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Humana Dentalfeds.humana.com1-877-692-24682022A Regional Dental Plan with PPO and EPO OptionsServing: Alabama, the majority of Arizona, Arkansas, California,Colorado, District of Columbia, Florida, Georgia, the majorityof Illinois, Indiana, Kansas, Kentucky, Louisiana, parts of Maryland,Mississippi, Missouri, North Carolina, Ohio, Oklahoma, SouthCarolina, Tennessee, Texas, Utah,Virginia and West VirginiaIMPORTANT Rates: Back Cover Changes for 2022: Page 3 Summary of Benefits: Page 60This plan has five enrollment regions; please see the end of this brochure to determine your region andcorresponding rates.PPO Options:EPO Options:High PPO Option Self OnlyStandard Advantage EPO Option Self OnlyHigh PPO Option Self Plus OneStandard Advantage EPO Option Self Plus OneHigh PPO Option Self and FamilyStandard Advantage EPO Option Self and FamilyAuthorized for distr ibution by the:United StatesOffice of Personnel ManagementHealthcare and Insurancehttp://www.opm.gov/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 the High PPO and the Standard Advantage EPO options under Humana DentalCompany contract OPM02-FEDVIP-02AP-10 with OPM, as authorized by the FEDVIP law. The address for ouradministrative office is:Humana DentalPO 14287Lexington, KY 40512877-692-2468http://feds.humana.comThis 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. You and your family membersdo not have a right to benefits that were available before January 1, 2022 unless those benefits are also shown in thisbrochure.If you are enrolled in this plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus Onecoverage, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Familycoverage, each of your eligible family members is also entitled to these benefits, if they are also listed on the coverage.OPM negotiates benefits and rates with each carrier annually. Rates are shown at the end of this brochure.Humana Dental is responsible for the selection of in-network providers in your area. Contact us at 877-692-2468 for thenames of participating providers or to request a provider directory. You may also request or view the most current directoryvia our website http://feds.humana.com. Continued participation of any specific provider cannot be guaranteed. Thus, youshould choose your plan based on the benefits provided and not for a specific provider’s participation. When you phone foran appointment, please remember to verify that the provider is currently in-network. If your provider is not currentlyparticipating in the provider network, you may nominate him or her to join. Contact us at 877-692-2468 to nominate aprovider who is currently not participating with the Humana Dental High PPO or Standard Advantage EPO Plan. You cannotchange plans, outside of Open Season, because of changes to the provider network.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.The Humana Dental High PPO and Standard Advantage EPO and all other FEDVIP plans are not a part of theFederal Employees 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 website,http://feds.humana.com and click on the “Privacy Practices” link at the bottom of the page. If you do not have access to theinternet or would like further information, please contact us by calling 800-459-6604.Discrimination is Against the LawHumana Dental Company complies with all applicable Federal civil rights laws, to include both Title VII of the Civil RightsAct of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, Humana Dental Company does notdiscriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.ENGLISH: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you.Call 1-877-692-2468 (TTY: 711).Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llameal 1-877-692-2468 (TTY: 711).
Table of ContentsIntroduction .1How We Have Changed For 2022.3FEDVIP Program Highlights .5A Choice of Plans and Options .5Enroll Through BENEFEDS .5Dual Enrollment .5Pre-Tax Salary Deduction for Employees .5Coverage Effective Date .5Annual Enrollment Opportunity .5Continued Group Coverage After Retirement .5Waiting Period .5Section 1 Eligibility .6Federal Employees .6Federal Annuitants .6Survivor Annuitants .6Compensationers .6Family Members .6Not Eligible .7Section 2 Enrollment .8Enroll Through BENEFEDS .8Enrollment Types .8Dual Enrollment .8Opportunities to Enroll or Change Enrollment .9When Coverage Stops .10Continuation of Coverage .11FSAFEDS/High Deductible Health Plans and FEDVIP .11Section 3 How You Obtain Care .12Identification Cards/Enrollment Confirmation .12Where You Get Covered Care .12Plan Providers .12In-Network .12Out-of-Network .12Emergency Services .12Plan Allowance .13Pre-Treatment Plan.13Alternate Benefit .13FEHB First Payor .13Coordination of Benefits .13Service Area .14Rating Areas .14Limited Access Areas .14Dental Review .14Section 4 Your Cost for Covered Services .15Co-payment .15Annual Benefit Maximum .15Lifetime Benefit Maximum .162022 Humana Dental1Enroll at www.BENEFEDS.com
In-Network Services .16Out-of-Network Services .16Emergency Services .16Calendar Year .16Section 5 Dental Services and Supplies Class A Basic - High PPO Option .17Class B Intermediate - High PPO Option .19Class C Major - High PPO .23Class D Orthodontic - High PPO Option .28General Services - High PPO Option .29Section 5 Dental Services and Supplies Class A Basic - Standard Advantage EPO Option.31Class B Intermediate - Standard Advantage EPO Option .34Class C Major - Standard Advantage EPO Option .38Class D Orthodontic - Standard Advantage EPO Option .46General Services - Standard Advantage EPO Option .47Section 6 International Services and Supplies .50Section 7 General Exclusions – Things We Do Not Cover.51Section 8 Claims Filing and Disputed Claims Processes .55How to File a Claim for Covered Services .55Deadline for Filing Your Claim.55Disputed Claims Process .55Section 9 Definitions of Terms We Use in This Brochure .56Stop Health Care Fraud! .59Summary of Benefits .60Rate Information .612022 Humana Dental2Enroll at www.BENEFEDS.com
How We Have Changed For 2022Changes to the plan:Changes to the plan include: D8670, Periodic orthodontic treatment visit. The current frequency is listed as 1 treatment per lifetime. We are changingto no frequency, no charge.The following procedure codes will change their limit description for the Standard Advantage EPO option for 2022:Class C Major services - Changing limit description: D3355 - Pulpal regeneration - initial visit (1 per tooth per lifetime) D3356 - Pulpal regeneration - interim medication replacement (1 per tooth per lifetime) D3357 - Pulpal regeneration - completion of treatment (1 per tooth per lifetime) D5110 - Complete denture maxillary (1 per 5 years) D5120 - Complete denture mandibular (1 per 5 years) D5130 - Immediate denture maxillary (1 per 5 years) D5140 - Immediate denture – mandibular (1 per 5 years) D5211 - Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) (1 per 5 years) D5212 - Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) (1 per 5 years) D5213 - Maxillary partial denture - cast metal (including retentive/clasping materials, rests and teeth) (1 per 5 years) D5214 - Mandibular partial denture - cast metal (including retentive/clasping materials, rests and teeth) (1 per 5 years) D5221 - Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth) (1 per 5years) D5222 - Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth) (1 per 5years) D5223 - Immediate maxillary partial denture - cast metal framework with resin denture base (including retentive/claspingmaterials, rests and teeth) (1 per 5 years) D5224 - Immediate mandibular partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) (1 per 5 years) D5225 - Maxillary partial denture - flexible base (including any retentive/clasping materials, rests, and teeth) (1 per 5years) D5226 - Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (1 per 5 years)We have added the following Dental codes to the Standard Advantage EPO and High PPO option for 2022:Class C Major services: D5227 - immediate maxillary partial denture - flexible base (including any clasps, rests and teeth) D5228 - immediate mandibular partial denture - flexible base (including any clasps, rests and teeth) D5725 - rebase hybrid prosthesis D5765 - soft liner for complete or partial removable denture – indirect2022 Humana Dental3Enroll at www.BENEFEDS.com
We have removed the following Dental codes to both the Standard Advantage EPO and High PPO option for 2022:Class D Orthodontic services: D8060 - interceptive orthodontic treatment of the transitional dentition D8690 - orthodontic treatment (alternative billing to a contract fee) D8050 - interceptive orthodontic treatment of the primary dentition2022 Humana Dental4Enroll 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 are 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.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.Coverage Effective DateIf you sign up for a dental and/or vision plan during the 2021 Open Season, your coveragewill begin on January 1, 2022. Premium deductions will start with the first full pay periodbeginning on/after January 1, 2022. You may use your benefits as soon as your enrollmentis confirmed.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 8,2021 through midnight EST December 13, 2021. 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 PeriodThere is no waiting period associated with this plan.2022 Humana Dental5Enroll 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 Members2022 Humana DentalExcept 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.6Enroll at www.BENEFEDS.com
With respect to TRICARE-eligible individuals, family members include your spouse,unremarried widow, unremarried widower, unmarried child, and certain unmarriedpersons place in your legal custody by a court. Children include legally adopted children,stepchildren, and pre-adoptive children. Children and dependent unmarried persons mustbe under age 21 if they are not a student, under age 23 if they are a full-time student, orincapable of self-support because of a mental 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).2022 Humana Dental7Enroll at www.BENEFEDS.com
Section 2 EnrollmentEnroll ThroughBENEFEDSYou must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. BENEFEDSis a secure enrollment website (www.BENEFEDS.com) sponsored by OPM. If you do nothave access to a computer, call 877-888-FEDS (877-888-3337), TTY number 877-889-5680 toenroll or change your enrollment.If you are currently enrolled in FEDVIP and do not want to change plans your enrollmentwill continue automatically. Please Note: Your plans’ premiums may change for 2022.Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health BenefitsElection 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 linkto BENEFEDS.Enrollment TypesSelf Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. Youmay choose a Self Only enrollment even though you have a family; however, your familymembers will not be covered under FEDVIP.Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitantplus one eligible family member whom you specify. You may choose a Self Plus One enrollmenteven though you have additional eligible family members, but the additional family memberswill not be covered under FEDVIP.Self and Family: A Self and Family enrollment covers you as the enrolled employee orannuitant and all of your eligible family members. You must list all eligible family memberswhen enrolling.Dual EnrollmentIf you or one of your family members is enrolled in or covered by one FEDVIP plan, that personcannot be enrolled in or covered as a family member by another FEDVIP plan offering the sametype of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIPdental plans or two FEDVIP vision plans.Open SeasonIf you are an eligible employee, annuitant, or TRICARE-eligible in
Humana Dental feds.humana.com 1-877-692-2468 . 2022 . A Regional Dental Plan with PPO and EPO Options . IMPORTANT Rates: Back Cover Changes for 2022: Page 3 Summary of Benefits: Page 60 Serving: Alabama, the majority of Arizona, Arkansas, California, Colorado, District of Columbia, Florida, Georgia, the majority
