Insurance Services Programs

FEHB Handbook

Health Plans Page 1 of 1

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Health Plans

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• TYPES OF PLANS
• DESCRIPTION OF PLANS
• PARTICIPATING PLANS
• COORDINATION OF BENEFITS
• COORDINATION WITH MEDICARE
• PAYMENT OF BENEFITS IN MEDICALLY UNDERSERVED AREAS
• YOUR HEALTH PLAN CHOICE

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TYPES OF PLANS

• Fee-for-Service Plans
• Health Maintenance Organizations
• Point of Service

Two types of plans participate in the FEHB Program: fee-for-service plans and health maintenance organizations (HMOs).

Fee-for-Service Plans

These plans reimburse you or your health care provider for the cost of covered services. You may choose your own physician, hospital, and other health care providers. Most fee-for-service plans have preferred provider (PPO) arrangements. If you receive services from a preferred provider, you usually have lower out-of-pocket expenses (i.e., a smaller copayment and/or a reduced or waived deductible). All fee-for-service plans require precertification of inpatient admissions and preauthorization of certain procedures.

Fee-for-service plans include:

• The Governmentwide Service Benefit Plan, administered by the Blue Cross and Blue Shield Association on behalf of Blue Cross and Blue Shield Plans, and is open to everyone eligible to enroll under the FEHB Program.
• Plans sponsored by unions and employee organizations. Some of these plans are open to all Federal employees who hold full or associate memberships in the organizations that sponsor the plans; others are restricted to employees in certain occupational groups and/or agencies. Generally, the employee organization requires a membership fee or dues paid directly to the employee organization, in addition to the premium. This fee is set by the employee organization and is not negotiated with OPM.
  

Health Maintenance Organizations

Health Maintenance Organizations (HMOs) provide or arrange for comprehensive health care services on a prepaid basis through designated plan physicians, hospitals, and other providers in particular locations. Each HMO sets a geographic area for which health care services will be available, called its service area. This area is described in the plan's brochure. You may join a particular HMO if you live within its service area. Some plans also accept enrollments from employees who work in the area even though they live elsewhere. If you have questions about whether you live or work within a HMO's service area, you should contact the plan before you enroll in it.

Generally, you must choose a primary care physician and have all care coordinated through that physician. Your physician is responsible for obtaining any pre-certification required for inpatient admissions or other procedures.

The three types of HMOs are:

• Group Practice Plans. These plans provide care through groups of physicians who practice at medical centers.
• Individual Practice Plans. These plans provide care through participating physicians who practice in their own offices.
• Mixed Model Plans. These plans are a combination of Group Practice and Individual Practice plans.

Point of Service

Some fee-for-service plans and HMOs offer a point of service product. This gives you the choice of using a designated network of providers or using non-network providers at an additional cost to you. If you don't use network providers, you must pay substantial deductibles, coinsurance, and copayments.

DESCRIPTION OF PLANS

• FEHB Guide
• Brochures
• Participating Provider Directories

FEHB Guide

Each year prior to Open Season, OPM publishes an FEHB Guide for distribution through employing offices to enrollees and eligible persons. The Guide lists all participating plans in the FEHB Program, the premiums required, and other information, including quality indicators. You can also access the FEHB Guide from the FEHB home page.

Brochures

The benefits, cost, exclusions, limitations, and other major provisions of each participating plan are described in the brochure for that particular plan. You can get copies of the brochures for the various plans that you are eligible to join so you can make an informed choice among them. You can access all plan brochures from the FEHB home page. You can also get brochures from your employing office, and by contacting the plans directly at phone numbers listed in the FEHB Guide. You need to keep your selected plan's current brochure as a continuing source of information on the benefits that your plan provides.

Participating Provider Directories

Each HMO and each fee-for-service plan with preferred provider arrangements publishes a participating provider directory that lists its participating physicians, hospitals, and other providers. Before you enroll in a plan, you should review its participating provider directory. Every year during Open Season, you should ask for an updated directory and contact your chosen providers to see if they will continue to participate in the plan. Many plans have their provider directories on their web sites. These can be accessed directly or from the FEHB home page.

Providers sometimes cease participation during an FEHB contract year; if you enroll in a fee-for-service plan, you should verify the provider's participation status before you receive services.

The continued participation of any provider with a health plan is not guaranteed. You are not eligible to change plans outside of an Open Season or other qualifying event solely because a particular health care provider stops participating with your plan.

PARTICIPATING PLANS

Before each Open Season begins, OPM provides agencies with an updated list of the names, addresses, and telephone numbers of all fee-for-service plans and HMOs that currently participate in the FEHB Program.

COORDINATION OF BENEFITS

• Coordination with health care furnished by Uniformed Services Facilities (USF) and the Department of Veterans Affairs (DVA)
• Coordination with TRICARE (formerly CHAMPUS)

If you or a covered family member are entitled to benefits from a source other than your FEHB plan, such as a spouse's health insurance coverage, Medicare, Medicaid, or no-fault automobile insurance, coordination of benefits will take place. You must disclose information about the other source of benefits to your plan's Carrier.

Coordination with health care furnished by Uniformed Services Facilities (USF) and the Department of Veterans Affairs (DVA)

These Government agencies are entitled to seek reimbursement from FEHB plans for certain services and supplies furnished to you or a family member. Generally, FEHB benefits are payable for (1) inpatient hospital costs at a Uniformed Services facility, and (2) services and supplies provided by a DVA facility for treatment of a non-service connected disability.

Coordination with TRICARE (formerly CHAMPUS)

TRICARE provides health care for active-duty military personnel whose orders do not specify a period of 30 days or less, and their dependents; retired and former military personnel currently entitled to retired or retainer pay, or equivalent pay, and their dependents; and dependents of deceased military personnel. If you are covered by both an FEHB plan and TRICARE, the FEHB plan pays benefits first as the primary payer and TRICARE is the secondary payer. (All provisions applicable to CHAMPUS now apply to TRICARE.)

COORDINATION WITH MEDICARE

• Basic Medicare Provisions
• FEHB Plans and Medicare
• When Your FEHB Plan is Primary
• When Medicare is Primary
• Enrollment Change Permitted

Basic Medicare Provisions

Medicare is generally for persons age 65 or over. It has two parts:

• Part A (Hospital Insurance) helps pay for inpatient hospital care, skilled nursing facility care, home health care, and hospice care. You are entitled to Part A without having to pay premiums if you or your spouse worked for at least 10 years in Medicare-covered employment. (You automatically qualify if you were a Federal employee on January 1, 1983.) A percentage of your salary, up to a maximum determined by the Social Security Administration, is deducted from your pay for this coverage.
• Part B (Medical Insurance) helps pay for doctors' services, outpatient hospital care, x-rays and laboratory tests, medical equipment and supplies, home health care (if you don't have Part A), certain preventive care, ambulance transportation, other outpatient services, and some other medical services Part A doesn't cover, such as physical and occupational therapy. You must pay premiums for Part B, which are withheld from your monthly social security payment or your Civil Service Retirement System (CSRS) annuity.