Retirement & Financial Planning Report

The FEHB health insurance and FEDVIP dental and vision insurance programs are paired in many people’s minds. They are both forms of health insurance—in contrast to the government’s other two insurance programs, which offer life and long-term care insurance—generally, the same people who are eligible for FEHB are eligible for FEDVIP (the main exception being that FEHB children’s coverage is less restrictive and continues up to age 26 rather than age 22), and in some cases the same insurance companies act as carriers.

The FEDVIP program, though is much newer and smaller. One issue that has arisen in FEDVIP for those who have enrolled—and which may be a contributing factor for those who haven’t—involves coordination of benefits. Many FEHB plans do offer at least some dental or vision benefits, and there is a perception among some that taking FEDVIP coverage amounts to paying twice for the same benefits.

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However, dental and vision benefits under standard FEHB plans are limited—for example, dental coverage might be provided to repair damage done to teeth in an accident. Potential enrollees should make sure they understand what their FEHB plan does and doesn’t cover in the dental and vision area before making any decisions regarding FEDVIP.

FEDVIP is the “secondary” payer to any benefits provided under an FEHB plan. If you are enrolled in both FEDVIP and FEHB, you must provide your FEHB enrollment information during the FEDVIP enrollment process (which takes place online, on www.benefeds.com). It’s a good idea to provide your FEHB information to the medical office that is providing the dental or vision services under FEDVIP.

Also, if you change your FEHB health plan during the year, you need to notify BENEFEDS immediately. If you fail to provide this information, payment of claims will be delayed.

How to Fight an FEHB Claim Denial

FEHB enrollees sometimes get into disputes with their plans about whether a medical procedure or service should be covered, and, if covered, at what level. When such differences like that arise, there is an appeals process in place for settling the matter.

However, before you go down that path, it’s important for you to be certain that the ground you are on is solid. Begin by carefully reading the language in your plan’s brochure. The brochure is a contract, and, like any other contract you enter into, you’ll have to rely on the contract language to prove your point. If a medical procedure or service isn’t covered in the brochure or is specifically excluded, you don’t stand a chance of it being covered.

On the other hand, if you’ve done your homework and still don’t agree with your plan’s decision, you should ask them to reconsider it. You can find the procedure for doing that in your FEHB plan brochure. If the plan won’t budge and you still think you’re right, you should write to the Office of Personnel Management (OPM) and ask them to review your claim. Once again, the information you need to do that is in your plan brochure.

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OPM will let you know that they’ve received your appeal, and, if they don’t need any more information than you’ve already provided, you’ll usually get a final decision within 60 days. On the other hand, if they need more information, they’ll tell you that within 14 days of the date they receive your appeal. You’ll also be given a phone number in case you want to check on the status of your claim. If OPM sides with you, your claim will be paid. If it doesn’t, you always have the option of filing suit in federal district court.