May 2019 Volume LIV Number 3

 
 
 
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Coding Corner

May 2019 Volume LIV Number 3

2019 Brings Changes to FEDVIP that Will Affect Your Patients
 
The Federal Employee Dental and Vision Insurance Program (FEDVIP) has provided dental and vision benefits to federal employ- ees, retirees, and their dependents since 2004. For our members who participate in FEDVIP or the Federal Employee Health Benefit (FEHB) program, this article describes key plan modifications made by some national payers for their FEDVIP dental plans in 2019. Detailed summaries of the 2019 FEDVIP dental plan options and benefits can be found at www.opm.gov/healthcare-insurance/ dentalvision/plan-information.

WHAT IS FEDVIP?
The FEDVIP program is made up of four regional HMO/PPO payers (Dominion Dental, Emblem Health Dental, Humana, and Triple-S Salud) and six national payers (Aetna, Blue Cross Blue Shield [FEP Dental Blue], Delta Dental, Government Employees Health Association, Inc. [GEHA], MetLife, and United Concordia). These payers admin- ister FEDVIP dental plans for eligible federal and postal employees, retirees, and their eligible family members where the enrollee pays for coverage. International coverage is offered under the nationwide plans.
 
WHO IS AN ELIGIBLE FEDVIP BENEFICIARY?
Federal employees can choose to enroll in a dental plan for self only, self plus one, or self and family coverage. Eligible family members include the employee’s spouse and unmarried dependent children, including stepchildren, legally adopted children, and foster children living with the federal em- ployee in a regular parent-child relationship under age 22, and older disabled children incapable of supporting themselves.
 
Rules for family member eligibility differ between FEHB and FEDVIP. Visit https:// www.opm.gov/healthcareinsurance/dental-vision for complete details on eligibility for FEHB and FEDVIP. The federal employees may also contact the federal agency in which they are employed or retirement system for additional information or clarification regarding family member eligibility. Eligible federal employees (and their family members) are not required to be enrolled in the FEHB plan to enroll in a FEDVIP plan. Similarly, a doctor may choose to participate with a FEDVIP plan and not participate with the FEHB plan. Likewise, all of the national FEDVIP plans allow federal employee members to obtain treatment from out-of-network providers. Treatment provided by a non-enrolled dentist may result in reduced benefits.
 
FEDVIP 2019 BENEFIT PLAN HIGHLIGHTS
Aetna’s Changes for the High Option FEDVIP Plan 
 
The 12-month waiting period for Class D Orthodontic Services has been removed.
 
The plan increased the Annual Benefit Maximum for in-network benefits from $25,000 to $30,000. 
 
It is important to note that the out-of- network Annual Benefit Maximum is $2,000. Once the $2,000 is reimbursed for in- or out-of-network services, services rendered by an in-network provider only are eligible for reimbursement for up to the $30,000 maximum. No benefits, in- or out-of-network combined will exceed $30,000.
 
The filing deadline for submission of claims for Aetna must be submitted by December 31 of the year following the year in which services were rendered, unless the claim could not be submitted due to admin- istrative operations of  government or legal incapacity, as long as the claim was submitted as soon as possible. Benefit checks must be cashed within two years of  payment.
 
Delta Dental Changes
Adult orthodontic coverage has been added to the High Option plan.
 
Patients with Type 1 or Type 2 diabetes are allowed a third prophylaxis in a calen- dar year (D1110 or D1120). To receive this additional prophylaxis, a statement from the patient’s physician documenting the Type 1 or Type 2 diabetes is required.
 
FEP Dental Blue’s Changes
Standard Option calendar limitation for any combination of procedures D1110, D1120, and D4346 has increased to three per calendar year. The High Option plan remains at a limitation of two per calendar year for any combination of procedures D1110, D1120, and D4346. For ages 14 and over, any of the three combinations refer- enced above are processed as D1110. D4346 is processed as D1110 and the patient is not responsible for the difference in fee.
 
CDT 2019 new codes D0412 (blood glu- cose level test), D5876 (add metal substruc- ture to acrylic full denture), D9613 (infiltra- tion of sustained release therapeutic drug), and D9946 (occlusal guard, hard appliance, partial arch) are specifically listed as excluded from coverage.

Government Employees Health Association, Inc. (GEHA) Changes
 
The following CDT codes were added as covered services:
  • D1516 space maintainer – fixed – bilat- eral, maxillary
  • D1517 space maintainer – fixed – bilat- eral, mandibular
  • D1526 space maintainer – removable – bilateral, maxillary
  • D1527 space maintainer – removable – bilateral, mandibular
  • D9944 occlusal guard – hard appliance, full arch
  • D9945 occlusal guard – soft appliance, full arch
  • D9946 occlusal guard – hard appliance, partial arch
 
The High Option lifetime maximum for orthodontic covered services has increased to $3,500 per person for 2019.
 
Procedure code D4346 is considered for reimbursement under periodontal services, not preventive, and is limited to a single D4346 procedure every two calendar years.

Metlife’s FEDVIP Changes for the High Option Plan
The annual maximum of benefits per person increased from $35,000 to unlimited.
 
The in- and out-of-network orthodontic coinsurance increased from 50 to 70 percent.
 
The orthodontic services lifetime maxi- mum for dependent children increased from $3,500 to $5,000 for treatment started Jan. 1, 2019 or after.
 
The orthodontic services lifetime maxi- mum for adults increased from $1,500 to $3,000 for treatment started Jan. 1, 2019 or after.
 
Metlife’s FEDVIP Changes for the Standard Option Plan
The out-of-network annual maximum increased from $800 to $1,000.
 
The out-of-network orthodontic services lifetime maximum for dependent children in- creased from $1,500 to $2,000 for treatment started Jan. 1, 2019 or after.
 
Dependent child coverage for orthodontic services increased from $1,500 to $2,000 for treatment started Jan. 1, 2019 or after.
 
Adult coverage for orthodontic services was added with a combined in- or out-of- network lifetime maximum of  $2,000. This maximum will be for adult orthodontic treat- ment that begins on Jan. 2, 2019 or after.
The following age limitations for depen- dent child orthodontic services:
 
Increase from age 19 to age 22 for fed- eral civilian enrollees.
TRICARE® enrollee dependent children will be covered to age 21 with fulltime student covered until age 23. No age limitation for dependent children who are incapable of self-support for both federal civilian and TRICARE® enrollees. All subject to orthodontic plan provisions.
 
United Concordia Changes
Annual maximum is unlimited.
 
Upon submission of proof of prior orthodontic coverage in 2018, the 12 month waiting period for orthodontic services, may be waived.
 
Procedure code D4346 is considered under the periodontal services benefit class for ages 16 and over, once in a 24 month period and shares a frequency limitation with a prophylaxis of two per calendar year.
 
Plan modifications made by some regional payers for their FEDVIP dental plans in 2019 are highlighted below.
 
Humana FEDVIP Changes
The plan summary description indicates the addition of the following CDT codes as covered services for 2019:
  • D1516 space maintainer – fixed – bilat- eral, maxillary
  • D1517 space maintainer – fixed – bilat- eral, mandibular
  • D1526 space maintainer – removable – bilateral, maxillary
  • D1527 space maintainer – removable – bilateral, mandibular
  • D9944 occlusal guard – hard appliance, full arch
  • D9945 occlusal guard – soft appliance, full arch
  • D9946 occlusal guard – hard appliance, partial arch
 
Procedure code D4346 is considered un- der periodontal services with required copay as listed in the plan description. D4346 is subject to a limitation of one per 36 months.
 
Humana FEDVIP is a copay plan; there- fore, there are no claims to submit for in- network services. This FEDVIP plan does not offer out-of-network benefits. An out-of-net- work provider treating a patient for emergen- cy services should submit a 2012 ADA dental claim form for emergency services rendered to be considered for reimbursement. Refer to the plan summary description for details regarding emergency services rendered by an out-of-network provider.
 
Dominion Changes
A third annual prophylaxis has been added for all members, at a reduced fee.
 
The following CDT codes have been added, subject to any required copay as out- lined in the plan description:
  • D0600 non-ionizing diagnostic proce- dure capable of  quantifying, monitoring and recording changes in structure of enamel, dentin, and cementum
  • D0601 caries risk assessment and docu- mentation, with a finding of low risk
  • D0602 caries risk assessment and docu- mentation, with a finding of moderate risk
  • D0603 caries risk assessment and docu- mentation, with a finding of high risk
  • D7979 non-surgical sialolithotomy
  • D9222 deep sedation/general anesthesia– first 15 minutes
  • D9239 intravenous moderate (conscious) sedation/analgesia – first 15 minutes
 
There are no claims to be submitted since Dominion is a copay based HMO plan. There are no out-of-network benefits for this plan, emergency services may be considered. See the plan summary description for details on submitting emergency services provided by an out-of-network provider.
 
Triple-S Salud Plan Changes
The following CDT codes were added as covered services:
  • D8695 removal of fixed orthodontic ap- pliances for reasons other than comple- tion of  treatment, covered under the benefit maximum

Emblem Health Changes
Emblem’s plan summary description indicated no significant changes to the plan summary/ description for 2019; however, it is advisable to review the summary as needed to answer any specific questions about the Emblem Health FEDVIP plan.
CHANGES IN THE TRICARE
 
PROGRAM THAT MAY AFFECT YOUR PATIENTS
One of the most significant changes affecting the FEDVIP program for 2019 is the TRICARE®   retiree dental program that ended Dec. 31, 2018. The retirees and family members previously eligible and covered by the TRICARE® Retiree Dental Program (TRDP) became eligible to enroll in a FED- VIP benefit plan just as other eligible federal employees. Patients in this group will have more plans with various provider networks to choose from than before under the TRI- CARE® Retiree Dental Program.
 
Active duty uniformed service members (and family members) will continue to be provided dental and vision coverage by TRI- CARE®. They are not eligible for FEDVIP plan enrollment.
 
TRDP members newly enrolled in a FEDVIP plan for 2019 will be covered for in- progress treatment regardless of  any current FEDVIP plan exclusions for care initiated prior to the enrollee’s effective date. However, FEDVIP payers will not cover in-progress treatment if  the enrollee has enrolled in a plan with a waiting period or if the plan does not cover the in-progress treatment. For example, orthodontic benefits vary by plan with plans available with a waiting period or without a waiting period.
 
OUT-OF-NETWORK  BENEFITS
Patients covered by FEDVIP may elect to receive dental care from an out-of-network provider for most plans. Services rendered by an out of network provider are reimbursed at an out-of-network plan allowance.
 
Many of the FEDVIP plans, such as the plan administered by Aetna, set their out-of- network allowable fees using Fair Health fee data. Fair Health fee data is obtained from actual claims submitted by dental providers for services rendered. This information includes the date of service, place of service, procedure code (CDT, CPT®, and HCPCS) and the fee for the service(s) rendered.
 
Fair Health then combines this informa- tion into a database to determine the average fee in a given geographical area (zip code). The fee data is grouped in percentiles from lowest to highest with charges in the middle being 50th percentile of  the area. Aetna FEDVIP uses the 80th percentile fee range for a given geographical area to determine the allowable amount paid for services ren- dered by an out-of-network provider.
 
The patient’s coinsurance is calculated based on this plan allowance. For Aetna FED- VIP members, the patient is responsible for the coinsurance plus the difference between the billed amount and the plan allowance when electing to receive services performed by an out-of-network provider.
 
Each FEDVIP plan outlines any out-of- network benefits available in the plan descrip- tion and can vary by plan. More information about Fair Health fee data may be found by visiting www.fairhealth.org.
 
If the FEDVIP enrollee lives in an area with limited access to in-network providers and treatment is rendered by an out-of-network provider, most FEDVIP plans will consider reimbursement for covered services at the in-network benefit level. (This is called a "gap exception.") However, the patient is financially responsible for any difference between the amount billed for the service and the actual payment from the FEDVIP plan.

ALTERNATE BENEFIT REIMBURSEMENT
Most FEDVIP dental plans have the least expensive alternate benefit (LEAT) clause. A LEAT clause means that the plan will con- sider applying alternate benefits, providing reimbursement for the least costly treatment in certain instances. If the patient and dentist proceed with the more expensive treatment option, the patient may be financially re- sponsible for the charges above the alternate benefit reimbursement, even if provided by an in-network dentist.
 
It is important for the in network dentist to follow the PPO contract provisions and ensure the appropriate documentation is obtained from the patient prior to implemen- tation of treatment. If the proper docu- mentation is not obtained as outlined in the PPO contract processing policy manual, the patient may not be financially responsible for any charges above the network allowance for the alternate benefit.
 
NON-COVERED  SERVICES
Practices participating in FEDVIP plans should be aware that the administration of FEDVIP benefit plans are subject to federal law, not prevailing state insurance laws. A state insurance commissioner has no jurisdic- tion over federal dental plans. Specifically, state fee capping of non-covered procedures legislation does not apply to FEDVIP plans.
 
This means that participating FEDVIP providers may be required to honor the maximum FEDVIP fees even for non-covered dental services unless a provision of the FEDVIP, as outlined in the plan description, allows the patient and dentist to enter into a private contract.
 
For example, GEHA added a private contract provision in 2016. GEHA defines a private contract as a contract signed by the patient agreeing to pay the billed amount for upgraded or specialty services. Should the patient sign an agreement, the patient will be responsible for the difference between the billed amount and GEHA’s payment.
 
Review all contracts and plan provisions before asking a patient to enter into a private contract. Contact the payer to confirm the plan’s definition of an upgraded or specialty service as defined by the plan.
 
COORDINATION OF BENEFITS
Determining the order of benefits can be challenging when there are multiple plans and one or more of the plans is a FEDVIP plan. Oftentimes, the COB rules of  each plan are different, causing much frustration for patients and dental teams alike.
 
When COB rules of primary and second- ary, etc. do not agree (two plans state they are primary or both are secondary), a three-way call between both plan administrators and the practice is beneficial in settling the order of benefits issue. Usually, the plan that has been in effect the longest will be primary. Sometimes, it is helpful for the patient to get involved with settling an order of benefits issue.
 
The order of benefits is outlined in each FEDVIP plan summary. When a patient is enrolled in an FEHB plan and a FEDVIP plan, the claim should be submitted to the FEHB first, then to the FEDVIP plan.
For example, a retired federal employee may present with benefit information for a FEHB, FEDVIP, and may also be actively employed with group dental benefits. Deter- mine the proper order of benefits prior to the submission of any claims to help avoid pay- ment delays and/or future refund requests from payers.
 
For a practice with many federal plans, it is useful for the business team to familiarize themselves with the COB rules for each FED- VIP plan. Each FEDVIP plan document is available for review, including COB informa- tion, by visiting www.opm.gov/healthcarein- surance/   dental-vision/plan-information.
 
It is important for the patient to present an ID card to the provider for his FEHB and FEDVIP plan. Most often the FEHB plans have limited dental benefits and patients do not always realize their FEHB plan includes some dental benefits.
 
It is advisable that the provider ask for the FEHB card. Having this information will allow the provider to submit the claim to the primary carrier, FEHB, preventing any claim rejections when the FEDVIP dental plan is submitted as primary. However, the FEDVIP plan payer may request from the enrollee verification of health plan coverage (FEHB) on an annual basis or at the time of service. A delay in response from the enrollee may result in the FEDVIP plan paying as primary until the health plan information is verified, possibly resulting in an overpayment.
 
If a patient has dental coverage through both FEHB and FEDVIP plans, then the FEHB plan is primary. When services are provided by a doctor participating in both the FEHB plan and the patient’s FEDVIP plan, the FEDVIP plan allowance is the prevailing charge in these cases (i.e., allowable fee that can be charged to the patient).
 
Federal law requires the FEDVIP plan to coordinate benefits with the primary FEHB plan. The patient’s responsibility is the differ- ence between the total paid by the FEHB and FEDVIP plans and the FEDVIP maximum allowable fee.
 
Note that sometimes, the FEDVIP plan processes the claim providing payment based on an estimated amount due from the pri- mary payer. Always read the Explanation of Benefits (EOB) carefully to confirm that no overpayment has been received.
 
The provider is responsible for notify- ing the secondary (FEDVIP) payer of any overpayment. This information is generally included in the remarks on the secondary (FEDVIP) EOB. Traditional coordination of benefits rules apply when FEDVIP plans coordinate with non–FEHB primary plans.
 
The following example exhibits how to properly calculate the patient’s responsibil- ity and provider write off when the provider is in-network with a FEDVIP plan and the patient is enrolled in a FEHB plan.
  • Composite Filling D2391
  • Submitted Fee $ 124
  • FEDVIP (GEHA) Contracted Fee $ 80 
  • Primary Insurance (BCBS FEHB) Payment $ 41
  • Secondary Insurance (GEHA) Payment $ 25 
  • Total Paid by Both Insurance Plans $ 66 
  • Patient Responsibility $ 14
  • Provider Write-Off $ 44
Coordination of benefits can be complex, especially with FEDVIP plans, thus it is ben- eficial for the practice to visit www.opm.gov/ healthcare-insurance/dentalvision/plan-information for details and examples of how to properly calculate the patient’s total financial responsi- bility and the provider PPO write-off for each FEDVIP plan. COB rules and examples can be found in the detailed summaries of the FEDVIP dental plans. FEDVIP plan sum- maries and descriptions are available to the public at the beginning of annual open en- rollment season in November and December.
 
Conclusion
The information presented is intended to be an overview of 201 changes to FEDVIP plan descriptions. Detailed summaries of the 2019 FEDVIP dental plan options and benefits can be found at www.opm.gov/healthca- reinsurance/dentalvision/planinformation.
 
1It is very important to note that changes in dependent eligi- bility to age 26 under the Affordable Care Act do not apply to eligibility for children under FEDVIP. The limit remains under age 22 for FEDVIP type plans.
 
For more information, contact Dental Benefit Director Mary Essling at (312) 337- 2169 or messling@aapd.org