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Advice for 2020 Dental Federal Enrollment

This is the open enrollment period for the federal government, and as in the past, we wanted to provide what we hope will be useful analysis and information regarding the available dental benefit options, with which we participate. The following is a review of information from the Office of Personnel Management.

Why are we providing this information to you?We want our patients to make the best decisions about their dental health and about their choice of dental insurance coverage.

The Basics:In examining possible insurance, there are core principles to understand:

  • If you have more than one insurance plan, then your insurance plans will decide who is primary and secondary (and a few patients even have tertiary insurance). A federal VIP plan is usually secondary, paying after the primary plan. Each plan pays against its own limits and rules.
  • High option versus low option plans – Some VIP plans offer either high option and low option plans (we were not able to verify a Humana low option plan). The high option plan costs more, but will provide considerably more in terms of total coverage, but is not necessarily the best option for many patients.
  • Coordination between more basic dental plans and VIP plans is a critical issue.For example, not all VIP plans coordinate appropriately with the CareFirst limited dental coverage under their medical plans, categorized as FEP low option (104/105/106) or high option (111/112/113) plans. We’ve included in the table below our feelings as to how well such coordinate. Better coordination for the patient results from respecting the fee schedule of the primary insurance, and providing benefits up to the full amount available to the patient. FEPBlue, for example, is deceptively unfair in coordinating, to the patient’s detriment (higher costs to the patient). If you have one of the FEP numbered plans, we discourage you from selecting FEPBlue as your dental VIP plan. Most other high-option plans do a relatively good job of paying up to their maximums to reduce or remove any gap in coverage.
  • The primary features of PPO dental insurance which should inform your selection of a plan and understanding the benefits of a policy are:
    • the monthly/annual premium cost of the insurance;
    • maximum annual benefits (the total ceiling of benefits the insurance will pay per patient per annual period) that resets on a calendar or benefit year, yet note that ortho maximums are for a lifetime;
    • the deductible, both individual and family, and to which procedures such apply (e.g., cleanings are regularly excluded from the deductible);
    • co-insurance or coverage classes and percentages (each plan will have predefined coverage percentages for classes of procedures);
    • Classes of Procedures:
      • Basic, which includes restorative (fillings), and regular periodontal procedures (versus one-off and less frequent procedures such as a full-mouth debridement or scaling and root planing); and
      • Major, which includes crowns, bridges, gum surgery, implants, and dentures.
    • Downgrades: A downgrade means that insurance replaces a higher cost procedure that uses better materials that are more attractive with a lower cost, less sound or appealing procedure, so in the case of posterior fillings (there is no downgrade for anterior or front-teeth fillings) the insurer pays the covered percentage for an amalgam (metal) filling and the patient is responsible for the difference between what was covered for the lower fee amalgam procedure and the procedure actually completed.

Our Recommendations and Deciding Between Plans

Our office would recommend the Aetna or GEHA plans, in considering price and the coverage offered.  GEHA offers better perio-related coverage, so if you had to decide between Aetna or GEHA, if you are a perio patient, you may want to consider GEHA.  In this chart, we provide a breakdown of the major coverage items introduced above, for the federal VIP plans (and which should also apply to standalone plans, i.e. the plan is selected as primary), with a breakdown of the different coverages provided by each type of plan with which we participate.  We didn’t include Cigna because it doesn’t offer a VIP plan, but does offer a standalone plan.  UHC is a new entrant, and until they develop a track record, we are holding off on making a recommendation. Delta, on the other hand, has one of the higher premiums for its plans, without complementary coverage limits.  We would discourage patients from selecting either Delta or FEP Blue.

The high option plans offer a lot of coverage, and for a higher fee.  Not everyone needs this much dental coverage.  In making your decision, consider how much work you have had done each of the last three years (or that you have been putting off), and if you would benefit from the higher maximums and higher coverage limits for each type of procedure when compared against the higher premium cost.  For some patients, the high option is too much coverage, particularly if you are in good oral health, have good dental genes, and don’t anticipate needing much coverage in the near future.  In other cases, i.e. families or individuals who are planning for some major procedures, including orthodontics or Invisalign, one option may be to opt for a high-option plan to complete any major work, including periodontal, surgical or implant procedures, and once your oral health has stabilized, to switch to a low option plan.  Each of you will have to make an independent and personal decision, as the above is provided only as general guidance, but we’re happy to help each of you evaluate such.