Federal Dental Plans Comparison

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Federal Employee Cannot enroll in the Federal Dental Plans offered Here at www Benefeds com

Comparison Federal Benefeds Dental Plans

Exclusions & Limitations

Comparison Chart of Exclusions, Limitations and Time Frequency

Finding the Fine Print in Federal Dental Insurance Plans Coverage

Questions to Ask Before Deciding on Federal Benefeds Dental Plans. FAQ

Pre-Certification, Predetermination, Prior Review and Pre Authorization

Defining Reasonable and Customary Fee, Usual & Customary Charge, UCR, Maxium Allowable Charge, Discounted Fee Schedule, Network Allowance, Plan Allowance Negotiated Fee

COMPARISON FEDERAL BENEFEDS DENTAL INSURANCE PLANS
EXCLUSIONS, LIMITATIONS, WAITING PERIODS AND TIME FREQUENCY

There are many factors to analyze when conducting a Comparison of Federal Employees Benefeds Dental Insurance Plans, premium cost, reimbursement percentages for Preventive, Basic and Major Services and the Annual Maximum Benefit per person. Also the choice between a PPO Network with Out of Network Benefits, a Traditional Indemnity Dental Insurance with the Freedom to Use Any Dentist or possibly a Dental HMO Pre Paid Capitation Dental Program or a Discount Dental Referral Plan. Comparison of the Coverages Provided and an understanding of the Type of Dental Health Care Delivery System attached to each Dental Plan are just some of the factors to review and analyze.

It is equally important to compare and do a Comparison of the Federal Employees, Benefeds, Dental Plans EXCLUSIONS and LIMITATIONS, but MORE IMPORTANT to do a Comparison of the Federal Employees, Benefeds Dental Plans LOST or MISSING TOOTH PROVISIONS that apply to natural teeth you or a dependant may have lost or was placed or treated BEFORE your Federal Employees Dental Insurance Plans Coverage Effective Date. Additionally, Review and Compare the Federal Benefeds Dental Plans TIME LIMITS and WAITING PERIODS OR EXCLUDED BENEFITS that apply to the Repair and/or Replacement of Any DENTAL WORK DONE IN THE PAST AND ALREADY PLACED. When and if previous dental work is covered or will previous dental work ever become a covered service in the future. Another Section to Review and Compare is the TIME FREQUENCY FOR BENEFITS, ANALYZE what DENTAL PROCEDURES are subject to TIME FREQUENCY.

Knowing your Federal Employees Benefeds Dental Insurance Plans Benefits and having a general understanding of these Provisions will allow you to work closer with your Family Dentist to achieve superior Dental Health, with less aggravation and less out of pocket expense. A Comparison of the Federal Employee Dental Insurance Plans Claims Procedures, Average Claims Processing Turn-Around Time and attitude of the Dental Insurance Plans Claims Management toward Loss Ratios. Predetermination of Benefits, Pre-Authorization, Prior Review, Reports along with the Documentation required by the Dental Plans before a Treatment Plan can be approved. A Dental Insurance Plans Claims could be over managed creating long delays for approval of treatment plans and slow claims processing.

FEDERAL DENTAL PLANS COMPARISON

TIME FREQUENCY, LIMITATIONS AND EXCLUSIONS

BENEFITS IN OR OUT OF NETWORK	SMILE DENTAL	METLIFE	GEHA	AETNA	UNITED
REPLACEMENT OR REPAIR OF EXISTING Removable or Fixed Prostheses, dentures, crowns, inlays, onlays and fixed bridgework, initiated or PLACED PRIOR TO THE EFFECTIVE DATE OF THE PLAN.	YES, COVERED FROM THE EFFECTIVE DATE. (provided it has been 5 years from the date of placement or last replaced.) If replacement is necessary due to the loss or extraction of a natural tooth while covered, the 5 year replacement rule is waived.	NOT COVERED	ONLY IF DUE TO ACCIDENTIAL BODILY INJURY. Plan has a Third Party Responsibility Lein Provision to seek reimbursement from the responsible party. $2,000 Lifetime Maximum	NOT COVERED	NOT COVERED
Reline or Rebase Existing Dentures or Partial Denture Placed Prior to the effective date is available once every:	2 years, provided it has been 1 year from the date placed	NOT COVERED	NOT COVERED	NOT COVERED	NOT COVERED
Periodontal scaling and root planning per quadrant, benefits are available once every:	6 months	2 years	2 years	2 years	2 years
Periodontal Gingivectomy, gingival curettage	As Needed	Once every 3 years	Once every 2 Calandar years	As Needed	Once every 2 years
Periodontal Osseous surgery including flap entry.	As Needed	Once every 3 years	Once every 2 Calandar years	As Needed	Once every 2 years
BENEFITS TO PAY FOR THE REPAIR OR REPLACEMENT OF TEETH LOST OR MISSING PRIOR TO THE EFFECTIVE DATE OF COVERAGE.	YES, Gold & Silver Plans pay to replace missing teeth or dental work placed Prior to the Plan Effective Date, if the insured loses any related natural teeth while covered under the Plan, starting on the effective date. Any Teeth Lost or Missing Prior to the Plan effective date are covered after being insured under the Plan for 36 months.	NOT COVERED	NOT COVERED	NOT COVERED	NOT COVERED

DISPUTED CLAIMS	SMILE DENTAL	METLIFE	GEHA	AETNA	UNITED
Time insured has to file a Dispute or Reconsideration of the Initial Decision from the Date of Receipt of the Federal Dental Plans Initial Decision	Dental Plan Follows Rules and Regulations according to your State Department of Insurance	FEDVIP law DOES NOT provide a role for OPM to review disputed claims. 31 days	180 days	180 days	180 days
Time Federal Dental Plans have to Respond	" "	(not stated)	30 days	30 days	60 days
Time insured has to provide Additional Information to the Federal Dental Plans if requested to support the dispute	" "	(not stated)	60 days	60 days	30 days
Time Insured has to request an Independent Third Party Review	" "	(not stated) To QUALIFY for Third Party Review the charge for a procedure Must Exceed $1,000 and the reason for denial MUST BE based on the Metlife Dental necessity criteria or the Alternate Benefits Provision	90 days no min. $ amt.	30 days - claim must exceed $300	30 days no min. $ amt.

EXCLUSION OR LIMITATION	SMILE DENTAL	METLIFE	GEHA	AETNA	UNITED
Type of Dental Insurance Plans	Fee for Service Traditional Indemnity 100/20-40-60/10-25-50 R&C Variable Frame Current UCR Table	PPO Network Plan with 60/40/20 Std. 90/60/40 High oon Fixed Frame 80%-of Company Defined Fee Schedule	PPO Network Plan with Fee/55/35 Std. Fee/80/50 High oon Fixed Frame GEHA Fixed Fee Schedule	PPO Network Plan with Fee/60/40 oon Fixed Frame-75% of Company Defined Fee Schedule	PPO Closed Panel Plan Fixed Fee Network-Fixed Fee Schedule
Waiting Periods for Class A-B-C	None	None	None	None	None
Waiting Period for Orthodontics Class D	Not Covered	2 Years	2 Years	2 Years	2 Years
Take Over Credit or Transfer Credit for time spent insured under a Federal Dental Plan toward Orthodontics, Class D Waiting Period	N/A	None NO Credit Toward 2 Year Waiting Period is given if Insured switches from the Metlife Dental Standard Option to the Metlife Dental High Option Plan or vise versa during an Open Season. Insureds must remain covered under the Same Plan during 2-Yr. Waiting Period also during the time Benefits are Paid Out at 50%, as Billed, for the Service.	None Not Directly Addressed. Both GEHA Dental Standard and High Option Federal Dental Plans state that the Insured must be covered under The Plans for 2 Years.	None	None
ADDITIONAL NOTEABLE: Federal Dental Plans Exclusions, Limitations and Not Covered Services. The listed Policy Exclusions, Limitations and Not Covered Services are verbatim and appear throughtout each Federal Dental Plans Covered Benefits Section.	NONE This LINK will take you to a Sample Smile Dental Plan Policy including the page of Dental Expenses Not Covered.	#1) Not Covered: Removable or fixed prostheses initiated prior to the effective date of coverage. #2) Not Covered: Resin-based composite for Posterior teeth is Not a listed covered service. #3) Inlay-metallic one, two or 3 surface - An Alternate Benefit will be provided. #4) Prosthodontic Services are Limited to One in 5 years. #5) Class C Major Services Limited to One per Tooth every 5 Years. #6) Stainless Steel Crowns: Primary or Permanent Teeth: Limited to One per Tooth in 5 years	#1) For services listed with an asterisk (), the choice of a lower cost treatment is available. If you or your Dentist choose this treatment or service, we will allow the lower cost Alternate Benefit unless evidence is submitted with the bill to explain why the less expensive treatment could not be done. Services listed with an asterick() include all crowns, posts, inlays, onlays and resin based composite fillings for posterior teeth. Also listed with an (*) asterick is the Removal of Impacted Tooth-complete boney, with unusal surgical complications. #2) Removal of impacted tooth-removal of impacted third molars in Covered Persons is not covered unless specific documentation is provided that substantiates the need for removal and is approved by the Plan. #2) Section 6 No.2 General Exclusions: We DO NOT COVER the following: No.2 Services or treatment for the provision of an initial prosthodontic appliance(i.e. fixed bridge restoration, removable partial or complete denture, etc.) when it replaces natural teeth Extracted or Missing, Prior to the Effective Date of Coverage. #3) Fillings are Limited to one restoration per tooth surface every 2 calendar years. Subject to Least Costly, Dentally Accepted Material (amalgam, mercury & silver). #4) Stainless Steel Crowns: Primary or Permanent Teeth: Limited to One, per patient, per tooth, per Lifetime for covered Persons Under 15 years of age.	#1) Not Covered: Partial or full removable denture, fixed bridgework or other covered prosthetic services if it includes replacement of one or more natural teeth Missing Prior to you being covered. This does not apply, if it also includes, replacement of a natural tooth, that is removed, while you are covered, and was NOT an abutment to a prosthetic appliance, Installed during the Prior Eight Years. #2) Not Covered: Removable or fixed prostheses Initiated Prior to the Effective Date of coverage. #3) Not Covered: Replacement of existing dentures, casts and processed restorations, crowns, removable dentures, fixed bridgework, or other COVERED prosthetic services that had been Installed less then Eight Years Prior to the current replacement.	No Out of Network Benefits Payable #1) Not Covered: Removable or fixed prostheses Prior to the Effective Date of coverage. Or inserted/cemented after the coverage ending date. #2) Prosthodontic Services are Limited to One in 5 years. #3) Class C Major Restorative Services are Limited to One per 5 years. #4) Not Covered: Composite resin inlays. #5) Not Covered: Cast unilateral removable partial dentures. #6) Stainless Steel Crowns: Primary or Permanent Teeth: Limited to One per patient, per tooth, per Lifetime, covered through Age 14.

FEDERAL DENTAL PLANS COMPARISON

"OUT OF NETWORK"

PLAN BENEFITS

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BENEFITS	SMILE DENTAL	METLIFE Standard & High	GEHA Standard & High	AETNA	UNITED
Annual Deductible	$50 with a maxium of 3 deductibles per family or $150 maximum per year	$100-Std. / $50-High per covered person with NO Family Maxium. Each covered person must meet the deductible	$10 copay per visit - Plus Difference in Allowable Fixed Fee	Difference in Allowable Fee and Charged Fee.	No Coverage. Dental Emergency Only
Annual Maximum	Gold-$1,500 Silver-$1,000 Bronze-$750	Std-$600 High-$3,000	$1,200	$1,200	Lifetime Maximum of $2,000 for Dental Accidents
Reimbursements are based upon	Current Reasonable and Customary Fees for the Geographic area by zip code.	The 80th Percentile of the Metlife Company-Defined Allowable Fee Schedule. Insured Responsible for Difference in Charged Fee.	The Maximum Allowance as Determined by GEHA. Insured Responsible for Difference In Charged Fee.	The 75th Percentile of the Aetna Company-Defined Allowable Fee Schedule. Insured Responsible for Difference in Charged Fee.	Payment for Dental Emergency Only. NO Coverage Out of Network. Insured Responsible for Entire Fee Charged.

SERVICES	SMILE DENTAL	METLIFE	GEHA	AETNA	UNITED
Preventive Services Class A - Plan Pays	Gold, Silver & Bronze: 100% of the Current Reasonable and Customary Fee; Based on the Zip Code The Service is Received In. No Balance Bill.	Standard Option: 60%High Option: 90% of the Metlife Allowable Fee; based on 80% of the MetLife - Defined Table. Insured will pay difference in Metlife Fee and the Current R&C	Allowance Flat Fee Paid as determined by GEHA for both Standard & High Options. Insured will pay difference in GEHA Determined Flat Fee and the Current R&C	Allowance Flat Fee Paid as determined by the Aetna Defined Table of Allowance. Insured will pay difference in Aetna Flat Fee and the Current R&C	No Coverage Outside of PPO Network other then Emergency Care.
Basic Services Class B Plan Pays	Gold, Silver & Bronze Plans: First 12 months: 20% 13th mo-24th mo: 40% 25th mo & Thereafter:60% Always paid on the Current Reasonable and Customary Fee; based on zip code of the area Service is received. No Balance Bill.	Standard Option: 40%High Option: 60% of the Metlife Allowable Fee; based on 80% of the Metlife Defined Table of Allowance. Insured will pay the difference in the Metlife Fee Paid and the Current R&C	Standard Option: 55%High Option: 80% of the Fee Allowance as Determined by GEHA. Insured will pay the difference in the GEHA Fee Paid and the Current R&C	60% of the Aetna Allowable Fee; based on 75% of the Aetna Defined Table of Allowance. Insured will pay the difference in the Aetna Fee Paid and the Current R&C	No Coverage
Major Services Class C Plan Pays	Gold & Silver Plans: First 12 months: 10% 13th mo-24th mo: 25% 25th mo & Thereafter: 50% Always paid on the Current Reasonable and Customary Fee; based on zip code of the area Service is received. No Balance Bill.	Standard Option: 20% High Option: 40% of the Metlife Allowable Fee; based on 80% of the Metlife Defined Table of Allowance. Insured will pay the difference in the Metlife Fee Paid and the Current R&C	Standard Option: 35%High Option: 50% of the Fee Allowance as Determined by GEHA. Insured will pay difference in the GEHA Fee Paid and the Current R&C	40% of the Aetna Allowable Fee; based on 75% of the Aetna Defined Table of Allowance. Insured will pay difference in the Aetna Fee Paid and the Current R&C	No Coverage
Tax Free Premiums	Premiums qualify for tax free reimbursement under an HSA, HRA, or LEX HCFSA or accounts that are attached to the HDHP	Premiums are deducted pre-tax	Premiums are deducted pre-tax	Premiums are deducted pre-tax	Premiums are deducted pre-tax
Premium Rate Structure	Four-Tier Rates: Self; Self + One; Self + Child(ren); Self + Family	Three Tier Rates: Self; Self + One; Self + Family	Three Tier Rates: Self; Self + One; Self + Family	Three Tier Rates: Self; Self + One; Self + Family	Three Tier Rates:

Refer to each Federal Dental Plans Certificate of Coverage, or PDF File, for additional comparison information or details concerning coverage. Review the Covered Services Sections, which include plans limitations & exclusions. All of the above Exclusions & Limitations were found throughout the Certificates: Covered Services Sections and Do Not appear in Exclusions & Limitations. For your convenience there is a link on our home page to the Federal Employees Benefeds Dental Plans PDF File.

COMPARING FEDERAL EMPLOYEE DENTAL PLANS

AND FINDING THE FINE PRINT IN DENTAL INSURANCE PLANS

Many times the Dental Plans Provisions outlined above are overlooked and/or misunderstood since written into the Dental Insurance Plans, in fine print, at the bottom, or referenced with an asterisk and all throughout the Dental Plans Section Titled: "Covered Benefits" many, if not all, of the time frequency, limititations, waiting periods and exclusions are Not in the Dental Plans Section Titled: "Plan Exclusions and Limitations."

Similar to Pre-Existing Conditions or Waiting Periods but in reality Permanent Exclusion Riders, members unexpectedly, most often after Dental Procedures have been completed, are informed there is No Coverage or Dental Plan Benefits and the insured member is responsible for paying the entire Dental Bill. For example, if you are missing a tooth, Prior to joining a Federal Dental Insurance Plan, will the Federal Dental Insurance pay for the initial placement of the needed bridgework? The Federal Dental Insurance Plans will Not pay due to a Provision that requires, the tooth must be lost while covered under the Federal Dental Plan, in other words a Permanent Exclusion. In addition certain Federal Dental Insurance Plans require you must lose at least one Tooth Related to the Tooth Already Missing Before your Effective Date, EXCEPT the Tooth you lose while covered under the Plan CANNOT be an abutment to a prosthetic appliance. An abutment would be the tooth that a fixed bridge is attached to or the crown on either side of a single unit fixed bridge. The abutment is the most likely tooth to go bad since it is already crowned and used to support a bridge or has been stressed from supporting a partial over the years.

Time Limit Frequencies on Procedures and/or Waiting Periods before the insured can Replace any existing Dental Work done in the past, if covered under the policy are necessary to know and compare, since dental work and dental appliances don't last forever and periodontal services could be required more often then the Dental Plans Time Limit Frequencies allow. Again, listed under or part of the "Covered Benefits Section" and not addressed under "Dental Plan Exclusions and Limitations," there are Waiting Periods insureds must satisfy before Dental Insurance benefits are available for replacement of Dental procedures done in the past. Additionally, the Frequency of a Benefit is an important factor. Some Dental Insurance Plans will refuse to pay benefits for a second teeth cleaning if six months, and not a day less, have passed since the last cleaning appointment. This is a timed frequency benefit which makes it difficult to properly schedule a families cleaning appointments. Concerning replacement, when Dental services fail prematurely, most of the time, we refuse to go back to the Dentist that preformed the services, and filing formal complaints against the Dentist is never a pleasant situation. Finding and Keeping a Quality Dentist will save teeth and thousands of dollars by avoiding the need to have bargain cut rate, inferior quality and/or less expensive "alternate treatment" Dental procedures done over again.

The Smile - Federal Employee Dental Plan

Difference

The NALC Gold and Silver Dental Insurance Plan Options cover dental work that was Placed Prior to your Effective Date starting on the First Day of Coverage. If an Insured member were to lose a natural tooth after becoming covered under the NALC Smile, Federal Employee Dental Plan it of course would be covered from the effective date. If the tooth lost is related to or adjacent to a Tooth Missing Prior to the Effective Date, or the lost tooth is an abutment to an existing dental appliance, then BOTH TEETH are Covered. In addition, the Replacement of existing dentures or fixed bridgework that cannot be repaired and the replacement of existing inlay, onlay or crowns Placed Before the Effective Date of coverage are also covered, provided it has been 5 years from the date they were initially placed or last replaced starting on the Effective Date of the Smile Dental Plan. The 5 year limitation is even waived if the insured were to loose a natural tooth while covered under the plan. Unique among Dental Plans after being insured under the Smile Dental Plan for 36 months, the Gold and Silver NALC Smile, Federal Employee Dental Insurance Plans will pay for any Teeth Missing Prior to the Effective Date. The Benefits for Teeth Missing Prior to the Effective Date become available due to a limitation listed under, Major (class C) Covered Prosthetic Services, addressing coverage for lost teeth while covered under the Dental Plan that no longer applies after being insured under the Dental Plan for 36 months. These Benefits alone separate the NALC Smile, Federal Employee Dental Insurance Plans from the competition. Members are rewarded with Increased Benefits for their continuation of coverage. Most Dental Plans will Never pay any benefits for teeth missing prior to the effective date or pay benefits for dental work and/or prosthetic appliances placed before the policy effective date. Benefits for Major (class C) services in the first twelve months of coverage are 10% Increasing to 25% at the end of 12 months, then Increasing again to 50% at the end of 24 months may seem minimal at first, but the Dental Plan provides coverage from the Effective Date and has No Waiting Periods. Enroll in the NALC Smile Federal Employee Dental Plan a Dental Plan that provides First Day Coverage for your Already Placed Existing Dental Work and provides Benefits for Teeth Lost or Missing Prior to the Dental Plan Effective Date. A Federal Dental Plan worth keeping without a lot of red tape or hidden exclusions. No List of Provider Dentist to hassle with. Never be "Out of Network" or penalized with reduced benefits or get balance billed the difference in the Dental Plans Allowable PPO Network Fee or Company Defined Allowable Fee.

DENTAL HEALTH QUESTIONS TO ASK BEFORE SELECTING A DENTAL PLAN

Most of us know or have an idea of what are Dental needs are. Cleaning twice per year per person are built into Dental Plans premium cost, so it is assumed all members will seek a cleaning twice per year per person. In addition to the Smile Gold and Silver Federal Dental Plans the Smile Federal Dental Plan offers you a Bronze Plan that covers Preventive and Basic Services Only and No Major Services at a very affordable monthly premium. The Bronze Dental Plan works well for individuals or families that don't foresee the need for Major Dental work other then possibly x-rays, fillings or oral surgery which are all covered under Basic Services. Ask yourself these questions, which will better enable you to make the right choice of a Voluntary Dental Insurance Plan that will serve your families current and future Dental Health needs.

Do you have a Dentist, or would you prefer to go to, or back to a particular Dentist?

Have you checked the background of your Dentist or the Dentist you would select from a PPO Network with an Internet Dentist Background Checker, your local State Dental Association or Public Court Records?

If considering a PPO Network or Dental HMO, do the PPO Networks or Dental HMO's have enough participating Providers and Specialists to treat and service the members enrolled? Call and check the available appointment times and are they within a reasonable time frame? Can each member in your family get an appointment, twice per year, to have their teeth cleaned and be able to maintain Good Dental Health by utilizing the already paid for teeth cleaning benefits?

If considering a PPO Network or Dental HMO are the Dentist in your area reluctant to participate as a provider due to the compensation agreements offered by the PPO Network or Dental Insurance Plan? What is the procedure and how difficult is it to see a Dental Specialists? How many specialists are on the list and what are the benefits if my child(ren) seek services from a Pedodontist? Are there enough Endodontist?

Does anyone proposed for coverage need dental work, other then Preventive, Now and would the dental work be covered?

Is any family member missing any teeth, and considering bridgework to replace the missing tooth? Will the Dental Insurance pay any benefits for teeth missing or lost prior to being covered?

Does any family member need or foresee the need to have Previously Performed Dental Services repaired or replaced? How old must the Previous Dental Work be before it would be considered eligible for repair or replacement? Can you get the Dental Records if requested to prove how old it is?

Is my current dental work over 10 or 15 years old and getting to the point of possible replacement? If so, how long do I need to be covered before I can have it replaced and will the dental plan I select provide benefits without having to lose teeth while covered under the Plan?

Will the Dental Insurance Plan pay benefits toward the cost of General Anesthesia including Intravenous Sedation, for oral surgery or is it a limited benefit?

Does anyone need Periodontic (gums) Surgery or Continued Maintenance and will the cleanings, scaling and root plannings be covered, what is the time frequency of the periodontic benefit?

Do I want to be Locked In to one Dental Insurance Plan for approximately four years for a Child Only Orthodontic Benefit?

Can you postpone or get some type of alternate treatment for a currently needed Dental procedure not covered for the time necessary for it to become covered under the Dental Insurance Plan

Are you and your dependants in Good Dental Health and only concerned about semi annual cleanings or possibly fillings, x-rays or oral surgery and don't have any Major Dental problems, or foresee Major problems and don't want to pay the increased premium rates for a Dental Plan that includes Major (class C) services and Orthdontic (class D) services?

Would a Dental HMO better suit your dental needs because there is no annual maximum benefit and you or your family need a lot of dental work that would far exceed the Indemnity Plan annual maximums?

PRE-CERTIFICATION, PREDETERMINATION, PRIOR REVIEW AND PRE AUTHORIZATION

Policyholders and Dental Offices having to submit supplemental written reports including evidence to justify a recommended treatment plan, in addition to a Predetermination Claim Forms and Standard Claim Forms can quickly become annoyed. Dental treatment is postponed or the Policyholder and Dental Office become impatient with the delay of pending claim payments, which could be denied, paid as Alternate Treatment resulting in partial payment or remain pending for incomplete documentation. Predetermination of Benefits should be submitted BEFORE treatment is STARTED if the proposed treatment exceeds $300 to $500. Pretreatment review is Rarely Required, but is often requested by Dental Insurance Plans. If Pretreatment review is NOT Submitted it puts the insured in a position to receive a minimum benefit or the "Alternate Treatment" benefits. So submitting a Predetermination or pretreatment review BEFORE any dental treatment is performed is HIGHLY Recommended. ALWAYS submit Pretreatment review for your own benefit and you will know more about where you stand. Approval of a Predetermination Claim does not guarantee payment of claims but should surface obvious Non Covered services and provide the insured an estimate of their out of pocket cost. A Predetermination notifies an insured of any additional documents or records that may be required before the treatment plan can be approved. Submitting a Predetermination can alert the insured that the Dental Insurance Company will only approve "Alternate Treatment" benefits or the less expensive course of treatment. This means the Dental Plan has determined that the restorative need to the rendered service was not established and the benefits are reduced. An example would be allowing benefits for a filling and not a crown. This can be a major difference in benefits and the insureds out of pocket expense.

The NALC Voluntary Federal Employee Dental Plans request that a predetermination form be submitted if the course of treatment is to exceed $300. There is no contractual Penalty to the insured for not submitting pretreatment review but the Dental Plan has the option and can pay for the least expensive method of treatment regardless of the method used. It is HIGHLY recommended that the insured member submit pretreatment review to be able to get the maximum benefits in addition to the reasons outlined above. The Dentist treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays would be required. The insured is Not required to submit written supplemental reports or justification summaries this would be unusual and something an insured might do if involved in a claims appeal. The average time for claims turn around with the NALC Dental Plan is 15 to 30 business days. Preventative (class A) claims are generally within 15 business days. As a part of the General Provisions contained in the Security Life Dental Plan Certificate it states under Time Payment of Claims " We will pay immediately, or within 30 days following receipt of due written proof of loss, all benefits under the policy. If we fail to pay your claim within 30 days of Our receipt of due written proof of loss, We will pay interest at a rate of 9% per annum. Interest will be paid from the 30th day after Our receipt of due written proof of loss to the date We pay the claim.

WHAT IS THE DEFINITION OF REASONABLE AND CUSTOMARY FEE, UCR, ALLOWABLE FEE, SCHEDULED FEE, NETWORK ALLOWANCE, PLAN ALLOWANCE, MAXIMUM ALLOWABLE CHARGE AND NEGOTIATED NETWORK FEE ?

Defining the definition of a Reasonable and Customary Fee is somewhat like defining the Retail Price of Diamond Jewelry or Furniture. Reasonable and Customary Fee is referred to in most Dental and Medical Insurance contracts as the R&C Fee, or can be referred to as the UCR Fee meaning the Usual, Customary and Reasonable Fee. Other terminology utilized is The Average Charged Fee or The Most Common Fee Charged in the Geographic Area where the Charge is Incurred. Insurance Company actuaries need to know what the average cost of dental or medical services will be, to calculate what they think will be the correct factors or premium rates for a given policy. One of the most common ways to get the Reasonable and Customary Fees is through the Health Insurance Association of America (HIAA) now called the America's Health Insurance Plans (AHIP) which represents nearly 1,300 Insurance Companies that provide coverage to more then 200 million Americans. Some policies will state that the Reasonable and Customary Fee is based on the average HIAA or AHIP fee and the R&C is adjusted upward or downward each month and reported to the claims division. Another method is for Dental Insurance Companies to calculate a Reasonable and Customary Fee as a percentile (e.g. 90th percentile table) of fees reported on claims. The calculation of the R&C maximum fee is based upon carrier-defined geographic areas and carrier-defined time periods.

An important point to make is that the Reasonable and Customary Fee or UCR Fee is NOT the same as an Allowable Fee, Scheduled Fee, Negotiated Fee, Network Allowance, Plan Allowance, Maximum Allowable Charge, or Network Allowable Fee. These acronyms refer to either an Internal Maximum Fixed Fee Schedule, most often printed in the policy, or the Reduced or Discounted Fee Negotiated for the Dental Insurance Company by a Provider Network Company. When a policy states that it will pay its benefit percentage based upon the Provider Network established Reasonable or Allowable Fee, this means you will likely be balanced billed by the dental office for the difference in the Reduced Negotiated Network Fee and the Reasonable and Customary Fee. Understanding that some Provider Network Reduced Fees can be Discounted as much as 50 percent off of the Normal Fee or Current Reasonable and Customary Fee. For example, if the Normal or R&C Fee is $800 and the Allowable Network Fee is $400, and the policy is due to pay 50 percent of the Allowable Fee, the reimbursement would be $200 and the insured would be Balance Billed in the amount of $600. The Insurance Policy ends up only paying 25 percent of the Normal Reasonable and Customary Fee and Not 50 percent because the reimbursement is based on the Network or Plan Allowable Fee, Reduced Discounted or the Negotiated Network Fee. This would be an example of being Out of Network with a 50 percent benefit payable on the Allowable Network Fee.

Additionally, a Dental Insurance Policy that has a Maximum Allowable Fee Schedule will only reimburse the insured member up to the amount shown in the Policies Internal Schedule of Benefits. The Policy may state that it pays 80 or 50 percent of the R&C not to exceed the Schedule of Benefits. The schedule of benefits, or Internal Maximum Allowable Fee Schedule could be only 35 or 40 percent of the normal Reasonable and Customary Fee. Many times the Fixed Fee Schedule is part of the Policy and the Fixed Fees for the services covered are listed, but sometimes the schedule is only available to the Insurance Company and the insured has no idea how much the benefit will be. These Plans are like Co-Payment Plans but since they are indemnified they could be considered a reverse Co-Payment Plan. An example would be: the normal Reasonable and Customary Fee is $800, the Policy pays 50 percent of the R&C not to exceed the Maximum Allowable Schedule of Benefits. On the Policy Internal Schedule of Maximum Allowable Charges the Covered Service is listed for $250. The insureds benefit would be $250. The percentage of the R&C seems to only exist for the benefit of the Insurance Company in the event that if 50 percent of the actual Charged Fee was less then $500, the reimbursement to the insured would be less then the Internal Schedule. Which very rarely ever happens unless in an area where the cost for the covered services were extremely low. The insured would then be responsible for $550. These type of Fixed Internal Schedule of Maximum Allowable Charges Insurance Plans will also use Provider Networks and the Internal Maximum Allowable Fee many times will still be less then the Reduced Network Fee, leaving a balance bill to the insured even when using a provider in the Plan Network.

The Dental Plan Comparison information should familiarize you with some of the inter-working details pertaining to the Federal Employee FEDVIP Dental Insurance Plans but also with Dental Plans in general. We hope the Dental Plan Comparison enables you to make a better decision with a greater understanding when comparing the available Federal Employee Dental Programs. If you have any questions please feel free to eMail us at the address below. Keep Smiling!

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