3-4-16; 8:45 am]
BILLING CODE 5001-06-P
