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 may 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

The only waiting period is for orthodontic services.  To meet this requirement, the person receiving the services must be enrolled in this plan for the entire twelve month waiting period.  

Compliance with the American Dental Association (ADA)

Triple-S Salud, Inc. adopted and complies with the codification system and service description in accordance with the Current Dental Terminology (CDT) of the American Dental Association (ADA).

Every year we make the changes according to the ADA’s Council of Dental Benefit Programs that are the responsible for maintaining the CDT Code in accordance with ADA Bylaws, policies, and federal regulations.

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) 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). 

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. 

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.

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 7, 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
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: 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 in 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 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.

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.

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you may 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 claims on behalf of the Triple-S Salud's Dental Plan to the FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA) to claim reimbursement.

Identification Cards/ Enrollment Confirmation

We will send you an identification (ID) card when you enroll.  You should carry your ID card with you at all times.  You must show it whenever you receive services from a plan provider.  Your ID card does not have an expiration date to ensure the continuity of services.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081 or write to us at Triple-S Salud, Inc. (Triple-S Salud), Customer Service Division, 1441 Roosevelt Avenue, San Juan, Puerto Rico 00920.  You may also request replacement cards through our Web site at www.ssspr.com.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

Plan Providers

We list plan providers in the provider directory, which we update periodically.  The list is on our Web site at: www.ssspr.com or you may call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081 .

In-Network

The primary care dentists are duly authorized plan dentists with a regular license issued by the designated entity of the government of Puerto Rico, and who are bona fide members of the “Colegio de Cirujanos Dentistas de Puerto Rico”, who have signed a contract with Triple-S Salud, Inc. to render dental services.

Out-of-Network

We will only reimburse out-of-network services when rendered by orthodontists.  No other services rendered by out-of-network providers are covered including emergency services performed by an out-of-network dentist.  If you receive dental services from other out-of-network providers, services are not covered and you will have to pay 100% of the charges and we will not reimburse you.

Emergency services performed by an out-of-network dentist are not covered.  You will have to pay 100% of the charges and we will not reimburse you.

Pre-Authorization/Pre-Determination of Benefits

Some of the objectives of the pre-determination of benefits are to allow both the participant and the insured to confirm beforehand the eligibility of the service for the dental coverage, the scope of the covered services, limits, exclusions, necessity and deductibles and coinsurances applicable under the insureds contract. Pre-determinations will be evaluated based on the pre-determination policies that Triple-S Salud, Inc. has established. We will not be liable for payment of services, if they have been rendered or received without this pre-authorization/pre-determination.

The following dental benefits will require a pre-authorization/pre-determination of benefits: all crowns, fixed and removable prostheses, periodontal procedures and endodontic retreatments.

The dentist is responsible for the pre-determination of benefits and will list all services of the treatment plan on the ADA claim form and include radiographs and a report with the clinical evaluation justifying the necessity for the services.  The dentists will submit the form by paper or electronically.  For questions regarding this process, call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081.

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 FEHB first payor.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

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

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

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

To enroll in this plan, you must live in our service area.  This is where our providers practice.  Our service area is only Puerto Rico.

You must get your care from providers within the service area who contract with us.  If you receive care outside our service area, you will have to pay 100% of the charges.  We will not pay for services out of our service area.

If you move outside of our service area, you may enroll in another plan at that time.  You do not have to wait until Open Season to change plans.  Contact BENEFEDS at www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to change plans.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our plan, you pay 15% of our allowance for oral surgery.

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.

How to File a Claim for Covered Services

When you see plan providers, you will not have to file claims.  Just present your identification card and pay your coinsurance.

You will only need to file a claim when you receive orthodontic services.  You will have to submit the claim within one (1) year since the date of service. Sometimes these providers bill us directly.  Check with the provider.  If you need to file the claim, here is the process:

1. Claims for orthodontic reimbursement: In most cases, providers file claims for you.   Dentists must file an ADA claim form.  For claims questions and assistance, call us at 787-774-6081, TTY 787-792-1370, 1-800-716-6081.  When you receive orthodontic services, you must file an ADA claim form or a claim that includes the information shown below.  Bills and receipts should be itemized and:

        (a) Must be sent to: Triple-S Salud, Inc. PO Box 363628, San Juan, PR 
             00936-3628; and

        (b) Verify that the receipts have the information about the dentist printed on it 
              and that the name of the insured agrees with the contract number.  The
              Request for Reimbursement Form will be accepted as a receipt as long
              as it has the dentist information printed; the dentist’s signature and 
              his/her license number.

        (c) When requesting reimbursement for the first time, the insured must include:

                            • the treatment plan detailing the first visit
                            • down payment
                            • monthly payments
                            • total cost
                            • duration of treatment

        (d) Receipts must agree with what was established in your treatment plan.

        (e) If the insured pays more than one visit in the same receipt, he/she must 
              send the exact dates (month, day, and year) of the services for which he/she paid.

        (f) Payments in advance or total payment of the treatment will not be considered for 
             reimbursement.

        (g) If you pay for retainers, it must be indicated if they are mandibular or maxillary.

        (h) If you request reimbursement for orthodontic devices, it must be indicated if they 
              are fixed (D8220) or removable (D8210).

        To request reimbursement through Coordination of Benefits add:

                           • Contract number of the other plan
                           • If the reimbursement is for amounts left unpaid by your other 
                             plan, you must include the other plan’s Explanation of Benefits.

2. We have a period of 30 days after our receipt of the claim to:

        (a) Notify you of our determination.

        (b) Request additional information.  You will have up to 60 days to provide the 
              requested information.

        (c) Inform you that more time is needed to make a decision.  This extension may 
             consist of a maximum of 15 additional days.

Send us all the documents for your claim as soon as possible.  You must submit the claim 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 reasonably possible.

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:

• Write to us within the 180 days from the date of our determination.
• Include in your letter the reason why you believe that the initial determination is incorrect.
• Enclose copies of the documents that support your claim, such as a letter from the dentists, and the explanations of benefits.
• Submit your written complaint to the following address: Triple-S Salud, Inc., Customer Service Division, Complaints and Grievances Unit, PO Box 363628, San Juan, PR 00936-3628.

2. We will notify you about our decision on your complaint no later than 30 days from the date your complaint was received.  If we need more time to make our decision, we will notify you in writing.  In said cases, the term to answer your complaint will not exceed a period of 15 days.

3. If the dispute is not resolved through the reconsideration process, you may request a review of the denial.  You may request a reconsideration within 60 days from the date you received the notification of our determination.  You may send your reconsideration request to the same address to which you sent your complaint.  In your reconsideration request, you must include the reason(s) why you understand Triple-S Salud was mistaken in its initial determination.  We must answer your request for reconsideration with a term of 30 days.

4. If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, review the decision.  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.

Enrollee

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

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.

In-Progress Treatment

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