Dental Federal Enrollment – Washington, DC

Making High-Quality Dentistry Affordable

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.

Dental team member discussing dental federal enrollment with patients

The Basics

Dental patient smiling at team member behind reception desk

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. 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.
  • 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.

      Federal Gov VIP Table

    • 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

Team member and patient reviewing dental federal enrollment forms

This year, we add a new recommended insurer, and that is the Humana high option plan (but NOT the low-option, EPO plan), particularly for those who have had or foresee needing dental treatment. The GEHA high plan (if you foresee needing treatment) and the Aetna low plan (for those not needing treatment) are still recommended, depending on whether you will have treatment needs in excess of the maximum amounts of the low-option plans. The GEHA high-option plan is comparable to the Humana plan, and both offer the best perio-related coverage. If you have GEHA and you have liked it, great, stick with it. If you are debating, take a look at the Humana plan high-option plan. UHC is a newer entrant, and its plan is similar to MetLife’s. We don’t recommend this plan versus Humana, GEHA or Aetna. Delta, on the other hand, has one of the higher premiums for its plans, without complementary coverage limits. We would discourage patients from selecting Delta.

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.