Flashcards in TRICARE DENTAL (01-30-2012) TRICARE DENTAL PROGRAM BENEFIT BOOKLET Deck (29)
The TRICARE Dental Program (TDP) has two geographical service areas: inside the Continental United States (CONUS) and outside of the Continental United States (OCONUS).
The TDP CONUS service area includes the 50 United States, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands.
The OCONUS service area is further categorized into non-remote and remote locations.
Non-remote countries include:
Remote OCONUS locations are those OCONUS countries in which the uniformed services do not have a fixed ODTF,
To be eligible for the TDP, the sponsor must have at least 12 months remaining on his or her service commitment with the service branch at the time of enrollment
When the Defense Enrollment Eligibility Reporting System (DEERS) indicates less than 12 months remaining, United Concordia will validate the intent of the sponsor to continue their service commitment. service commitment will be based on the time remaining in any single status or in any uninterrupted combination of active duty, National Guard
Individuals eligible to enroll in the TDP include the following: spouses and unmarried children (including stepchildren, adopted children, and wards) under the age of 21. Family members will be eligible up to the end of the month in which they turn 21.
Family members may be eligible after age 21 if:
They are full-time students enrolled at an accredited college or university and they are more than 50-percent dependent on the sponsor for financial support
If the student terminates his or her education prior to turning 23, eligibility ends at the end of the month in which education terminates.
These students are eligible to the end of the month in which they turn age 23
National Guard and Reserve service members: Members of the National Guard and Reserve may enroll in the TDP when they are not on active duty orders for a period of more than 30 consecutive days
National Guard or Reserve member who is called or ordered to active duty for a period of more than 30 consecutive days receives the same entitlements as an active duty service member and cannot be enrolled in the TDP
The family member does not have to be command-sponsored, listed on the sponsor’s change of assignment orders, or formally recognized as a family member on an accompanied tour to receive dental care in the OCONUS service area.
The following individuals are not eligible to enroll in the TDP:
Active duty service members, including National Guard and Reserve members called or ordered to active duty for more than 30 consecutive days
Retired service members and their families
Parents and parents-in-law
Foreign military personnel
Dentists’ recommendations are for all children to have their first dental examination by age 1.
Any enrollee who fails to pay premiums will be prohibited from re-enrolling in the program for 12 months.
All enrollees must remain enrolled in the TDP for at least 12 months, unless the disenrollment request
After completing the 12-month minimum enrollment period, enrollment may be continued on a month-to-month basis until a cancellation request is received
Any enrollee who fails to pay premiums will be prohibited from re-enrolling in the program for 12 months
***If the TDP Enrollment/Change Form and the initial payment are received by the 20th of the month, coverage will be processed for the first day of the following month.
If the TDP Enrollment/Change Form and initial premium payment are received after the 20th of the month, coverage will be processed for the first day of the second month.
If you fail to pay your monthly premium(s), you will be disenrolled from the TDP, but you will still be responsible for payment of all remaining premiums (including the Government’s 60-percent share) through the end of your 12-month initial enrollment period.
You will be prohibited from re-enrolling in the program, or “locked out,” for 12 months following the last month that premiums were paid.
When a military sponsor dies while on active duty for a period of more than 30 consecutive days, surviving family members enrolled in the TDP will continue to receive TDP benefits for three years from the month following the sponsor’s death.
The survivor benefit expires three years from the month following the sponsor’s death, regardless of survivor benefit enrollment coverage begin date.
Effective December 1, 2006, if a surviving spouse was an active duty member at the time of the military sponsor’s death, but subsequently separates or is discharged from active duty following the death of their military sponsor, the surviving spouse is also eligible for the survivor benefit.
Enrollment in the survivor benefit coverage is not automatic for:
Eligible surviving family members not enrolled at the time of the sponsor’s death due to being under the age of 4
Active duty spouses
Eligible surviving family members who relocated to a duty station where space-available dental care was readily available
The Government pays 100 percent of the TDP Survivor Benefit premium for three years from the month following the sponsor’s death; however, family members are still responsible for any applicable cost-shares.
Your dental coverage is completely portable— meaning it moves with you. Whether traveling on vacation or business, or when you move to a new duty location, the TDP has you and your family covered.
Enrolled members who relocate to locations within the OCONUS service area may elect, within 90 calendar days of the relocation, to disenroll from the TDP.
TDP Enrollee Premium Shares: Active Duty Family Members 60% Government 40% Enrollee
There is a $1,200 annual maximum benefit per enrollee per contract year for non-orthodontic services. Each contract year begins February 1 and ends January 31 of the following year.
There is a $1,500 lifetime maximum benefit per enrollee for orthodontic treatment. If an enrollee receives orthodontic services, payments for these services will not exceed $1,500 during the enrollee’s eligibility lifetime.
Dentists are required to collect cost-shares for certain covered services.
Failure to collect cost-shares for covered services could disqualify the dentist from participating in United Concordia’s dentist network.
TDP access standards guarantee that a participating general dentist will be located within 35 driving miles of your home and that you will be able to arrange an appointment within 21 days of your call to the dental office.
If you are unable to obtain an appointment with a general dentist within 21 days of your call and within 35 driving miles of your home, please notify United Concordia’s Customer Service Department at 1-800-866-8499
Dentists who have not signed a contract with United Concordia are considered nonparticipating dentists. Nonparticipating dentists may bill members their full fee.
For TDP enrollees in OCONUS locations, access standards for the location of a dentist within 35 driving miles of their home and the 21-day limit for obtaining an appointment are not applicable.
OCONUS command-sponsored TDP enrollees in non-remote areas must utilize an HNP if available within 50 driving miles (81 kilometers) of their residence for all dental care not provided by the ODTF
All claim forms should be submitted to United Concordia as soon as possible after the date of service, preferably within 60 days. Claims submitted more than 12 months after the month in which the service was provided will be denied.
All payments issued to a dentist from the OCONUS service area will be paid in foreign currency,One exception is Turkey, where claims will be paid in U.S. dollars.
Panoramic and full mouth X-rays are not routinely covered for patients under age 5 unless approved by a United Concordia Dentist Advisor. Patient-specific rationale (specific signs or symptoms) must be submitted for review. I
One full mouth X-ray (complete series or panoramic X-ray) is covered in a 36-month period.
Cephalometric films are covered for patients under age 23.
Adult prophylaxes will be allowed on patients 13 years of age and older.
Sealants are only covered on permanent molars through age 18.
Two topical fluoride applications are covered in a consecutive 12-month period.
Orthodontic treatment is available for family members (non-spouse) up to, but not including, 21 years of age
Orthodontic progress payments are based on the length of treatment planned by the dentist up to the $1,500 lifetime maximum.
If you’re not completely satisfied with your treatment or have a complaint, United Concordia has processes in place for you to file an appeal or grievance.
Parties to the initial determination can request an appeal, including:
The patient who received dental services
Sponsors, parents, or guardians of members who are under 18 years of age
The following cannot request an appeal:
Dentists who are disqualified or excluded from being authorized dentists
Nonparticipating dentist (unless appointed in writing by an appealable party to act on their behalf),
The following issues cannot be appealed:
Disputes regarding requirement of law or regulation
The amount United Concordia determines to be the allowable charge
Dentists who have been excluded or suspended by a Government agency or state or local licensing authority
There are three levels of appeal: reconsideration, formal review, and hearing.
Patients may request a formal review from the TRICARE Management Activity (TMA) if they disagree with United Concordia’s reconsideration and if the amount remaining in dispute is $50 or more.