Appendix G
FEDVIP Definitions

RI 70-01 For Federal Civilian Employees

Coordination of Benefits (COB) - Under this rule, the FEHB plan is considered the primary payor and pays first, while the FEDVIP plan is considered the secondary payor. Payment is coordinated under the COB rule to ensure that no more than 100% of any claim is paid by both plans.

Eligible Dependents - Your spouse and unmarried dependent children under age 22. Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.

In-Network Services - Services provided by members of the plan's provider network.

Nationwide Plan - A plan which provides services throughout the United States and around the world.

Out-of-Network Services - Services provided by health care professionals who are not a member of the plan's provider network.

Plan - The insurance company which participates in the FEDVIP program. Also called carrier.

Precertification - Also called predetermination. This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered.

Provider - A licensed health care professional; for example: dentists, oral surgeons, optometrists and ophthalmologists.

Provider Network - A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost.

Qualifying Life Event - An event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an Open Season. There is no QLE under FEDVIP which allows for cancellation, except upon deployment to active military duty.

Regional Plan - A plan which provides services only in specified geographic regions.

Usual and Customary - A widely used method, which may vary from company to company, for determining benefit reimbursement levels. The initials simply mean:

Usual. The fee that an individual dentist most frequently charges for a given dental service.

Customary. A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area.

Reasonable. A fee which is justifiable considering special circumstances of the particular care rendered.

Waiting Period - The length of time a person must be covered under the plan before they are eligible for certain benefits. For example, most plans have a 24 month waiting period for orthodontic benefits. This means that you must be covered continuously by the same plan for 24 months before you are eligible for orthodontic coverage.

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