U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

RI 70-01 For Federal Civilian Employees

Health Maintenance Organization Plans and Plans Offering a Point-of-Service Product

Health Maintenance Organization (HMO) - A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas. HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services. Your eligibility to enroll in an HMO is determined by where you live or, for some plans, where you work.

• The HMO provides a comprehensive set of services - as long as you use the doctors and hospitals affiliated with the HMO. HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for in-hospital care.
• Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP). Your PCP provides your general medical care. In many HMOs, you must get authorization or a "referral" from your PCP to see other providers. The referral is a recommendation by your physician for you to be evaluated and/or treated by a different physician or medical professional. The referral ensures that you see the right provider for the care most appropriate to your condition.
• Medical Care from a provider not in the plan's network is not covered unless it's emergency care or your plan has an arrangement with another plan.

Plans Offering a Point-of-Service (POS) Product - A Point-of-Service plan is like having two plans in one - an HMO and a FFS plan. A POS allows you and your family members to choose between using, (1) a network of providers in a designated service area (like an HMO), or (2) out-of-network providers (like a FFS plan). When you use the POS network of providers, you usually pay a copayment for services and do not have to file claims or other paperwork. If you use non-HMO or non-POS providers, you pay a deductible, coinsurance, or the balance of the billed charge. In any case, your out-of-pocket costs are higher and you file your own claims for reimbursement.

The tables on the following pages highlight what you are expected to pay for selected features under each plan. Always consult plan brochures before making your final decision.

Primary care/Specialist office visit copay - Shows what you pay for each office visit to your primary care doctor and specialist. Contact your plan to find out what providers it considers specialists.

Hospital per stay deductible - Shows the amount you pay when you are admitted into a hospital.

Prescription drugs - Plans use a variety of terms to define what you pay for prescription drugs such as generic, brand, Level I, Level II, Tier I, Tier II, etc. In capturing these differences we use the following: Level I includes most generic drugs, but may include some preferred brands. Level II may include generics and preferred brands not included in Level I. Level III includes all other covered drugs with some exceptions for specialty drugs. The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged.

Mail Order Discount - If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (e.g., you get a greater quantity or pay less through mail order), your plan's response is "yes." If the plan does not have a mail order program or it is not superior to its pharmacy benefit, the plan's response is "no."

Member Survey Results - See Appendix D for a description.

See the tables

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