Enrollment Brochure - Veterans Affairs Dental Insurance Program
Transcription
Enrollment Brochure - Veterans Affairs Dental Insurance Program
Veterans Affairs Dental Insurance Program (VADIP) An overview of Delta Dental’s Plans for Veterans and CHAMPVA Enrollees deltadentalvadip.org A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION Introduction In 2013, the U.S. government authorized a national dental insurance program for Veterans enrolled in Veterans Affairs (VA) health care and individuals enrolled in the VA’s Civilian Health and Medical Program (CHAMPVA). On behalf of the VA, Delta Dental offers you enrollment in the Veterans Affairs Dental Insurance Program (VADIP). We at Delta Dental value the service you have provided to our country and are proud that we have an opportunity to serve you. As the administrator of VADIP, it is our goal to provide you with a dental benefits program that offers the best value and service available. The information in this brochure will introduce you to the three plan options available under Delta Dental’s VADIP: Standard, Enhanced and Comprehensive. You will also find out who’s eligible for the program, a description of the service area that provides you broad access to care, a chart comparing the benefits of each plan and the advantages of selecting a network dentist, and most importantly, how to enroll in VADIP. Eligibility Eligible VADIP beneficiaries include: • Any Veteran enrolled in VA health care • Any individual enrolled in the VA’s Civilian Health and Medical Program (CHAMPVA) Dependents who do not qualify as CHAMPVA beneficiaries are not eligible. To enroll in VA health care or for VADIP eligibility questions, visit the Veterans Affairs website at www.va.gov/healthbenefits or call 877-222-VETS (8387). To enroll in CHAMPVA, visit the CHAMPVA website www.va.gov/purchasedcare/ programs/dependents/champva or call 800-733-8387. To enroll in VADIP, see the “Enrollment” section of this brochure. Availability of Services Covered services under VADIP are offered nationwide in all 50 U.S. states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands. Dentist Network To save you the most money on your dental care, Delta Dental offers a nationwide network of VADIP dentists. Select “Dentist Search” at deltadentalvadip.org to find a VADIP network dentist near you. Our network dentists have agreed to provide your dental care at reduced fees, to prepare and submit all claims paperwork, and to accept payment directly from Delta Dental. Having treatment provided by an out-of-network dentist will most likely increase your out-of-pocket costs. Payment for services performed by out-of-network dentists are paid at a lower percentage, leaving you with a higher copayment and a greater dollar amount applied to your annual maximum. Additionally, you will be responsible for paying your copayment as well as any difference between the plan allowed amount and the dentist’s approved amount (called “balance billing”). Convenient Online Services Within 24 hours after you’ve enrolled in Delta Dental’s VADIP, you’ll be able to register to use the online Consumer Toolkit® where you can verify your enrollment, manage your benefits, download claim forms, view benefit statements, and print an enrollment card. In addition to the Consumer Toolkit, the website also provides a plan overview video, program news and a network Dentist Directory with multiple search functions. All of this and much more is available online, at your convenience, at deltadentalvadip.org. Smileway® Wellness Program Preventive dental care is the number one way to keep your smile healthy. Our SmileWay Wellness site at deltadentalvadip.org is your one-stop shop for oral health-related tools, tips and resources to help you review your oral hygiene habits, get educated about the importance of good oral health and stay informed so that you can maintain your healthy smile. Sign up for the Grin! newsletter, a free resource emailed to you quarterly with articles, tips and tools to help you take great care of your smile. Choose Delta Dental with Confidence Here are four top reasons why you should choose Delta Dental’s VADIP: • Affordable premiums • Choice of three great plans—Standard, Enhanced and Comprehensive • 100% coverage for preventive care when visiting a network dentist • Large nationwide dentist network Your dental health is our priority. Over 60 million people have chosen Delta Dental. Join us. We are proud to provide this dental plan to those who have served our country. Premium Rating Regions Use the first three digits of your residence ZIP code to find your rating region for Delta Dental’s VADIP in the chart below. Note that Puerto Rico (006, 007, 009) and the U.S Virgin Islands (008) are included in Region 2; the District of Columbia (200, 202 – 205) is included in Region 3; and American Samoa (967), Guam (969) and the Commonwealth of the Northern Mariana Islands (969) are included in Region 4. See the other side of this page to find a list of the current monthly premiums for the VADIP based on the plan option you choose, your rating region and the number of people in your family who will be enrolling in Delta Dental’s VADIP. Region 1 150 – 179 182 – 188 195 – 196 215 – 218 247 – 268 370 – 374 376 – 385 400 – 404 407 – 409 411 413 420 – 427 431 433 437 – 439 443 – 451 453 455-458 461 467 470 – 479 634 – 639 644 – 647 650 – 651 653 – 657 667 – 669 674 677 716 – 729 764 766 768 – 769 795 – 796 006 – 009 012 – 013 028 – 030 032 035 – 040 042 – 054 056 – 059 104 109 117 119 – 149 180 – 181 189 – 194 197 199 206 – 212 214 219 224 – 246 270 – 299 301 – 302 304 – 310 312 – 329 335 – 342 344 346 – 347 349 – 352 354 – 369 386 – 398 405 – 406 410 412 414 – 418 Region 2 430 432 434 – 436 440 – 442 452 454 460 462 - 466 468 – 469 480 – 516 520 – 528 530 – 532 534 – 535 537 – 550 556 – 567 570 – 577 580 – 588 590 – 599 609 – 620 622 – 631 633 640 – 641 648 652 658 660 – 662 664 – 666 670 – 673 675 – 676 678 – 681 683 – 693 700 – 701 703 – 708 710 – 714 730 – 731 734 – 741 743 – 763 765 767 770 – 794 797 – 799 805 – 807 811 – 814 820 – 836 843 – 844 850 – 853 855 – 857 850 859 - 860 863 – 865 873 – 874 877 – 885 889 – 891 893 898 999 Region 3 000 010 – 011 014 – 015 023 – 027 031 033 – 034 041 062 – 063 080 – 084 090 – 098 103 105 – 108 110 – 116 118 198 200 202 – 205 300 303 311 334 551 553 – 555 604 – 605 808 – 810 815 – 816 837 – 838 840 – 842 845 – 847 870 – 872 875 962 964 Region 4 016 – 022 055 060 – 061 064 – 079 085 – 089 100 – 102 201 220 – 223 330 – 333 600 – 603 606 – 608 800 – 804 894 – 895 897 919 – 925 930 932 934 – 939 953 955 – 957 959 – 961 963 965 – 969 971 – 979 983 985 – 986 988 – 998 Region 5 900 – 908 910 – 918 926 – 928 931 933 940 – 952 954 958 970 980 – 982 984 Plan Summary of Coverage The following chart depicts the three plans offered to you under Delta Dental’s VADIP. When your treatment is provided by a VADIP network dentist, your cost shares will be substantially lower. Your total out-of-pocket costs will increase when your care is provided by an out-of-network dentist. Check the Dentist Directory at deltadentalvadip. org to find a VADIP network dentist near you. Standard Service Category In Network Enhanced Out of Network Year 1+ In Network Comprehensive Out of Network In Network Out of Network Year 1 Year 2+ Year 1 Year 2+ Year 1 Year 2+ Year 1 Year 2+ Diagnostic1 100% 80% 100% 100% 80% 80% 100% 100% 80% 80% Preventive1 100% 80% 100% 100% 80% 80% 100% 100% 80% 80% Basic Restorative 50% 30% 50% 50% 30% 30% 60% 60% 40% 40% Major Restorative2 NAB NAB NAB NAB NAB NAB NAB 50% NAB 30% Endodontics2 NAB NAB NAB 50% NAB 30% NAB 50% NAB 30% Periodontics2 NAB NAB NAB 50% NAB 30% NAB 50% NAB 30% Oral Surgery2,3 50% 30% 50% 50% 30% 30% 50%3 50% 30% 30% Prosthodontics2 NAB NAB NAB NAB NAB NAB NAB 50% NAB 30% General Services NAB NAB NAB NAB NAB NAB 50% 50% 30% 30% Orthodontics NAB NAB NAB NAB NAB NAB NAB NAB NAB NAB Deductible $50 $50 $501 $501 $501 $501 $0 $0 $501 $501 Annual Maximum $500 $500 $1,000 $1,000 $1,000 $1,000 $1,500 $1,500 $1,500 $1,500 NAB = Not a Benefit The deductible is waived for diagnostic and preventive services under the Enhanced plan. Under the Comprehensive plan, the deductible is waived for diagnostic and preventive services provided out-of-network, and there is no deductible for any services provided in-network. 2 Enhanced Plan: The waiting period is 12 months for endodontics and periodontics. Comprehensive Plan: The waiting period is 12 months for major restorative, endodontics, periodontics, oral surgery3, and prosthodontics. 3 Simple extractions (procedure codes D7111 and D7140) are the only oral surgery services covered under the Standard and Enhanced plan, and the only oral surgery services covered in the first 12 months under the Comprehensive plan. 1 Enrollment Enrollment in VADIP is voluntary. Each new subscriber (Veteran or CHAMPVA beneficiary) electing to enroll must fulfill an initial enrollment period of 12 consecutive months. After the initial 12-month period, you can continue your enrollment on a month-to-month basis as long as you remain eligible for coverage. There is a grace period of 30 days from your coverage effective date. You may disenroll without any further obligation, provided you have not used any program services during the grace period. Otherwise, you must remain enrolled in the program for the duration of the initial 12-month period. A one-month premium prepayment is required at the time of enrollment to ensure you receive benefits the first day your coverage becomes effective. Coverage will begin on the first day of the month following the receipt and acceptance of your enrollment application and one-month premium prepayment. There are two ways to enroll in VADIP: 1. Enroll online at deltadentalvadip.org. We accept Visa©, MasterCard© or Discover© for the first month prepayment; or 2. Complete and return the enclosed enrollment application with your check, money order or credit card payment information. Once your enrollment is processed, we’ll send you a welcome letter (via email, if we have your email address, or U.S. mail if we don’t) that includes program information with links to your online benefits booklet and enrollment cards. Although your enrollment card is not necessary to receive dental treatment, it contains helpful information for your reference. Electronic Funds Transfer You must establish an ongoing EFT payment through your bank in order to be enrolled. You’ll need to set up electronic funds transfer (EFT) for your monthly VADIP premium payment. If you are completing the enclosed paper enrollment application, be sure you also complete the EFT authorization form included with the application. Mail both the application and form to the address on the form. If you are enrolling online, you can complete your EFT authorization during your enrollment. Instructions for setting up your EFT are contained within the online enrollment application. Monthly Premium Rates Delta Dental’s VADIP has been designed to provide you with complete dental benefits at an affordable cost. Monthly premium amounts will vary depending on the plan option you choose, where you live and the number of eligible members you elect to enroll. Coverage is available as a single person, two party or a family. Premium rates may change annually. Monthly premium rates for the current year are shown below. See the opposite side of this page to find the rating region for your three-digit ZIP code. You may also find the current premium rate for your region by visiting our website at deltadentalvadip.org and accessing the Rate Calculator. VADIP Monthly Premium Rates January 1, 2016 – December 31, 2016 Plan Name Standard Plan Enhanced Plan Comprehensive Plan Rating Region Veteran Only CHAMPVA CHAMPVA +1 CHAMPVA +2 1 $12.32 $12.32 $24.64 $36.95 2 $13.88 $13.88 $27.76 $41.64 3 $15.43 $15.43 $30.84 $46.27 4 $17.22 $17.22 $34.46 $51.68 5 $18.46 $18.46 $36.91 $55.38 1 $17.88 $17.88 $35.76 $53.63 2 $20.00 $20.00 $39.99 $59.99 3 $22.07 $22.07 $44.12 $66.19 4 $24.50 $24.50 $49.00 $73.50 5 $26.15 $26.15 $52.34 $78.50 1 $31.17 $31.17 $62.34 $93.50 2 $35.22 $35.22 $70.44 $105.66 3 $39.17 $39.17 $78.34 $117.51 4 $43.87 $43.87 $87.73 $131.60 5 $47.03 $47.03 $94.07 $141.10 A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION Federal Government Programs PO Box 537009 Sacramento, CA 95853-7009 For more information about Delta Dental’s Veterans Affairs Dental Insurance Program, visit deltadentalvadip.org. VADIP is administered and underwritten by Delta Dental of California through its subsidiary, Delta Dental Insurance Company. U.S. Department of Veterans Affairs Veterans Health Administration VADIP Enr Brochure (11/15) #94380