GEHA HD plan and FedVIP Dental - Federal employee open season question

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nyblitz
Posts: 354
Joined: Mon Apr 09, 2007 7:33 am

GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by nyblitz » Thu Nov 12, 2015 10:58 am

Greetings,

After the ENORMOUS amount of advice from this forum, as well as working through spreadsheets, the GEHA HD plan makes the most sense for my family. Thanks!

Fortunately, GEHA provides partial dental coverage for 2016 and it appears that they must be the First Payer.

Unfortunately, my children's dentist is not in network with GEHA so when I'm evaluating Dental insurance, the examples of how payment is made do not really apply.

**OOPS left this out initially** --> So my dilemma is that I would like to also purchase Dental insurance through FedVIP so this policy would be IN network with the pediatric dentist. But it appears that as they would be the Second Payer there could be problems getting claims paid.**

I am contacted my dentist to see what they say, but was wondering if anyone has any advice/insight?

And yes, I am considering skipping the FedVIP dental coverage.

Thanks again!

edited to add the starred in sentence in the middle. :-)
Last edited by nyblitz on Thu Nov 12, 2015 12:15 pm, edited 1 time in total.

kazper
Posts: 623
Joined: Fri Aug 01, 2014 7:45 pm

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by kazper » Thu Nov 12, 2015 11:37 am

Realize that out of network coverage may mean you are stuck with the entire bill, without the negotiated reductions between GEHA and the dentist. For my son (4), the total bill is usually around $100 total, which is currently split. But that is the negotiated rate. It would be higher with an out of network dentist, and they're likely to have you foot the entire bill...

kazper
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Joined: Fri Aug 01, 2014 7:45 pm

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by kazper » Thu Nov 12, 2015 11:38 am

One other thing, GEHA is relatively laxed about when you receive service. Some plans require you to go exactly 6 months (or 1 year) after your last visit. GEHA simplifies it by saying twice per year (or once for doctors).

nyblitz
Posts: 354
Joined: Mon Apr 09, 2007 7:33 am

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by nyblitz » Thu Nov 12, 2015 11:46 am

Kazper,

Thanks for answering - you've been helpful in this and other threads!

To clarify (and I don't think I did initially) GEHA is out of network, but the FedVIP Dental plan insurance would be IN network.

If this is the case (I get headaches and hassles with 2 insurances), it may become GEHA + no PEDS dental insurance + place $ in the LEX vs. MHBP HD plan with FedVIP.

Hmmm...

Mako
Posts: 109
Joined: Wed Feb 28, 2007 9:34 am
Location: Elkton, MD

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by Mako » Thu Nov 12, 2015 2:29 pm

I don't have the same issue because my FEHB and FEDVIP have always been the same network. But check the plan brochure for whatever FEDVIP plan you are considering, under the coordination of benefits section. Mine says:
When you have double coverage, one plan normally pays its benefits in full as the primary
payor and the other plan pays a reduced benefit as the secondary payor. We will consider
any benefits payable by your FEHB medical plan before we calculate benefits payable by
us. In addition to benefits payable by your FEHB medical plan, if you or your covered
dependents have other dental coverage, you must tell GEHA. When we are secondary or
tertiary (third) payor, our payment will be the lesser of the following:
• Regular benefits; or
• The remaining balance which when added to the other carrier(s’) payment will not
exceed our Plan Allowance.
There is no change in benefit limits or maximums when we are the secondary payor.
Which to me means that if the primary pays nothing due to being out of network, the FEDVIP plan will still pay their normal amount (because that is their regular benefit and it is not lessened by any other carrier's payment). I doubt you'd have a problem having claims paid, though one can never be 100% sure until you see it happen.

I note that GEHA HDHP pays for very little dental other than for preventative, and most FEDVIP plans take care of 100% preventative anyway. In any case, the GEHA HDHP plan brochure (p. 38, section 5 intro) says that preventative coverage for children is paid at both in network and out of network providers. I assume this applies to dental as well since dental preventative is in that same section. In light of these things, if you get a FEDVIP plan you probably aren't missing much by using someone out of GEHA's network. Whether you want to drop FEDVIP completely is a different matter.

Kaufmanrider
Posts: 112
Joined: Sun Feb 23, 2014 9:32 am

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by Kaufmanrider » Thu Nov 12, 2015 3:43 pm

In the past I had a dentist who was not in network for my BCBS Basic Preventative Dental, but they were in network for my FEP Dental-GEHA. Dental office had to Bill BCBS first, which they denied payment. Dental office then billed GEHA and included the BCBS denial. GEHA paid.

nyblitz
Posts: 354
Joined: Mon Apr 09, 2007 7:33 am

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by nyblitz » Thu Nov 12, 2015 8:12 pm

Mako,

Thanks for pointing out the detailed sections, especially from GEHA.

As you state, p. 38 (GEHA) says:

"Benefits in this Section are covered in full if rendered by preferred providers. Preventive services from a non-preferred provider would be applied to your calendar year deductible and payable under Traditional medical coverage benefits. Preventive care for children is covered in full from preferred and non-preferred providers. The calendar year deductible does not apply to benefits in this Section. For other covered services not listed below see Section 5(a)."

The FedVIP program we're most likely to chose (Metlife) says the following, and as reading the above from GEHA it appears that the examples WOULD apply to us, so this is very helpful:

"If you have dental coverage through your FEHB plan and coverage under FEDVIP , your FEHB plan will be the first payor of any benefit payments. When services are rendered
by a provider, who participates with both your FEHB and your FEDVIP plan, the FEDVIP plan allowance will be the prevailing charge, in these cases. W e are responsible for facilitating the process with the primary FEHB payor . Y ou are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance. See examples 1 and 2 below.
It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program."

Kaufmanrider,

Thanks for sharing your experience, and coupled with Mako's post above gives me more confidence that it'll likely work out fine with GEHA as FEHB and Metlife as FedVIP.

Please note Kazper's helpful reply was entered prior to me editing my original post with information I had meant to include (Sorry for that Kazper - but again, thanks for your reply too).

toofache32
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Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by toofache32 » Sat Nov 14, 2015 3:34 am

Also realize that many offices (including mine) will not take on the burden of billing a 2nd insurance since it's already to much headache to bill just one. We bill the first insurance and the patient must pay their portion up front. It's up to the patient to argue with the 2nd insurance company and get reimbursed since we have already argued with the first.

kazper
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Joined: Fri Aug 01, 2014 7:45 pm

Re: GEHA HD plan and FedVIP Dental - Federal employee open season question

Post by kazper » Sat Nov 14, 2015 7:30 am

toofache32 wrote:Also realize that many offices (including mine) will not take on the burden of billing a 2nd insurance since it's already to much headache to bill just one. We bill the first insurance and the patient must pay their portion up front. It's up to the patient to argue with the 2nd insurance company and get reimbursed since we have already argued with the first.
I agree it is a lot of burden and can be confusing/take a while, but I am surprised they won't do it. The geha plans only cover 50% this year for dental visits. So every time one of us went for cleanings, they would bill geha and our secondary dental insurance. Now that geha will cover 100% of preventative, I will need to rethink the necessity of supplemental dental. It will only be used for fillings, crowns, or route canals now.

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