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.

If you sign up for a dental and/or vision plan during the 2021 Open Season, your coverage will begin on January 1, 2022.  Premium deductions will start with the first full pay period beginning on/after January 1, 2022.  You may use your benefits as soon as your enrollment is confirmed.

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.

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 08, 2021 through midnight EST December 13, 2021.  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.

There are no waiting periods in our plans.

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.

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.

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.

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) enrollees
• 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).

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 plan's premiums may change for 2022.

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.

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members.  You must list all eligible family members when enrolling.

If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.

• 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 08, 2021 through midnight EST December 13, 2021, Open Season.  Coverage is effective January 1, 2022.

  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
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 enrollment 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: No
Decrease Enrollment Type: No
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 in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium.

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 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 and confirms 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.

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.

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

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).

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.

If you are enrolled in an FSAFEDS HCFSA, you can take advantage of the Paperless Reimbursement option, which allows you to be reimbursed from your HCFSA without submitting an FSAFEDS claim. When Delta Dental receives a Federal Employees Dental Program claim for payment, we forward information about your out-of-pocket expenses (such as copayment and deductible amounts) to FSAFEDS for processing. FSAFEDS then reimburses you for your eligible out-of-pocket costs without the need for a claim form or receipt. Reimbursement is made directly to your bank from your HCFSA account via electronic funds transfer. You may need to file a paper claim to FSAFEDS in certain situations. Visit www.FSAFEDS.com for more information.

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. You will be required to submit your claim on behalf of Delta Dental's Federal Employees Dental Program to the FSAFEDS Health Care Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA).

When you enroll for the first time, you will receive a welcome letter along with an identification card ("ID Card"). ID Cards are issued in the primary member's name only. It is important to bring your FEDVIP and FEHB ID cards to every dental appointment. Because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage, presenting both ID cards can ensure that you receive the maximum allowable benefit under each program along with accurate and timely claims processing.

If you require a replacement ID card, you will be able to print your ID card through the Member Portal at deltadentalins.com/fedvip. An ID card is neither a guarantee of benefits nor is it required in order for you to obtain dental services. Your provider may call 855-410-3255 or visit deltadentalins.com/fedvip/dentists/ to confirm your enrollment in the plan and the benefits available to you.

If you were enrolled in Delta Dental's Federal Employees Dental Program in 2021 and continue coverage for 2022, please visit deltadentalins.com/fedvip where you can view and print the Plan Brochure, find network dentists and much more.

The provider network for Delta Dental's Federal Employees Dental Program consists of independently credentialed and contracted providers. IMPORTANT: Note there are different dentist networks for other Delta Dental plans—so be sure to use the Dentist Search function at deltadentalins.com/fedvip to find a dentist who participates in the network for Delta Dental's Federal Employees Dental Program. Contact your dentist to verify he/she is participating in Delta Dental's Federal Employees Dental Program. You may also contact Customer Service at 855-410-3255 for a list of Federal Employees Dental Program network providers near you.

Delta Dental's Federal Employees Dental Program network dentists are available in the 50 U.S. states, the District of Columbia and Puerto Rico. Our list of participating network dentists is updated daily. When you make your appointment, please advise the dental office that you are enrolled in the Federal Employees Dental and Vision Insurance Program (FEDVIP) and wish to use your in-network benefits; be sure to confirm that the dentist is a participating network provider for Delta Dental's Federal Employees Dental Program.

Delta Dental's Federal Employees Dental Program network does not require an enrollee to select a primary care provider. When you use a Delta Dental Federal Employees Dental Program network provider, you are responsible only for billable charges up to our negotiated plan allowance per procedure. You are not responsible for treatment service charges in excess of the in-network negotiated per-procedure maximum unless you consent in writing to additional treatment charges.

You may obtain care from any licensed dentist.  If the dentist is not part of our network, benefits will be considered out-of-network.  When you see a dentist who is outside of Delta Dental's participating network for the Federal Employees Dental Program, you will have a lower annual maximum benefit and we pay for services based on an out-of-network plan allowance. You are responsible for any difference between the plan payment and the amount submitted/approved.

Emergency services are defined as those dental services needed to relieve pain or prevent the worsening of a condition that would be caused by a delay.

All expenses for emergency services are payable as any other expense and are subject to plan limitations such as deductibles, frequencies and maximums. If you use an out-of-network provider for emergency services, benefits will be paid under the out-of-network plan provisions. You are responsible for the difference between the plan payment and the amount submitted/approved.

The plan allowance is the amount we allow for a specific procedure. When you use an in-network Delta Dental Federal Employees Dental Program provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment. When you use an out-of-network dentist, you are responsible for the difference between the plan allowance and our payment plus the difference up to the submitted/approved charges.

You and your provider may request us to predetermine benefits for dental procedures that your dentist has planned. This is especially recommended for more complex and/or major procedures. We will provide both you and your dentist with a non-binding, written Pre-treatment Estimate indicating if the procedures are covered and, if so, an estimate of what we will pay for those specific procedures.

When the treatment is complete, the provider will fill in the date(s) of service on the Pre-treatment Estimate, sign and date the notice, and return it to Delta Dental at the address provided for claims submission (see Section 9 Claims Filing and Disputed Clams Processes). Pre-treatment Estimates submitted for payment will be processed in accordance with Delta Dental's claims processing policies. The final determination of eligibility, maximums, program benefits, limitations and allowable fees will be made by Delta Dental when the Pre-treatment Estimate is processed for payment.

It is important to know that, per FEDVIP requirements, the FEHB plan will always be the first payor when you are also covered under Delta Dental's Federal Employees Dental Program.  Therefore, it is important to provide your dental office with both your FEHB ID card and your Delta Dental Federal Employees Dental Program enrollment card at each appointment. Your dental office should submit your FEHB carrier first.

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, which is supported when your dental office submits to your FEHB carrier first.

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/vision costs under no-fault insurance that pays benefits without regard to fault.

If you are covered under a non-FEHB plan, Delta Dental's Federal Employees Dental Program dental benefits will be coordinated using traditional COB provisions for determining payment.

If your other dental coverage is part of your FEHB plan, it is important to note that by law, your FEHB plan must pay first. Your dentist must submit your claim to your FEHB carrier first and then to Delta Dental. It is your responsibility to let the dentist know if you have both FEHB and FEDVIP coverage so the claim is submitted and processed correctly. Your dental provider should submit to the primary carrier first, then any subsequent insurance carrier thereafter. 

If the amount we pay is more than we should have paid under the First Payor provision or when benefits are coordinated, we may recover the excess from one or more of:

• the person we have paid;
• insurance companies; or
• other organizations.

However, the member will never be held responsible for a greater out-of-pocket amount than he/she would have been responsible for had there been no overpayment.

Your rates are determined based on where you live.  This is called a rating area.  If you move, you must update your address through BENEFEDS at www.BENEFEDS.com or by phone at 877-888-3337.  Your rates might change because of the move.

If you live in an area with insufficient access (based on contractual standards) to a Delta Dental Federal Employees Dental Program network provider and you receive covered services from an out-of-network dentist, we will pay the same benefit level as if you used the services of an in-network dentist.  Your responsibility is limited to any difference between the amount billed and our payment.

A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services. There is no family deductible limit. Covered charges credited to the deductible are also counted towards the Plan maximum and limitations.

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: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75

Class C
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75

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

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: 60% 

Class C
In-Network High Option: 50%
In-Network Standard Option: 65%
Out-of-Network High Option: 60% 
Out-of-Network Standard Option: 80% 

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

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.  The total Annual Benefit Maximum will never be greater than the In-Network Maximum Annual Benefit.

Maximum Annual Benefits:

In-Network High Option: Unlimited
In-Network Standard Option: $1,500
Out-of-Network High Option: $3,000
Out-of-Network Standard Option: $1000

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: $3,500 for dependents up to 21 for TRICARE-eligible individuals (or 23 if they’re full-time college students) or 22 for civilian dependents; $2,000 for members and spouses
In-Network Standard Option: $2,000 for dependent children up to age 19
Out-of-Network High Option: $3,500 for dependents up to 21 for TRICARE-eligible individuals (or 23 if they’re full-time college students) or 22 for civilian dependents; $2,000 for members and spouses
Out-of-Network Standard Option: $1,000 for dependent children up to age 19

If the dentist you use is not part of our network, benefits will be considered out-of- network.  Because these providers are not part of our network, we pay for services rendered by an out-of-network provider based on an out-of-network plan allowance; you will be responsible for your co-insurance percentage plus the billed amount over plan allowance.

The calendar year refers to the plan year, which is defined as January 1, 2022 to December 31, 2022.

The installation of complete or partial removable dentures, fixed partial dentures (bridges), implants and other prosthodontic services will be covered when replacing or repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior to your coverage effective date under the Delta Dental Federal Employees Dental Program. Initial prosthodontic services to replace natural teeth that were missing prior to your Delta Dental Federal Employees Dental Program date of coverage are not covered.

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 2022 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 2022 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 covered benefits in this plan.

The plan participant will be responsible for paying the dentist and submitting the claims to Delta Dental’s Federal Employee Dental Program for reimbursement. Mail completed claim forms to:

Delta Dental of California
Federal Employees Dental Program
PO Box 537007
Sacramento, CA  95853-7007

To avoid delay in the payment of your claims please have your dental provider submit your claims directly to Delta Dental's Federal Employees Dental Program for payment.

Delta Dental's Federal Employees Dental Program network providers will submit your claims directly to Delta Dental's Federal Employees Dental Program. If you would like to submit a paper claim, you may download a claim form from the website at deltadentalins.com/fedvip. Mail completed claim forms to:

Delta Dental of California
Federal Employees Dental Program
PO Box 537007
Sacramento, CA 95853-7007

When a claimant files a claim for dental insurance benefits described in this plan brochure, the claim  should be sent to us within 12 months of the date of service.  If the claim is not submitted within the time limits described in this section, the delay may cause a claim to be denied or reduced.

For services you receive outside of the 50 United States, the District of Columbia or Puerto Rico, send itemized bills/receipts that include an English translation and the date the services were rendered.  Benefits will be calculated using the daily rate of exchange for the date of service and reimbursed in United States currency. International participants will receive out-of-network benefits when services are performed by an internationally located provider. All international claims should be submitted to Delta Dental of California, Federal Employees Dental Program, PO Box 537007, Sacramento, CA 95853-7007.

It is to your benefit to reply promptly when we ask for additional information.  We may delay processing or deny your claim if you do not respond.  See Section 6 International Services and Supplies for more information.

Send us all of the documents for your claims as soon as possible.  You must submit your claim to us within 12 months following the delivery of the services in order for them to be considered for plan benefits, unless timely filing was prevented by administrative operations of the Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.  Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

We may require, at our option, supporting documentation such as clinical reports, charts, and/or x-rays.

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.

Disputed Claim Steps:

1. Ask us in writing to reconsider our initial decision.  You must include any pertinent information omitted from the initial claim filing and mail your additional proof to us within 90 days from the date of receipt of our decision.

2. Send your request for reconsideration to:

Delta Dental of California
Federal Employees Dental Program
Claims Appeals
PO Box 537015
Sacramento, CA 95853-7015

We will review your request and provide you with a written or electronic explanation of benefit determination within 30 days of the receipt of your request.

3. If you disagree with the decision regarding your request for reconsideration, you may request a second review of the denial.  You must submit your request to us in writing to the address shown above along with any additional information you or your dentist can provide to substantiate your claim so that we can reconsider our decision.  Failure to do so will disqualify the appeal of your claim.

4. If you do not agree with our final decision, under certain circumstances you may request an independent third party, mutually agreed upon by Delta Dental's Federal Employees Dental Program and OPM, to review the decision. To qualify for this independent third-party review, the reason for denial must be based on our determination that the rationale for the procedure did not meet our dental necessity criteria or our administration of the plan's alternate benefit provision; for example, a bridge being given an alternate benefit of a partial denture.

The decision of the independent third party is binding and constitutes the final review of your claim.

 CONFIDENTIALITY OF YOUR HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice is required by law to inform you of how Delta Dental and its affiliates ("Delta Dental") protect the confidentiality of your health care information in our possession. Protected Health Information (PHI) is defined as individually identifiable information regarding a patient's health care history, mental or physical condition or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives, uses and discloses your PHI to administer your benefit plan or as permitted or required by law. Any other disclosure of your PHI without your authorization is prohibited.

We follow the privacy practices described in this notice and federal and state privacy requirements that apply to our administration of your benefits. Delta Dental reserves the right to change our privacy practice effective for all PHI maintained. We will update this notice if there are material changes and redistribute it to you within 60 days of the change to our practices. We will also promptly post a revised notice on our website.  A copy may be requested anytime by contacting the address or phone number at the end of this notice. You should receive a copy of this notice at the time of enrollment in a Delta Dental program and will be informed on how to obtain a copy at least every three years.

Uses and disclosures of your PHI for treatment, payment or health care operations

For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our network of providers.

Your explicit authorization is not required to disclose information about yourself for purposes of health care treatment, payment of claims, billing of premiums, and other health care operations. If your benefit plan is sponsored by your employer or another party, we may provide PHI to your employer or plan sponsor to administer your benefits. As permitted by law, we may disclose PHI to third-party affiliates that perform services for Delta Dental to administer your benefits, and who have signed a contract agreeing to protect the confidentiality of your PHI, and have implemented privacy policies and procedures that comply with applicable federal and state law.

Some examples of disclosure and use for treatment, payment or operations include: processing your claims, collecting enrollment information and premiums, reviewing the quality of health care you receive, providing customer service, resolving your grievances, and sharing payment information with other insurers. Some other examples are:

• Uses and/or disclosures of PHI in facilitating treatment. For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested by your provider.
• Uses and/or disclosures of PHI for payment. For example, Delta Dental may use and disclose your PHI to bill you or your plan sponsor.
• Uses and/or disclosures of PHI for health care operations. For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our network of providers.

Other permitted uses and disclosures without an authorization

We are permitted to disclose your PHI upon your request or to your authorized personal representative (with certain exceptions) when required by the U. S. Secretary of Health and Human Services to investigate or determine our compliance with law, and when otherwise required by law. Delta Dental may disclose your PHI without your prior authorization in response to the following:

• Court order;
• Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful authority;
• Subpoena in a civil action;
• Investigative subpoena of a government board, commission, or agency;
• Subpoena in an arbitration;
• Law enforcement search warrant; or
• Coroner's request during investigations.

Some other examples include: to notify or assist in notifying a family member, another person, or a personal representative of your condition; to assist in disaster relief efforts; to report victims of abuse, neglect or domestic violence to appropriate authorities; for organ donation purposes; to avert a serious threat to health or safety; for specialized government functions such as military and veterans activities; for workers' compensation purposes; and, with certain restrictions, we are permitted to use and/or disclose your PHI for underwriting, provided it does not contain genetic information. Information can also be de-identified or summarized so it cannot be traced to you and, in selected instances, for research purposes with the proper oversight. 

Disclosures Delta Dental makes with your authorization

Delta Dental will not use or disclose your PHI without your prior written authorization unless permitted by law. You can later revoke that authorization, in writing, to stop the future use and disclosure. The authorization will be obtained from you by Delta Dental or by a person requesting your PHI from Delta Dental.

YOUR  RIGHTS  REGARDING  PHI

You may access your PHI by contacting Delta Dental at the address at the bottom of this notice.  You must include (1) your name, address, telephone number and identification number, and (2) the PHI you are requesting. Delta Dental may charge a reasonable fee for providing you copies of your PHI. Delta Dental will only maintain that PHI that we obtain or utilize in providing your health care benefits. Most PHI, such as treatment records or x-rays, is returned by Delta Dental to the dentist after we have completed our review of that information. You may need to contact your health care provider to obtain PHI that Delta Dental does not possess.

You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or state law. In some circumstances, you may have a right to have this decision reviewed. Please contact Delta Dental as noted below if you have questions about access to your PHI.

You have the right to request a restriction of your PHI.

You have the right to ask that we limit how we use and disclose your PHI, however, you may not restrict our legal or permitted uses and disclosures of PHI. While we will consider your request, we are not legally required to accept those requests that we cannot reasonably implement or comply with during an emergency.  If we accept your request, we will put our understanding in writing.  

You have the right to correct or update your PHI.

You may request to make an amendment of PHI we maintain about you. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. If your PHI was sent to us by another, we may refer you to that person to amend your PHI. For example, we may refer you to your dentist to amend your treatment chart or to your employer, if applicable, to amend your enrollment information. Please contact the privacy office as noted below if you have questions about amending your PHI.

You have rights related to the use and disclosure of your PHI for marketing.

Delta Dental agrees to obtain your authorization for the use or disclosure of PHI for marketing when required by law. You have the opportunity to opt out of marketing that is permitted by law without an authorization. Delta Dental does not use your PHI for fundraising purposes.

You have the right to request or receive confidential communications from us by alternative means or at a different address.

Alternate or confidential communication is available if disclosure of your PHI to the address on file could endanger you. You may be required to provide us with a statement of possible danger, as well as specify a different address or another method of contact. Please make this request in writing to the address noted at the end of this notice.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.

You have a right to an accounting of disclosures with some restrictions. This right does not apply to disclosures for purposes of treatment, payment, or health care operations or for information we disclosed after we received a valid authorization from you. Additionally, we do not need to account for disclosures made to you, to family members or friends involved in your care, or for notification purposes. We do not need to account for disclosures made for national security reasons, certain law enforcement purposes or disclosures made as part of a limited data set. Please contact us at the number at the end of this notice if you would like to receive an accounting of disclosures or if you have questions about this right.

You have the right to get this notice by email.

A copy of this notice is posted on the Delta Dental website. You may also request an email copy or paper copy of this notice by calling our Customer Service number listed at the bottom of this notice.

You have the right to be notified following a breach of unsecured protected health information.

Delta Dental will notify you in writing, at the address on file, if we discover we compromised the privacy of your PHI.

You may file a complaint to Delta Dental and/or to the U. S. Secretary of Health and Human Services if you believe Delta Dental has violated your privacy rights. Complaints to Delta Dental may be filed by notifying the contact below. We will not retaliate against you for filing a complaint.

You may contact Delta Dental at 866-530-9675, or you may write to the address listed below for further information about the complaint process or any of the information contained in this notice.

Delta Dental

PO Box 997330

Sacramento, CA  95899-7330

This notice is effective on and after January 1, 2016.

Note: Delta Dental's privacy practices reflect applicable federal law as well as known state law and regulations. If applicable state law is more protective of information than the federal privacy laws, Delta Dental protects information in accordance with the state law.

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Delta Dental ID card, or 1-866-530-9675.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Delta Dental o al 1-866-530-9675. (Spanish)

Last Significant Changes to this Notice:

• Clarified that Delta Dental does not used your PHI for fundraising purposes – effective January 1, 2016
• Clarified that Delta Dental’s privacy policy reflect federal and state requirements – effective January 1, 2015
• Updated contact information (mailing address and phone number) – effective July 1, 2013
• Updated Delta Dental’s duty to notify affected individuals if a breach of their unsecured PHI occurs – effective July 1, 2013
• Clarified that Delta Dental does not and will not sell your information without your express written authorization – effective July 1, 2013
• Clarified several instances where the law requires individual authorization to use and disclose information (e.g., fundraising and marketing as noted above) – effective July 1, 2013

DELTA DENTAL AND ITS AFFILIATES

Delta Dental of California offers and administers fee-for-service dental programs for groups headquartered in the state of California.

Delta Dental of New York offers and administers fee-for-service programs in New York.

Delta Dental of Pennsylvania and its affiliates offer and administer fee for-service dental programs in Delaware, Maryland, Pennsylvania, West Virginia and the District of Columbia. Delta Dental of Pennsylvania's affiliates are Delta Dental of Delaware; Delta Dental of the District of Columbia and Delta Dental of West Virginia.

Delta Dental Insurance Company offers and administers fee-for-service dental programs to groups headquartered or located in Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas and Utah and vision programs to groups headquartered in West Virginia.

DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, ME, MI, NC, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DC, DE, FL, GA, KS, LA, MS, MT, TN and WV — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York, Inc.; PA — Delta Dental of Pennsylvania; VA — Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.

Dentegra Insurance Company.

Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity.  This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers.  Annuitants are sometimes called retirees.

From January 1, 2022 through December 31, 2022.  Also referred to as the plan year.

Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays. 

Covered services shall include only those services specifically listed in Section 5 Dental Services and Supplies.  A covered service must be incurred and completed while the person receiving the service is a covered person.  Covered services are subject to plan provisions for exclusions and limitations and meet acceptable standards of dental practice as determined by us.

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

Dental services that initiated in 2021 that will be completed in 2022.

Network Allowance means the allowance per procedure that Delta Dental's Federal Employees Dental Program has negotiated with the provider and they have agreed to accept as payment in full for his/her services.

Delta Dental's Federal Employees Dental Program

The amount we use to determine our payment for services.  If services are provided by an in-network dentist the Plan Allowance is based on the discounted fee he or she accepts as payment in full for the procedure or procedures.  If services are provided by an out-of- network dentist the Plan Allowance is based on Delta Dental's Federal Employees Dental Program’s determination of usual and customary charges for the procedure or procedures.

The installation of complete or partial removable dentures, fixed partial dentures (bridges), implants, and other prosthodontic services will be covered when replacing or repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior to your coverage effective date under Delta Dental's Federal Employees Dental Program. Initial prosthodontic services to replace natural teeth that were missing prior to your Delta Dental Federal Employees Dental Program date of coverage are not covered.

There are no waiting periods in either of our Plan options, not even for orthodontics.

Delta Dental's Federal Employees Dental Program

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).

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

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.