A Choice of Plans and Options

You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options.  You can also select from several nationwide vision plans.  You may enroll in a dental plan or a vision plan, or both.  Some TRICARE beneficiaries may not be eligible to enroll in both.  Visit www.opm.gov/dental or www.opm.gov/vision for more information.

Coverage Effective Date

If you sign up for a dental and/or vision plan during the 2020 Open Season, your coverage will begin on January 1, 2021.  Premium deductions will start with the first full pay period beginning on/after January 1, 2021.  You can use your benefits as soon as your enrollment is confirmed.

Pre-Tax Salary Deduction for Employees

Employees automatically pay premiums through payroll deductions using pre-tax dollars.  Annuitants automatically pay premiums through annuity deductions using post-tax dollars.  TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.

Annual Enrollment Opportunity

Each year, an Open Season will be held, during which you may enroll or change your dental and/or vision plan enrollment.  This year, Open Season runs from November 9, 2020 through midnight EST December 14, 2020; You do not need to re-enroll each Open Season unless you wish to change plans or plan options; your coverage will continue from the previous year. In addition to the annual Open Season, there are certain events that allow you to make specific types of enrollment changes throughout the year. Please see Section 2, Enrollment, for more information.

Waiting Period

High Option: There is not a waiting period for any benefits on this plan.

Standard Option: The only waiting period under the Standard Option is for orthodontic services. To meet this requirement, the person receiving orthodontic services must be enrolled in the Aetna Dental plan for the entire and continuous 12-month waiting period to receive orthodontic coverage. Any change in the plan will result in a new 12 month waiting period. A re-enrollment into Aetna Dental, after transferring from another FEDVIP dental carrier, will require the member to satisfy a new 12-month orthodontia waiting period. (Note: Waiting periods do not start over while you are continuously enrolled in Aetna Dental. If you change from Aetna Dental High option to the Standard option, any continuous enrollment in either of our Aetna Dental options will count towards the Standard Option waiting period.) 

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
• retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.

Your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee.  There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB Program.

Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity.  You may enroll in FEDVIP again, when you begin to receive your annuity.

TRICARE-eligible individual

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.

Retired members of the uniformed services and National Guard/Reserve components, including "gray-area" retirees under age 60 and their families  are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.

Family Members

Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22.  This includes legally adopted children and recognized natural children who meet certain dependency requirements.  This also includes stepchildren and foster children who live with you in a regular parent-child relationship.  Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.  FEDVIP rules and FEHB rules for family member eligibility are NOT the same.  For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, an unremarried former spouse who meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibility requirements, and certain unmarried persons placed in your legal custody by a court.  Children include legally adopted children, stepchildren, and pre-adoptive children.  Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity. 

Not Eligible

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility or receipt of an annuity or portion of an annuity:

• Deferred annuitants
• Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
• FEHB Temporary Continuation of Coverage (TCC) enrollee
• Anyone receiving an insurable interest annuity who is not also an eligible family member
• Active duty uniformed service members.  Note:  If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE.  Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP).

Enroll Through BENEFEDS

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.com) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically.  Please Note:  your plans’ premiums may change for 2021.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page.  However, those sites may provide a link to BENEFEDS.

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You may choose a Self Only enrollment even though you have a family, however, your family members will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify.  You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP. 

Opportunities to Enroll or Change Enrollment

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 9, through midnight EST December 14, 2020, Open Season.  Coverage is effective January 1, 2021.

During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage.  The effective date of these Open Season enrollments and changes will be set by OPM.  If you want to continue your current enrollment, do nothing.  Your enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;
• a previously ineligible employee who transferred to a covered position;
• a survivor annuitant if not already covered under FEDVIP; or
• an employee returning to service following a break in service of at least 31 days.
• a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which BENEFEDS receives and confirms your enrollment. 

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an Open Season. 

The following chart lists the QLEs and the enrollment actions you may take.

Qualifying Life Event: Marriage
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No (enrollee deployment), Yes (spouse deployment)
Cancel: Yes
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay
From Not Enrolled to Enrolled: Yes (if first time enrollment or cancelled during LWOP)
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

*Position must be with a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium and you elect to enroll.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event.  There are two exceptions:

• There is no time limit for a change based on moving from a regional plan’s service area; and
• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of the loss of dental or vision insurance.  You must make the change no later than 60 days after the event. 

Generally, enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives the enrollment or change.  BENEFEDS will send you confirmation of your new coverage effective date.

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed.  That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next Open Season, unless you experience a QLE that allows such a change or cancellation.

This is a one time opportunity.  Once you make an election, you may not change your elected plan until the next Open Season.

Canceling an enrollment

You may cancel your enrollment only during the annual Open Season.  An eligible family member’s coverage also ends upon the effective date of the cancellation.

Your cancellation is effective at the end of the day before the date OPM sets as the Open Season effective date.

When Coverage Stops

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:

• no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
• as a Retired Reservist you begin active duty;
• as sponsor or primary enrollee leaves active duty
• begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
• are making direct premium payments to BENEFEDS and you stop making the payments;
• cancel the enrollment during Open Season;
• a Retired Reservist begins active duty; or
• the sponsor or primary enrollee leaves active duty.

Coverage for a family member ends when:

• you as the enrollee lose coverage; or
• the family member no longer meets the definition of an eligible family member.

Under FEDVIP, there is no 31-day extension of coverage.  The following are also NOT available under the FEDVIP plans:

• Temporary Continuation of Coverage (TCC);
• spouse equity coverage; or
• right to convert to an individual policy (conversion policy).

FSAFEDS/High Deductible Health Plans and FEDVIP

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account.  Please note that insurance premiums are not eligible expenses for either type of FSA.

If you have an HCFSA or LEX HCFSA FSAFEDS account and you haven’t exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over up to $550 of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31.  You must also actively reenroll in a health care or limited expense account during the NEXT Open Season to be carryover eligible. Your reenrollment must be for at least the minimum of $100.  If you do not reenroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over.

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time period permitted.  This is known as the “Use-it-or-Lose-it” rule.  Carefully consider the amount you will elect. 

For a health care or limited expense account, each participant must contribute a minimum of $100 to a maximum of $2,750.

Current FSAFEDS participants must re-enroll to participate next year.  See www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058.  Note: FSAFEDS is not open to retired employees, or to TRICARE eligible individuals.

Aetna will transmit plan payment information for members that enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA) to the FSAFEDS carrier. Members that participate are not required to submit claims on behalf of the Aetna Dental plan to be reimbursed.

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you can use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB and FEDVIP plans.

Identification cards/Enrollment Confirmation

ID cards are not provided, and are not required to obtain service.  We will send you an enrollment confirmation letter when you enroll. For members who wish to carry an ID card, you may print one online from our Aetna Member website.

It is important to tell your provider about your FEHB coverage at every appointment since most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage.  This ensures that you receive the maximum allowable benefit under each Program.

You may obtain care from any licensed dentist in the United States or overseas.

FEHB First Payor

When you visit a provider who participates with both, your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefits first. The FEDVIP plan allowance will be the prevailing charge in these cases.  You are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance.  We are responsible for facilitating the process with the primary FEHB payor.

SPECIAL NOTE: If you are enrolled in Aetna’s Consumer Driven Health Plan (CDHP) under the FEHB, the Dental Fund will not follow the FEHB First Payor rule for any service provided by a network dentist. However, preventive services provided by a non-network dentist would be payable from the Dental Fund and follow the FEHB First Payor rule.

Coordination of Benefits

We will coordinate benefit payments with the payment of benefits under other group health benefits coverage (non-FEHB) you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault. 

SPECIAL NOTE: If you are enrolled in Aetna’s Consumer Driven Health Plan (CDHP) under the FEHB, the Dental Fund will not follow the FEHB First Payor rule for any service provided by a network dentist.  However, preventive services provided by a non-network dentist would be payable from the Dental Fund and follow the FEHB First Payor rule.

We may request that you verify/identify your health insurance plan(s) annually or at time of service.  

Here is an example of how we would coordinate benefits if a non-FEHB plan was primary:

Primary plan payment based on schedule fee, we are secondary.
In-Network Dentist’s Fee: $200.00*
Plan Allowance: $150.00
Primary Plan’s Scheduled Amount: $125.00
Primary Plan’s Payment: $125.00
FEDVIP Payment: $25.00 ($150.00 - $125.00)
Member Payment: $0.00

*You are not responsible for the $50.00 difference between the dentist’s fee and the plan allowance, when you use an in-network dentist.  The dentist cannot bill you for this amount.

Limited Access Areas

Alternate Benefit

If more than one service or procedure can be used to treat the covered person’s dental condition, Aetna may decide to authorize coverage only for the less costly covered service or procedure when that service is deemed by the dental profession to be an appropriate method of treatment and the service selected must meet broadly accepted national standards of dental practice.  If you and your dentist choose the more expensive treatment, you are responsible for the additional charges beyond the allowance for the alternate service, even if services are provided by an in-network provider.

Dental Review

Our review process includes periodontal surgery, crowns, occlusal adjustments and there are other services that are looked at, if they are submitted on the same claim as another service.  Your provider should submit images with crowns and periodontal charting with periodontal surgeries.

Deductible

A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services. For Standard option, the family deductible limit is 2x the self only deductible ($100 for in-network and $200 for out-of-network). Note: Eligible dental services applied to the out-of-network deductible will be applied to satisfy the in-network deductible. Eligible dental services applied to the in-network deductible will be applied to satisfy the out-of-network provider deductible.

Class A
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $0

Class B
In-Network High Option: $0
In-Network Standard Option: $50
Out-of-Network High Option: $0
Out-of-Network Standard Option: $100

Class C
In-Network High Option: $0
In-Network Standard Option: $50
Out-of-Network High Option: $0
Out-of-Network Standard Option: $100

Orthodontics
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $0

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you meet your deductible, if applicable.

Class A
In-Network High Option: 0%
In-Network Standard Option: 0%
Out-of-Network High Option: 10%
Out-of-Network Standard Option: 40%

Class B
In-Network High Option: 30%
In-Network Standard Option: 45%
Out-of-Network High Option: 40%
Out-of-Network Standard Option: 70%

Class C
In-Network High Option: 60%
In-Network Standard Option: 65%
Out-of-Network High Option: 60%
Out-of-Network Standard Option: 70%

Orthodontics
In-Network High Option: 50%
In-Network Standard Option: 50%
Out-of-Network High Option: 50%
Out-of-Network Standard Option: 50%

Annual Benefit Maximum

Once you reach this amount, you are responsible for all additional charges. The Annual Benefit Maximums within each option are combined between in and out-of-network services. Note: In-Network and Out-of-Network amounts cross apply. For example on high option, once the $2,000 has been paid for in or out-of-network services, only in-network claims are eligible for reimbursement.

Maximum Annual Benefits

In-Network High Option: Unlimited
In-Network Standard Option: $1,500
Out-of-Network High Option: $2,000
Out-of-Network Standard Option: $1,000

Lifetime Benefit Maximum

The Lifetime Maximum is applicable to Orthodontia benefits only. There are no other lifetime maximums under this Plan.

Lifetime Orthodontic Maximum
In-Network High Option: up to $2,000
In-Network Standard Option: up to $2,000
Out-of-Network High Option: up to $2,000
Out-of-Network Standard Option: up to $2,000

Plan Allowance

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.  Network provider plans determine their allowance in different ways.  We determine our allowance as follows:

High option:

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money.  We refer to these providers as “network providers”.  These negotiated rates are our Plan allowance for network providers.  We calculate a member’s coinsurance using these negotiated rates.  The member is not responsible for amounts billed by network providers that are more than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers.  Because they are out of our network, we pay for out-of-network services based on the out-of-network Plan allowance.  To figure out the out-of-network Plan allowance, we get information from FAIR Health. Health plans send FAIR Health claims data for services they receive from providers. FAIR Health combines this information into databases that show how much providers charge for  services by zip code. Providers’ charges for specific procedures are grouped in percentiles from low to high. We use the 80^th percentile as the Plan allowance to calculate how much to pay for out of network services.  The 80^th percentile means 80 percent of charges in the database are the same or less for that service in a particular area.  We use the Plan allowance when calculating a member’s coinsurance amount.  The member is responsible for any amounts billed by the non-network provider that are above the Plan allowance, plus their coinsurance amount.

Standard option: 

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money. We refer to these providers as “Network providers”. These negotiated rates are our Plan allowance for network providers. We calculate a member’s coinsurance using these negotiated rates. The member is not responsible for amounts billed by network providers that are greater than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers. Our Plan allowance for out-of-network services is based on the in-network negotiated fee for the area. While network providers accept the negotiated fee, members may be billed by out-of-network providers for the difference between the Plan allowance and the provider’s fee.

In-Progress Treatment

In-progress treatment for dependents of retiring active duty service members who were enrolled in the TRICARE Dental Program (TDP) will be covered for the 2021  plan year; regardless of any current plan exclusion for care initiated prior to the enrollee's effective date.

This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2021  plan year such as crowns and implants.

FEDVIP carriers will not cover in-progress treatment if you enroll in a FEDVIP plan that has a waiting period, or does not cover the service. Several FEDVIP dental plans have options that offer orthodontia coverage without a 12-month waiting period, and without age limits.

Note - There are no waiting periods for any benefits on this plan, except class D services on our standard option.

International Claims Payment

Please send us all of your documents for your claim to:

Aetna
P.O. Box 14094
Lexington, KY 40512-4094

Customer Service Website and Phone Numbers

You may look up information on our plan or ask a question at www.aetnafeds.com.  (Our toll-free number will not work overseas).

There is one international region.  Please see the rate table for the actual premium amount.

Deadline for Filing Your Claim

Send us all of the documents for your claim, as soon as possible, to: Aetna, PO Box 14094, Lexington, KY 40512-4094.

You must submit claims by December 31 of the year after the year you received the service unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as possible.  Once we pay the benefits, there is a two-year limitation on the reissuance of uncashed checks.

Follow this disputed claims process if you disagree with our decision on your claim or request for services.  The FEDVIP law does not provide a role for OPM to review disputed claims.

1. Ask us in writing to reconsider our initial decision.  You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Aetna, Attention: National Accounts, P.O. Box 14597, Lexington, KY 40512-4597; and

Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.  This is your first level appeal.

2. We have 30 days from the date we receive your request to:

a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

b) Write to you and maintain our denial – go to step 3; or

c) Ask you or your provider for more information.  If we ask your provider, we will send you a copy of our request.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.

We will write to you with our decision.

3. If the dispute is not resolved through the reconsideration process, and the reason for the denial was based on medical necessity or for experimental or investigational reasons, you have the right to file a second level appeal.  That appeal must be submitted within 60 days following the receipt of our first level denial.

4. If you do not agree with our final decision, and the amount of your claim is more than $300 and the plan denied your claim because it did not consider the treatment medical necessity, you may request an independent third party, mutually agreed upon by us and OPM, review the decision.  You have 30 days from the date you received our final decision to request a third party review.

The decision of the independent third party is binding and is the final review of your claim.  This decision is not subject to judicial review.

Alternate Benefit

If more than one service or procedure can be used to treat the covered person’s dental condition, Aetna may decide to authorize coverage only for the less costly covered service or procedure when that service is deemed by the dental profession to be an appropriate method of treatment and the service selected must meet broadly accepted national standards of dental practice.  If you and your dentist choose the more expensive treatment, you are responsible for the additional charges beyond the allowance for the alternate service, even if services are provided by an in-network provider.

Class A Services

Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants and images.

Enrollee

The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.

In-Progress-Treatment

Dental services that initiated in 2020 that will be completed in 2021.

Plan Allowance

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Network provider plans determine their allowance in different ways. We determine our allowance as follows:

High option:

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money.  We refer to these providers as “network providers”.  These negotiated rates are our Plan allowance for network providers.  We calculate a member’s coinsurance using these negotiated rates.  The member is not responsible for amounts billed by network providers that are more than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers.  Because they are out of our network, we pay for out-of-network services based on the out-of-network Plan allowance.  To figure out the out-of-network Plan allowance, we get information from FAIR Health. Health plans send FAIR Health claims data for services they receive from providers. FAIR Health combines this information into databases that show how much providers charge for services by zip code. Providers’ charges for specific procedures are grouped in percentiles from low to high. We use the 80^th percentile as the Plan allowance to calculate how much to pay for out of network services. The 80^th percentile means 80 percent of charges in the database are the same or less for that service in a particular area.  We use the Plan allowance when calculating a member’s coinsurance amount.  The member is responsible for any amounts billed by the non-network provider that are above the Plan allowance, plus their coinsurance amount.

Standard option: 

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money. We refer to these providers as “Network providers”. These negotiated rates are our Plan allowance for network providers. We calculate a member’s coinsurance using these negotiated rates. The member is not responsible for amounts billed by network providers that are greater than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers. Our Plan allowance for out-of-network services is based on the in-network negotiated fee for the area. While network providers accept the negotiated fee, members may be billed by out-of-network providers for the difference between the Plan allowance and the provider’s fee.

Pre-Certification

Sponsor

Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on his or her direct affiliation with the uniformed services (including military members of the National Guard and Reserves).

TEI certifying family member

Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members.

TRICARE-eligible individual (TEI) family member

TEI family members include a sponsor's spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor's legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

Tooth Missing but Not Replaced Rule

The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic services will be covered if:

• The dentures, bridges or other prosthetic services are needed to replace one or more natural teeth that were removed while covered under a participating FEDVIP plan or the prior TRDP plan; and
• The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 5 years. The extraction of third molars does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.

Waiting Period

High Option: There is not a waiting period for any benefits on this plan option.
Standard Option: The only waiting period under the Standard Option is for orthodontic services. To meet this requirement, the person receiving orthodontic services must be enrolled in the Aetna Dental plan for the entire and continuous 12-month waiting period to receive orthodontic coverage. Any change in the plan will result in a new 12 month waiting period. A re-enrollment into Aetna Dental, after transferring from another FEDVIP dental carrier, will require the member to satisfy a new 12-month orthodontia waiting period. (Note: Waiting periods do not start over while you are continuously enrolled in Aetna Dental. If you change from Aetna Dental High option to the Standard option, any continuous enrollment in either of our Aetna Dental options will count towards the Standard Option waiting period.)