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Delta Dental'sFederal Employees Dental Programdeltadentalins.com/fedvip2021A Nationwide Dental PPO PlanWho may enroll in this Plan: All Federal employees, annuitants,and certain TRICARE beneficiaries in the United States andoverseas who are eligible to enroll in the Federal Employees Dentaland Vision Insurance Program.Enrollment Options for this Plan: High Option – Self Only High Option – Self Plus One High Option – Self and FamilyIMPORTANT Rates: Back Cover Changes for 2021: Page 4 Summary of Benefits: Page 57 Standard Option – Self Only Standard Option – Self Plus One Standard Option – Self and FamilyThis Plan has five enrollment regions, including international; please see the end of this brochureto determine your region and corresponding rates.Authorized e:United StatesStatesOfficeManagementOfficeofof PersonnelPersonnel Management.HealthcareHealthcare and ov/insure
IntroductionOn December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits EnhancementAct of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplementaldental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members.In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP).OPM has contracted with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expandedFEDVIP eligibility to certain TRICARE-eligible individuals.This brochure describes the benefits of Delta Dental's Federal Employees Dental Program under Delta Dental of Californiacontract OPM02-FEDVIP-02AP-05 with OPM, as authorized by the FEDVIP law. The address for our administrative officeis:Delta Dental of CaliforniaFederal Employees Dental ProgramPO Box 537007Sacramento, CA s brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,and exclusions of this brochure. It is your responsibility to be informed about your benefits.If you are enrolled in this plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self PlusOne, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage,each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage. You and yourfamily members do not have a right to benefits that were available before January 1, 2021, unless those benefits are alsoshown in this brochure.OPM negotiates benefits and rates with each carrier annually. Rates are shown at the end of this brochure.Delta Dental maintains the network of providers available to enrollees in the Federal Employees Dental Program. You mayview the most current network provider directory on our website at deltadentalins.com/fedvip, or you may contact us at855-410-3255 (TDD 866-847-1264) to request a list of participating providers in your area. Continued participation of anyspecific provider cannot be guaranteed. Thus, you should choose your plan based on the benefits provided and not for aspecific provider’s participation. When you phone for an appointment, please remember to verify that the provider iscurrently in Delta Dental's network for the Federal Employees Dental Program. You cannot change plans because of changesto the provider network. If your provider is not currently participating in the provider network, you may nominate him or herto join at tedentist.asp?DPO. Nomination forms are available on ourwebsite, or call us and we will have a form sent to you. Please note that Delta Dental offers various dental plans in the U.S.and not all Delta Dental network dentists are considered "in-network" for the Federal Employees Dental Program.Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialtyin all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance.Delta Dental's Federal Employees Dental Program and all other FEDVIP plans are not a part of the FederalEmployees Health Benefits (FEHB) Program.We want you to know that protecting the confidentiality of your individually identifiable health information is of the utmostimportance to us. To review full details about our privacy practices, our legal duties, and your rights, please visit our websiteat deltadentalins.com/fedvip. If you do not have access to the Internet or would like further information, please contact us bycalling 855-410-3255.Discrimination is Against the LawDelta Dental's Federal Employees Dental Program complies with all applicable Federal civil rights laws, to include both TitleVII of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, DeltaDental's Federal Employees Dental Program does not discriminate, exclude people, or treat them differently on the basisof race, color, national origin, age, disability, or sex.2021 Delta Dental'sFederal Employees Dental Program1Enroll at www.BENEFEDS.com
Table of ContentsIntroduction .1Table of Contents .2How We Have Changed for 2021 .4FEDVIP Program Highlights .6A Choice of Plans and Options .6Enroll Through BENEFEDS .6Dual Enrollment .6Coverage Effective Date .6Pre-tax Salary Deduction for Employees .6Annual Enrollment Opportunity .6Continued Group Coverage After Retirement .6Waiting Period .6Section 1 Eligibility .7Federal Employees .7Federal Annuitants .7Survivor Annuitants .7Compensationers .7Family Members .7Not Eligible .8Section 2 Enrollment .9Enroll Through BENEFEDS .9Enrollment Types .9Dual Enrollment .9Opportunities to Enroll or Change Enrollment .9When Coverage Stops .11Continuation of Coverage .11FSAFEDS/High Deductible Health Plans and FEDVIP .11Section 3 How You Obtain Care .13Identification Cards/Enrollment Confirmation .13Where You Get Covered Care .13Plan Providers .13In-Network .13Out-of-Network .13Emergency Services .13Plan Allowance .14Precertification/Predetermination Notice .14Alternate Benefit .14Dental Review .14FEHB First Payor .14Coordination of Benefits .14Right of Recovery .15Rating Areas .15Limited Access Area .15Section 4 Your Cost For Covered Services .16Deductible .16Coinsurance .162021 Delta Dental'sFederal Employees Dental Program2Enroll at www.BENEFEDS.com
Annual Benefit Maximum .16Lifetime Benefit Maximum .16In-Network Services .17Out-of-Network Services .17Plan Allowance .17Calendar Year .17Tooth Missing but Not Replaced Rule .17Section 5 Dental Services and Supplies Class A Basic .18Class B Intermediate .21Class C Major.26Class D Orthodontic .35General Services .38Section 6 International Services and Supplies .42Section 7 General Exclusions – Things We Do Not Cover.43Section 8 Claims Filing and Disputed Claims Processes .48How to File a Claim for Covered Services .48International Claims .48Deadline for Filing Your Claim.48Disputed Claims Process .48Section 9 Definitions of Terms We Use in This Brochure .54Stop Health Care Fraud! .56Summary of Benefits .57Rate Information .622021 Delta Dental'sFederal Employees Dental Program3Enroll at www.BENEFEDS.com
How We Have Changed for 2021We’re making discounts on LASIK services and hearing aids available to members, through our relationships with QualSightand Amplifon.We added the following procedure codes:D1353 Sealant repair – per toothD1354 Interim caries arresting medicament application – per toothD9311 Consultation with a medical health care professionalD2390 Resin-based composite crown, anteriorD2610 Inlay-porcelain/ceramic-one surfaceD2620 Inlay-porcelain/ceramic-two surfacesD2630 Inlay-porcelain/ceramic-three or more surfacesD2915 Re-cement or re-bond indirectly fabricated or prefabricated post and coreD2921 Reattachment of tooth fragment, incisal edge or cuspD3355 Pulpal regeneration – initial visitD3356 Pulpal regeneration – interim medication replacementD3357 Pulpal regeneration – completion of treatmentD5225 Maxillary partial denture-flexible base (including any clasps, rests and teeth)D5226 Mandibular partial denture-flexible base (including any clasps, rests and teeth)D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrantD5876 Add metal substructure to acrylic full denture (per arch)D6040 Surgical placement: eposteal implantD6050 Surgical placement: transosteal implantD6092 Re-cement or re-bond implant/abutment supported crownD6093 Re-cement or re-bond implant/abutment supported fixed partial dentureD6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includessurface cleaning of the exposed implant surfaces, including flap entry and closureD6104 Bone graft at time of implant placementD9932 Cleaning and inspection of removable complete denture, maxillaryD9933 Cleaning and inspection of removable complete denture, mandibularD9934 Cleaning and inspection of removable partial denture, maxillaryD9935 Cleaning and inspection of removable partial denture, mandibularD0340 2D cephalometric radiographic image- acquisition, measurement and analysisD0350 2D oral/facial photographic image obtained intra-orally or extra-orallyD0351 3D photographic imageD0470 Diagnostic castsD8681 Removable orthodontic retainer adjustmentD9219 Evaluation for moderate sedation, deep sedation or general anesthesiaD9613 Infiltration of sustained release therapeutic drug-single or multiple sitesD9943 Occlusal guard adjustmentD0701 Panoramic radiographic image – image capture onlyD0702 2-D cephalometric radiographic image- image capture onlyD0703 2-D oral/facial photographic image obtained intra-orally or extra-orally- image capture onlyD0704 3-D photographic image- image capture only2021 Delta Dental'sFederal Employees Dental Program4Enroll at www.BENEFEDS.com
D0705 Extra-oral posterior dental radiographic image – image capture onlyD0706 Intraoral – occlusal radiographic image – image capture onlyD0707 Intraoral – periapical radiographic image – image capture onlyD0708 Intraoral – bitewing radiographic image – image capture onlyD0709 Intraoral – complete series of radiographic images – image capture onlyD3471 Surgical repair of root resorption – anteriorD3472 Surgical repair of root resorption – premolarD3473 Surgical repair of root resorption – molarD3501 Surgical exposure of root surface without apicoectomy or repair of root resorption – anteriorD3502 Surgical exposure of root surface without apicoectomy or repair of root resorption –premolarD3503 Surgical exposure of root surface without apicoectomy or repair of root resorption - molarD6191 Semi-precision abutment – placementD6192 Semi-precision attachment – placementOther Changes:Benefit Limitations for Class C, Periodontic ServicesLocalized delivery of antimicrobial agents via a controlled release vehicle is not a covered benefit when provided inconjunction with scaling and root planing.Benefit Limitations for Class D Orthodontic ServicesCephalometric radiographs, 2D oral/facial photographic images, 3D photographic images, and diagnostic casts are onlycovered benefits when provided in conjunction with orthodontic treatment.2021 Delta Dental'sFederal Employees Dental Program5Enroll at www.BENEFEDS.com
FEDVIP Program HighlightsA Choice of Plans andOptionsYou can select from several nationwide, and in some areas, regional dental PreferredProvider Organization (PPO) or Health Maintenance Organization (HMO) plans, and highand 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 beneficiariesmay not be eligible to enroll in both. Visit www.opm.gov/dental or www.opm.gov/vision for more information.Enroll ThroughBENEFEDSYou enroll online at www.BENEFEDS.com. Please see Section 2 Enrollment for moreinformation.Dual EnrollmentIf you or one of your family members is enrolled in or covered by one FEDVIP plan, thatperson cannot be enrolled in or covered as a family member by another FEDVIP planoffering the same type of coverage; i.e., you (or covered family members) cannot becovered by two FEDVIP dental plans or two FEDVIP vision plans.Coverage Effective DateIf you sign up for a dental and/or vision plan during the 2020 Open Season, your coveragewill begin on January 1, 2021. Premium deductions will start with the first full pay periodbeginning on/after January 1, 2021. You may use your benefits as soon as yourenrollment is confirmed.Pre-tax Salary Deductionfor EmployeesEmployees automatically pay premiums through payroll deductions using pre-tax dollars.Annuitants automatically pay premiums through annuity deductions using post-taxdollars. TRICARE enrollees automatically pay premiums through payroll deduction orautomatic bank withdrawal (ABW) using post-tax dollars.Annual EnrollmentOpportunityEach year, an Open Season will be held, during which you may enroll or change yourdental and/or vision plan enrollment. This year, Open Season runs from November 09,2020 through midnight EST December 14, 2020. You do not need to re-enroll each OpenSeason unless you wish to change plans or plan options; your coverage will continue fromthe previous year. In addition to the annual Open Season, there are certain events thatallow you to make specific types of enrollment changes throughout the year. Please seeSection 2 Enrollment for more information.Continued GroupCoverage AfterRetirementYour enrollment or your eligibility to enroll may continue after retirement. You do notneed to be enrolled in FEDVIP for any length of time to continue enrollment intoretirement. Your family members may also be able to continue enrollment after yourdeath. Please see Section 1 Eligibility for more information.Waiting PeriodThe only waiting period is for orthodontic services. To meet this requirement, the personreceiving the services must be enrolled in this plan for the entire waiting period of 12months.2021 Delta Dental'sFederal Employees Dental Program6Enroll at www.BENEFEDS.com
Section 1 EligibilityFederal EmployeesIf you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP,if you are eligible for the Federal Employees Health Benefits (FEHB) Program or theHealth Insurance Marketplace (Exchange) and your position is not excluded by law orregulation, you are eligible to enroll in FEDVIP. Enrollment in the FEHB Program or aHealth Insurance Marketplace (Exchange) plan is not required.Federal AnnuitantsYou 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 foremployees of the Federal Government; retired for disability under CSRS, FERS, or another retirement system for employeesof the Federal Government.Your FEDVIP enrollment will continue into retirement if you retire on an immediateannuity or for disability under CSRS, FERS or another retirement system for employeesof the Government, regardless of the length of time you had FEDVIP coverage as anemployee. There is no requirement to have coverage for 5 years of service prior toretirement in order to continue coverage into retirement, as there is with the FEHBProgram.Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) 10retirement and postpone receipt of your annuity. You may enroll in FEDVIP again whenyou begin to receive your annuity.Survivor AnnuitantsIf you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant andyou are receiving an annuity, you may enroll or continue the existing enrollment.CompensationersA compensationer is someone receiving monthly compensation from the Department ofLabor’s Office of Workers’ Compensation Programs (OWCP) due to an on-the-job injury/illness who is determined by the Secretary of Labor to be unable to return to duty. You areeligible to enroll in FEDVIP or continue FEDVIP enrollment into compensation status.TRICARE-eligibleindividualAn individual who is eligible for FEDVIP dental coverage based on the individual'seligibility to previously be covered under the TRICARE Retiree Dental Program or anindividual eligible for FEDVIP vision coverage based on the individual's enrollment in aspecified 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 FEDVIPdental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligiblefor FEDVIP vision coverage. In addition, uniformed services active duty family memberswho are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.Family MembersExcept with respect to TRICARE-eligible individuals, family members include yourspouse and unmarried dependent children under age 22. This includes legally adoptedchildren and recognized natural children who meet certain dependency requirements. Thisalso includes stepchildren and foster children who live with you in a regular parent- childrelationship. Under certain circumstances, you may also continue coverage for a disabledchild 22 years of age or older who is incapable of self-support. FEDVIP rules and FEHBrules for family member eligibility are NOT the same. For more information on familymember eligibility visit the website at www.opm.gov/healthcare-insurance/ dental-vision/or contact your employing agency or retirement system.2021 Delta Dental'sFederal Employees Dental Program7Enroll at www.BENEFEDS.com
With respect to TRICARE-eligible individuals, family members include your spouse,unremarried widow, unremarried widower, unmarried child, an unremarried former spousewho meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibilityrequirements, 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 amental or physical incapacity.Not EligibleThe following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibilityor receipt of an annuity or portion of an annuity: Deferred annuitants Former spouses of employees or annuitants. Note: Former spouses of TRICAREeligible 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 familymember Active duty uniformed service members. Note: If you are an active duty uniformedservice member, your dental and vision coverage will be provided by TRICARE. Yourfamily members will still be eligible to enroll in the TRICARE Dental Plan (TDP).2021 Delta Dental'sFederal Employees Dental Program8Enroll at www.BENEFEDS.com
Section 2 EnrollmentEnroll ThroughBENEFEDSYou must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. BENEFEDS is asecure enrollment website (www.BENEFEDS.com) sponsored by OPM. If you do not haveaccess to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 toenroll or change your enrollment.If you are currently enrolled in FEDVIP and d
This brochure describes the benefits of Delta Dental's Federal Employees Dental Program under Delta Dental of California contract OPM02-FEDVIP-02AP-05 with OPM, as authorized by the FEDVIP law. The address for our administrative office is: Delta Dental of California . Federal Employees Dental Program . PO Box 537007 . Sacramento, CA 95853-7007
