Federal Employee Health Benefit Program

RI 70-6 For Individuals Receiving Compensation from the Office of Workers' Compensation Programs (OWCP)

Picking a Health Plan

Step 1: What type of health plan is best for you? You have some basic questions to answer about how you pay for and access medical care. Here are the different types of plans from which to choose.

See Definitions for a more detailed description of each type of plan.

Step 2: Medical care services. Are preventive care services important to you? What about the freedom to choose your own doctors? Do you prefer to pay a higher deductible in return for a lower premium? Estimate what you might spend on your health care for deductibles, coinsurance/copayments, and services that are not covered. What is the maximum you will have to pay out-of-pocket each year?

An easy-to-use tool allowing you to compare plans is available on the web at www.opm.gov/insure/07/spmt/plansearch.aspx. If you do not have Internet access, use the chart below by consulting the health plans' brochures to review your costs, including premiums, and estimate what you might spend on health care next year. Plan brochures can be obtained from your Human Resources office or on the OPM web site at www.opm.gov/insure/health.

Step 3: Think quality. How well do health plans keep their members healthy? How well do health plans treat members when they are sick? Good quality health care means doing the right thing at the right time, in the right way, for a person to achieve the best possible results. Good quality doesn't always mean receiving more care. We provide two types of quality information: accreditation (independent evaluations from private organizations) and member survey opinions (by enrollees).

HMO Accreditation. The evaluations shown in this Guide are performed by the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and URAC. The following are the accreditation levels used by each organization. Check your health plan's brochure for its accreditation level.

Note: This chart shows the accreditation levels available under each accrediting organization listed. It is not intended to draw comparisons among the different accrediting organizations.

Member Survey Results. Each year Federal Employees Health Benefits (FEHB) plans with 500 or more subscribers mail the Consumers Assessment of Health Plan Survey (CAHPS)' to a random sample of plan members. For Health Maintenance Organizations (HMO)/Point-of-Service (POS) plans, the sample includes all commercial plan members, including non-Federal members. For Fee-for-Service (FFS)/Preferred Provider Organization (PPO) plans, the sample includes Federal members only. The CAHPS survey consists of a set of standardized health plan performance measures that evaluate members' satisfaction with their health p lans. Independent vendors certified by the National Committee for Quality assurance (NCQA) administer the surveys.

Previously, OPM used symbols to indicate whether a plan's ratings on each of the CAHPS measures were: Average, Above Average, or Below Average compared to a national average. This year , OPM is reporting each plan's scores on the various survey measures. We now show the percentage of satisfied members on a scale of 0 to 100. Also, we list the national average for each measures. Since we offer both HMO plans Free-for-Service/PPO plans we compute a separate national average for each plan type.

Survey findings and member ratings are provided for the following key measures of member satisfaction:

In evaluating plan scores, you can compare individual plan scores against other plans and against the national average for each plan type. Generally, new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS. Therefore, some of the plans listed in the Guide will not have survey data.

Fee-for-Service (FFS) plans and their Preferred Provider Organizations (PPO) are organized much differently and perform different functions than Health Maintenance Organizations (HMO) and Point-of-Service (POS) plans. Consequently, the accreditation of these plans is different from HMOs and POS plans.The following chart shows activities common to FFS/PPO plans and the X indicates that your FFS/PPO plan (or a vendor with which it contracts has achieved accreditation in these areas.

Behavioral Health – a utilization management program that specializes in mental health and substance abuse or chemical dependency services.

Case Management – identifying plan members with special healthcare needs, developing a strategy that meets those needs, and coordinating and monitoring the ongoing care.

Disease Management – intensively managing a particular disease. Disease management encompasses all settings of care and places a heavy emphasis on prevention and maintenance. Similar to care management but more focused on a defined set of diseases.

Health Utilization Management – managing the use of medical services so that a patient receives necessary, appropriate, high-quality care in a cost-effective manner. It requires plans to use clinical personnel to make decisions.

Health Network Accreditation – this standard includes key quality benchmarks for network management, provider credentialing, utilization management, quality management and improvement and consumer protection.

Health Plan Accreditation – a comprehensive assessment of a plan's performance in key areas including network management, provider credentialing, utilization management, quality management and improvement, and consumer protection.

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