2021 GEHA Dental Benefits Guide

[Pages:12]2021 GEHA DENTAL PLANS

Choose from two comprehensive dental plans.

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Plan overview.

GEHA offers two dental plan options ? our High Option and Standard Option.

Both plans include: X Comprehensive dental services, from preventive care to crowns, bridges and dentures. X No deductibles and no waiting periods? for most services. X Benefit levels are the same for in-network and out-of-network providers.

High Option

X Includes an unlimited annual maximum benefit per person. X Pays a higher percentage for your covered services. X No waiting period for orthodontic services.

High

Standard Option

X GEHA's lowest premium dental plan. X Includes a $2,500 annual maximum benefit per person. X 12-month waiting period for orthodontic services.

Standard

1 No waiting period for Class A, Class B or Class C services. 12-month waiting period for Class D orthodontic services, Standard Option plan only.

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What's new in 2021.

Lower premiums on average

Nationally, on average, GEHA dental premiums have been reduced slightly for the 2021 plan year. Members in some areas will see a premium increase to more accurately reflect the cost of services for those areas.

Update on adult cleanings

High Option plan members with certain health conditions, such as pregnancy, diabetes and heart disease, can be eligible for a third cleaning in a calendar year if considered medically necessary.

37 new CDT dental procedure codes

We have added 37 new codes. For a full list of new codes, see the plan brochure at PlanBrochure

How to enroll

To sign up for a GEHA dental plan, visit

Follow the prompts to enroll in GEHA Connection Dental Federal.

You can also call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

877.590.4342

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Compare plan benefits.

No deductibles. No waiting periods.1

Choose

2021 plan year

High Option

Standard Option

What the plan pays

In-network or out-of-network2 In-network or out-of-network2

Basic ? Class A Two exams, two cleanings3 and one X-ray per calendar year 100%

100%

Intermediate ? Class B Fillings, extractions and periodontal maintenance

80%

55%

Major ? Class C Root canals, crowns, bridges, dentures, periodontal surgery 50% (implants limited to $2,500 per person/year)

35%

Orthodontics ? Class D Adults and children

70% No waiting period $3,500 lifetime maximum

70% 12-month waiting period $2,500 lifetime maximum

Calendar year maximum for Class A, B and C services

Unlimited per person

$2,500 per person

This is a brief description of services covered under the GEHA Connection Dental Federal plan. For a complete list of plan limitations and exclusions, please refer to the GEHA Connection Dental Federal Plan Brochure available online at PlanBrochure

How to enroll

To sign up for a plan, visit and follow the prompts to enroll in GEHA Connection Dental Federal. You can also call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

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In-network preventive care covered 100%.

GEHA dental plan members get access to more than 388,000 in-network locations nationwide and enjoy worldwide coverage.

To get the greatest value from your GEHA plan, you are encouraged to use in-network providers. All in-network preventive care is covered at 100% with any GEHA dental plan.

For other services, network providers will not bill you more than the agreed-upon fees for covered services. To find a provider, or to see if your provider is in-network, visit Find-Care

Out-ofnetwork services

For FEHB medical plans

Prior orthodontic services

If your out-of-network dentist charges more than GEHA's agreed-upon plan allowance for a specific service, you are responsible for the difference between the plan allowance and the out-of-network dentist's charge plus regular coinsurance.

If you have a FEHB medical plan with dental coverage, your medical plan will be considered the primary payer for some preventive, restorative and other services before any benefits are paid by any FEDVIP dental plan. This includes GEHA's FEDVIP plan.

GEHA does not cover cosmetic treatment or orthodontic work in progress (except for High Option members with orthodontics started under TRICARE).

1 There is no waiting period for Class A, Class B or Class C services. There is a 12-month waiting period for Class D orthodontic services on the Standard Option plan only.

2 If your out-of-network dentist charges more than GEHA's agreed-upon plan allowance for a specific service, you are responsible for the difference between the plan allowance and the out-of-network dentist's charge plus regular coinsurance.

3 High Option plan members with certain health conditions can be eligible for a third cleaning in a calendar year if considered medically necessary.

877.590.4342

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Step 1: Use your ZIP code to find rate code.

Find your state and the first three digits of your ZIP code in the chart below to determine your rate code. Use that code on the next page to determine your 2021 dental premium. Rates

State

AL, AR, FM, GU, IA, MH, MP, MS, ND, NE, PR, PW, VI ID, LA, MO, MT, NC, OK, SC, SD, TN, UT, VT AS, DE, HI, NM, OR CO, DC, NH, RI AK AZ AZ

CA

First 3 digits of ZIP code

Entire state or territory

Entire state

Entire state or territory

Entire state Entire state 850-853, 864 Rest of state 900-931, 933-935, 939-952, 954, 956-959

Rate code

1

2

3 4 5 3 2 5

CA

Rest of state

4

CT

064-069

5

CT

Rest of state

4

FL

329-334, 349

3

FL

Rest of state

2

GA

300-303, 305, 306, 311, 399

3

GA

Rest of state

2

IL

600-609, 613

3

IL

620, 622

2

IL

Rest of state

1

6

State IN IN IN KS KS KY KY MA MA MD MD MD ME ME MI

MI

MN

MN

NJ

NJ

NV

NV NY NY

First 3 digits of ZIP code

Rate code

460-462, 470, 472, 473 2

463, 464

3

Rest of state

1

660-662, 666

2

Rest of state

1

410

2

Rest of state

1

012

2

Rest of state

4

205-212, 214, 216, 217 4

219

3

Rest of state

2

039-042

4

Rest of state

3

480-485

3

Rest of state

2

550-555, 563

3

Rest of state

2

080-084

3

Rest of state

5

897

5

Rest of state

3

005, 100-119, 124-126 5

063

4

State NY NY

OH

OH PA PA PA PA

TX

TX TX VA VA WA WA WA WI WI WV WV WY WY INTL

First 3 digits of ZIP code

Rate code

127, 129-139, 144-149 1

Rest of state

2

430-433, 437, 440-443, 446, 447, 450-455, 459

2

Rest of state

1

172-174

4

180, 181, 183

5

189-196

3

Rest of state

1

755-759, 763-769,

776-779, 783-785,

1

788-799, 885

733, 786-787

3

Rest of state

2

201, 203, 205, 220-227 4

Rest of state

2

980-985

5

986

3

Rest of state

4

540

3

Rest of state

2

254

4

Rest of state

1

834

2

Rest of state

1

All International

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Step 2: Use your rate code to find your 2021 premium.

High Option

Biweekly

Rate code 1*

Self Only

$16.89

Self Plus One

$33.78

Self and Family

$50.68

Retirees monthly

Rate code 1*

Self Only

$36.60

Self Plus One

$73.19

Self and Family

$109.81

Standard Option

Biweekly

Rate code 1*

Self Only

$9.84

Self Plus One

$19.68

Self and Family

$29.51

Retirees monthly

Rate code 1*

Self Only

$21.32

Self Plus One

$42.64

Self and Family

$63.94

* Rate based on member's primary state of residence.

Rate code 2* $19.00 $37.97 $57.00 Rate code 2* $41.17 $82.27 $123.50

Rate code 2* $11.04 $22.08 $33.11 Rate code 2* $23.92 $47.84 $71.74

Rate code 3* $20.77 $41.54 $62.30 Rate code 3* $45.00 $90.00 $134.98

Rate code 3* $12.09 $24.14 $36.21 Rate code 3* $26.20 $52.30 $78.46

Rates

Rate code 4* $23.21 $46.41 $69.65 Rate code 4* $50.29 $100.56 $150.91

Rate code 5* $25.16 $50.34 $75.56 Rate code 5* $54.51 $109.07 $163.71

Rate code 4* $13.50 $26.98 $40.46 Rate code 4* $29.25 $58.46 $87.66

Rate code 5* $14.63 $29.24 $43.87 Rate code 5* $31.70 $63.35 $95.05

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Hearing aid discount

Get discounts through TruHearing on hearing aids. Most members save 30% to 60% off their hearing aids, averaging more than $2,100 in savings per pair. Hearing

Medical alert discount

Get free activation on LifeAlert? services, plus a 10% monthly discount. LifeAlert

Vision discounts are included with both dental plans.

With GEHA dental plans, you get discounts on eye exams, frames and lenses through EyeMedTM.

The EyeMed network includes LensCrafters, Target Optical, independent eye doctors and top optical retailers. Members also save on LASIK at participating US Laser Network locations.

This is a sampling of the supplemental vision discounts available with GEHA dental plans. To learn more, visit Vision

Examples of common in-network vision services for both plans.

High Option

Routine eye exams at qualified EyeMed providers (what you pay)

$5

Standard Option $5

Out-of-network exams are reimbursed by EyeMed

$45 per covered $45 per covered member, per year member, per year

Discount glasses purchased per year

No limit

No limit

Discount conventional contact lenses purchased per year

No limit

No limit

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