Fed Regist. 2016 Mar 7;81(44):11665-8.
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.
本最终规则修订了针对非参与提供者的福利支付规定，要求按较低者计费收取或同一地区（区域）或州类似服务的网络最大允许收费（减去适当的成本分摊），向医保直接付费计划（TDP）的非参与提供者报销费用，从而更紧密地反映行业惯例。本规则还更新了关于牙科密封剂的监管规定，将其明确归类为预防性服务，因此，取消目前适用于密封剂的20%成本分摊，使监管规定的措辞与法规一致。
