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