who lost their entitlement to regular military health services system benefits on or after October 1, 1994.

(3) Notification of eligibility. (i) The Department of Defense and the other Uniformed Services (National Oceanic and Atmospheric Administration

(NOAA), Public Health Service (PHS), Coast Guard) will notify persons eligible to receive health benefits under the CHCBP.

(ii) In the case of a member who becomes (or will become) eligible for continued coverage, the Department of Defense shall notify the member of their rights for coverage as part of pre-separation counseling conducted under 10 U.S.C. 1142.

(iii) In the case of a child of a member or former member who becomes eligible for continued coverage:

(A) The member or former member may submit to the Third Party Administrator a notice of the child's change in status (including the child's name, address, and such other information needed); and

(B) The Third Party Administrator, within 14 days after receiving such information, will inform the child of the child's rights under 10 U.S.C. 1142.

(iv) In the case of a former spouse of a member or former member who becomes eligible for continued coverage, the Third Party Administrator will notify the individual of eligibility for CHCBP when he or she declares the change in marital status to a military personnel office.

(4) Election of coverage. (i) In order to obtain continued coverage, written election by eligible beneficiary must be made, within a prescribed time period. In the case of a member discharged or released from active duty (or full time National Guard duty), whether voluntarily or involuntarily; an unremarried spouse of a member or former member; or a child emancipated from a member or former member, the written election shall be submitted to the Third Party Administrator before the end of the 60day period beginning on the later of:

(A) The date of the discharge or release of the member from active duty or full-time National Guard duty;

(B) The date on which the period of transitional health care applicable to

the member under 10 U.S.C. 1145(a) ends;

(C) In the case of an unremarried former spouse of a member or former member, the date the one-year extension of dependency under 10 U.S.C. 1072(2)(H) expires; or

(D) The date the member receives the notification of eligibility.

(ii) A member of the armed forces who is eligible for enrollment under paragraph (d)(1)(i) of this section may elect self-only or family coverage. Family members who may be included in such family coverage are the spouse and children of the member.

(5) Enrollment. Enrollment in the Continued Health Care Benefit Program will be accomplished by submission of an application to a Third Party Administrator (TPA). Upon submittal of an application to the Third Party Administrator, the enrollee must submit proof of eligibility. One of the following types of evidence will validate eligibility for care:

(i) A Defense Enrollment Eligibility Reporting System (DEERS) printout which indicates the appropriate sponsor status and the sponsor's and dependent's eligibility dates;

(ii) A copy of a verified and approved DD Form 1172, "Application for Uniformed Services Identification and Privilege Card";

(iii) A front and back copy of a DD Form 1173, "Uniformed Services Identification and Privilege Card" overstamped "TA" for Transition Assistance Management Program; or

(iv) A copy of a DD Form 214--"Certificate of Release or Discharge from Active Duty".

(6) Period of coverage. CHCBP coverage may not extend beyond:

(i) For a member discharged or released from active duty (or full time National Guard duty), whether voluntarily or involuntarily, the date which is 18 months after the date the member ceases to be entitled to care under 10 U.S.C. 1074(a) and any transitional care under 10 U.S.C. 1145.

(ii) In the case of an unmarried dependent child of a member or former member, the date which is 36 months after the date on which the person first ceases to meet the requirements for

190-117 D-00--11

being considered an unmarried dependent child under 10 U.S.C. 1072(2)(D).

(iii) In the case of an unremarried former spouse of a member or former member, the date which is 36 months after the later of:

(A) The date on which the final decree of divorce, dissolution, or annulment occurs; or

(B) If applicable, the date the oneyear extension of dependency under 10 U.S.C. 1072(2)(H) expires.

(iv) In the case of an unremarried former spouse of a member or former member, whose divorce occurred prior to the end of transitional coverage, the period of coverage under the CHCBP is unlimited, if:

(A) Has not remarried before the age of 55; and

(B) Was enrolled in the CHCBP as the dependent of an involuntarily separated member during the 18-month period before the date of the divorce, dissolution, or annulment; and

(C) Is receiving a portion of the retired or retainer pay of a member or former member or an annuity based on the retainer pay of the member; or

(D) Has a court order for payment of any portion of the retired or retainer pay; or

(E) Has a written agreement (whether voluntary or pursuant to a court order) which provides for an election by the member or former member to provide an annuity to the former spouse.

(v) For the beneficiary who becomes eligible for the Continued Health Care Benefit Program by ceasing to meet the requirements for being considered an unmarried dependent child of a member or former member, health care coverage may not extend beyond the date which is 36 months after the date the member becomes ineligible for medical and dental care under 10 U.S.C. 1074(a) and any transitional health care under 10 U.S.C. 1145(a).

(vi) Though beneficiaries have sixtydays (60) to elect coverage under the CHCBP, upon enrolling, the period of coverage must begin the day after entitlement to a military health care plan (including transitional health care under 10 U.S.C. 1145(a)) ends.

(e) CHCBP benefits-(1) In general. Except as provided in paragraph (e)(2) of

this section, the provisions of §199.4 shall apply to the CHCBP as they do to CHAMPUS.

(2) Exceptions. The following provisions of § 199.4 are not applicable to the CHCBP:

(i) Paragraph (a)(2) of this section concerning eligibility:

(ii) All provisions regarding nonavailability statements or requirements to use facilities of the Uniformed Services.

(3) Beneficiary liability. For purposes of CHAMPUS deductible and cost sharing requirements and catastrophic cap limits, amounts applicable to the categories of beneficiaries to which the CHCBP enrollee last belonged shall continue to apply, except that for separating active duty members, amounts applicable to dependents of active duty members shall apply.

(f) Authorized providers. The provisions of §199.6 shall apply to the CHCBP as they do to CHAMPUS.

(g) Claims submission, review, and payment. The provisions of §199.7 shall apply to the CHCBP as they do to CHAMPUS, except that no provisions regarding nonavailability statements shall apply.

(h) Double coverage. The provisions of §199.8 shall apply to the CHCBP as they do to CHAMPUS.

(i) Fraud, abuse, and conflict of interest. Administrative remedies for fraud, abuse and conflict of interest. The provisions of $199.9 shall apply to the CHCBP as they do to CHAMPUS.

(j) Appeal and hearing procedures. The provisions of § 199.10 shall apply to the CHCBP as they do to CHAMPUS.

(k) Overpayment recovery. The provisions of $199.11 shall apply to the CHCBP as they do to CHAMPUS.

(1) Third Party recoveries. The provisions of $199.12 shall apply to the CHCBP as they do to CHAMPUS.

(m) Provider reimbursement methods. The provisions of §199.14 shall apply to the CHCBP as they do to CHAMPUS.

(n) Peer Review Organization Program. The provisions of § 199.15 shall apply to the CHCBP as they do to CHAMPUS.

(0) Preferred provider organization programs available. Any preferred provider organization program under this part that provides for reduced cost sharing for using designated providers, such as

the "TRICARE Extra" option under §199.17, shall be available to participants in the CHCBP as it is to CHAMPUS beneficiaries.

(p) Special programs not applicable—(1) In general. Special programs established under this part that are not part of the basic CHAMPUS program established pursuant to 10 U.S.C. 1079 and 1086 are not, unless specifically provided in this section, available to participants in the CHCBP.

(2) Examples. The special programs referred to in paragraph (p)(1) of this section include:

(i) The Program for Persons with Disabilities under § 199.5;

(ii) The Active Duty Dependents Dental Plan under § 199.13;

(iii) The Supplemental Health Care Program under § 199.16; and

(iv) The TRICARE Enrollment Program under § 199.17, except for TRICARE Extra program under that section.

(3) Exemptions to the restriction. In addition to the provision to make TRICARE Extra available to CHCBP beneficiaries, the following two demonstration projects are also available to CHCBP enrollees:

(i) Home Health Care Demonstration; and

(ii) Home Health Care-Case Management Demonstration.

Premium

(2) Effects of failure to make premium payments. Failure by enrollees to submit timely and proper premium payments will result in denial of continued enrollment and denial of payment of medical claims. Premium payments which are late 30 days or more past the start of the quarter for which payment is due will result in the ending of beneficiary enrollment. Beneficiaries denied continued enrollment due to lack of premium payments will not be allowed to reenroll. In such a case, benefit coverage will cease at the end of the ninety day (90) period for which a premium payment was received. Enrollees will be held liable for medical costs incurred after losing eligibility.

(r) Transitional provisions. (1) There will be a sixty-day period of enrollment for all eligible beneficiaries (outlined in paragraph (d)(1) of this section) whose entitlement to regular military health services system coverage ended on or after August 2, 1994, but prior to the CHCBP implementation on October 1, 1994.

(2) Enrollment in the U.S. VIP program may continue up to October 1, 1994. Policies written prior to October 1, 1994, will remain in effect until the end of the policy life.

(3) On or after the October 1, 1994, implementation of the Continued Health Care Benefit Program, beneficiaries who enrolled in the U.S. VIP program prior to October 1, 1994, may elect to cancel their U.S. VIP policy and enroll in the CHCBP.

(4) With the exception of persons enrolled in the U.S. VIP program who may convert to the CHCBP, individuals who lost their entitlement to regular military health services system coverage prior to August 2, 1994, are not eligible for the CHCBP.

(8) Procedures. The Director, OCHAMPUS, may establish other rules and procedures for the administration of the Continued Health Care Benefit Program.

[59 FR 49818, Sept. 30, 1994, as amended at 62 FR 35097, June 30, 1997; 64 FR 46141, Aug. 24,

§199.21 TRICARE Selected Reserve Dental Program (TSRDP).

(a) Purpose. The TSRDP is a premium based indemnity dental insurance coverage program that will be available to members of the Selected Reserve of the Ready Reserve. Dental coverage will be available only to members of the Selected Reserve, no family coverage will be offered. The TSRDP is authorized by 10 U.S.C. 1076b.

(b) General provisions. (1) Benefits are limited to diagnostic services, preventive services, basic restorative services, and emergency oral examinations.

(2) Premium costs for this coverage will be shared by the enrollee and the government.

(3) The program is applicable to authorized providers in the 50 United States and the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands.

(4) Except as otherwise provided in this section or by the Assistant Secretary of Defense (Health Affairs) or designee, the TSRDP is administered in a manner similar to the Active Duty Dependents Dental Plan under §199.13 of this part.

(5) The TSRDP shall be administered through a contract.

(c) Definitions. Except as may be specifically provided in this section, to the extent terms defined in §§ 199.2 and 199.13(b) of this part are relevant to the administration of the TRICARE Selected Reserve Dental Program, the definitions contained in §§199.2 and 199.13(b) of this part shall apply to the TSRDP as they do to CHAMPUS and the Active Duty Dependents Dental Plan.

(d) Eligibility and enrollment.(1) Eligibility. Enrollment in the TRICARE Selected Reserve Dental Program is open to members of the Selected Reserve of the Ready Reserve.

(2) Notification of eligibility. The contractor will notify persons eligible to receive dental benefits under the TRICARE Selected Reserve Dental Program.

(3) Election of coverage. Following this notification, interested Reservists may elect to enroll. In order to obtain dental coverage, written election by eligible beneficiary must be made.

32 CFR Ch. 1 (7-1-00 Edition)

(4) Enrollment. Enrollment in the TRICARE Selected Reserve Dental Program is voluntary and will be accomplished by submission of an application to the TSRDP contractor. Initial enrollment shall be for a period of 12 months followed by month-to-month enrollment as long as the enrollee chooses to continue enrollment.

(5) Period of coverage. TRICARE Selected Reserve Dental Program coverage is terminated on the last day of the month in which the member is discharged, transferred to the Individual Ready Reserve, Standby Reserve, or Retired Reserve, or ordered to active duty for a period of more than 30 days.

(e) Premium sharing. The Government and the enrollee will share in the monthly premium cost.

(f) Premium payments. The enrollee will be responsible for a monthly premium payment in order to obtain the dental insurance.

(1) Premium payment method. The premium payment may be collected pursuant to procedures established by the Assistant Secretary of Defense (Health Affairs).

(2) Effects of failure to make premium payments. Failure to make monthly renewal premium payments will result in the enrollee being disenrolled from the TSRDP and subject to a lock-out period of 12 months. Following this period of time, eligible Reservists will be able to reenroll if they so choose.

(3) Member's share of premiums. The cost of the TSRDP monthly premium will be shared between the Government and the enrollee. Interested eligible Reservists may contact the dental contactor to obtain the enrollee premium cost. The member's share may not exceed $25 per month.

(g) Plan benefits. (1) The TSRDP will provide basic dental coverage, to include diagnostic services, preventive services, basic restorative services, and emergency oral examinations. The following is the TSRDP covered dental benefit (using the American Dental Association, The Council on Dental Care Program's Code On Dental Procedures and Nomenclature):

(i) Diagnostic: Comprehensive oral evaluation (00150), and Periodic oral evaluation (00120), Intraoral-complete series (including bitewings) (00210);

Intraoral-periapical-first film (00220); Intraoral-periapical-each additional

film (00230); Bitewings-single film (00272); Bitewings-two films (00272); Bitewings-four films (00274); Panoramic film (00330); Pulp Vitality Tests (00460). (ii) Preventive: Prophylaxis-adult (limit-two per year) (01110); Tropical application of fluoride (excluding prophylaxis)-adult (01204).

(iii) Restorative: Amalgam-one surface, permanent (02140); Amalgam-two surfaces, permanent (02150); Amalgamthree surfaces; permanent (02160); Amalgam-four or more surfaces, permanent (02161); Resin-one surface, anterior (02330); Resin-two surfaces, anterior (02331); Resin-three surfaces, anterior (02332); Resin-four or more surfaces or involving incisal angle (anterior) (02335); Pin retention-per tooth, in addition to restoration (02951).

(iv) Oral Surgery: Single tooth (07110); Each additional tooth (07120); Root removal-exposed roots (07130); Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth (07210); Surgical removal of residual tooth roots (cutting procedure) (07250).

(v) Emergency: Limited oral evaluation-problem focused (00140); Palliative (emergency) treatment of dental pain-minor procedures (09110). (2) Codes listed in paragraph (g)(1) of this section may be modified by the Director, OCHAMPUS, to the extent determined appropriate based on developments in common dental care practices and standard dental insurance programs.

(h) Maximum annual cap. TSRDP enrollees will be subject to a maximum $1,000.00 of paid allowable charges per year.

(i) Annual notification of rates. TSRDP premiums will be determined as part of the competitive contracting process. Information on the premium rates will be widely distributed.

(j) Authorized providers. The TSRDP enrollee may seek covered services from any provider who is fully licensed and approved to provide dental care in the state where the provider is located.

(k) Benefit payment. Enrollees are not required to utilize the special network of dental providers established by the TSRDP contractor. For enrollees who

do use this network, however, providers shall not balance bill any amount in excess of the maximum payment allowable by the TSRDP. Enrollees using non-network providers may be balance billed amounts in excess of allowable charges. The maximum payment allowable by the TSRDP (minus the appropriate cost-share) will be the lesser of:

(1) Billed charges; or

(2) Usual, Customary and Reasonable rates, in which the customary rate is calculated at the 85th percentile of billed charges in that geographic area, as measured in an undiscounted charge profile in 1995 or later for that geographic area (as defined by three-digit zip code).

(1) Appeal and hearing procedures. All levels of appeals and grievances established by the Contractor for internal review shall be exhausted prior to forwarding to OCHAMPUS for a final review. Procedures comparable to those established under § 199.13(h) of this part shall apply.

(m) Preemption of State laws. (1) Pursuant to 10 U.S.C. 1103, the Department of Defense has determined that in the administration of chapter 55 of title 10, U.S. Code, preemption of State and local laws relating to health insurance, prepaid health plans, or other health care delivery or financing methods is necessary to achieve important Federal interests, including but not limited to the assurance of uniform national health programs for military families and the operation of such programs at the lowest possible cost to the Department of Defense, that have a direct and substantial effect on the conduct of military affairs and national security policy of the United States. This determination is applicable to the dental services contracts that implement this section.

(2) Based on the determination set forth in paragraph (m)(1) of this section, any State or local law or regulation pertaining to health or dental insurance, prepaid health or dental plans, or other health or dental care delivery, administration, and financing methods is preempted and does not apply in connection with the TRICARE Selected Reserve Dental Program contract. Any such law, or regulation pursuant to