TRICARE; Revision of Participating Providers Reimbursement Rate; TRICARE Dental Program (TDP)

AGENCY:

Department of Defense.

ACTION:

Final rule.

SUMMARY:

The Department is publishing this final rule to revise the requirements and procedures for the reimbursement of TRICARE Dental program participating providers. Participating providers will no longer be reimbursed at the equivalent of a percentile of prevailing charges sufficiently above 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. Specifically, the revision will require TRICARE Dental Program participating providers to be reimbursed in accordance with the contractor's network agreements, less any cost-share amount due for authorized services.

EFFECTIVE DATE:

January 11, 2006.

FOR FURTHER INFORMATION CONTACT:

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

SUPPLEMENTARY INFORMATION:

I. Overview of the Rule

This final rule revises the provision found in 32 CFR 199.13 that requires the TRICARE Dental Program contractor to reimburse participating providers at the equivalent of a percentile of prevailing charges sufficiently above 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. This provision, however, places an unnecessary restriction on contractors that already have established, high quality provider networks with reimbursement rates below the 50th percentile that are of sufficient size to meet the access requirements of the TRICARE Dental Program. The reimbursement rates that have been negotiated over the life of the dental contract represent the general market rates for dental insurance reimbursement, and the final rule brings DoD reimbursement rates into line with the broader insurance market. Elimination of the 50th percentile requirement affords the Government and enrollees significant cost savings through lower provider reimbursement costs by the contractor. Additionally, contractors have other methods available to ensure the TDP members receive high quality dental services. These quality assurance methods include, but are not limited to, licensing and credentialing standards, patient satisfaction assessments, and provider trend analyses.

II. Review of Comments

The proposed rule was published in the Federal Register on August 31, 2005 (70 FR 51692). We received no public comments.

III. Regulatory Procedures

Executive Order 12866 directs agencies to assess 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, and other advantages; distributive impacts; and equity). Executive Order 12866 classifies a rule as significant if it meets any one of a number of specified conditions, including: Having an annual effect on the economy $100 million or more, adversely affecting a sector of the economy in a material way, adversely affecting competition, or adversely affecting jobs. A regulation is also considered a significant action if it raises novel legal or policy issues.

DoD concludes that this final rule is a significant regulatory action under the Executive Order since it raises novel policy issues under section 3(f)(4). DoD concludes, however, that this final rule does not meet the significance threshold of $100 million effect on the economy in any one year under section 3(f)(1).

The Congressional Review Act establishes certain procedures for major rules, defined as those with similar major impacts. The Regulatory Flexibility Act (RFA) requires that each Federal agency prepare, and make available for public comment, a regulatory flexibility analysis when the agency issues a regulation that would have significant impact on a substantial number of small entities.

This is a not a major rule under 5 U.S.C. 801. It is a significant regulatory action but not economically significant. This rule has been designated as significant and has been reviewed by the Office of Management and Budget as required under the provisions of E.O. 12866.

Paperwork Reduction Act

This final rule contains a new information collection requirement that has been submitted to and approved by the Office of Management and Budget. This information collection has been assigned OMB Control #0720-0035.

List of Subjects in 32 CFR Part 199

• Claims
• Dental health
• Health care
• Health insurance
• Individuals with disabilities
• Military personnel

For the reasons set out in the preamble, 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(g)(2)(ii) is revised to read as follows: