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Insurance Services Programs

Federal Employee Health Benefit Program

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


Accreditation - The status granted to a health care organization following a rigorous, comprehensive, and independent evaluation. The evaluation includes an assessment of the care and service being delivered in important areas of public concern, such as immunization rates, mammography rates, and member satisfaction.

Brand name drug – A prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer’s brand name.

Coinsurance – The amount you pay as your share for the medical services you receive, such as a doctor’s visit. Coinsurance is a percentage of the cost of the service (you pay 20%, for example).

Consumer-Driven Health Plans (CDHP)- Describes a wide range of approaches to give you more incentive to control the cost of either your health benefits or health care. You have greater freedom in spending health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. In return, you have a higher annual deductible than standard medical plans after you have used up the designated amount. The catastrophic limit is usually higher than those in other plans.

Copayment - The amount you pay as your share for the medical services you receive, such as a doctor’s visit. A copayment is a fixed dollar amount (you pay $15, for example).

Fee-for-Service (FFS) - Health coverage in which doctors and other providers receive a fee for each service such as an office visit, test, or procedure. The health plan will either pay the medical provider directly or reimburse you for covered services after you have paid the bill and filed an insurance claim. When you need medical attention, you visit the doctor or hospital of your choice.

Formulary – A list of both generic and brand name drugs that are preferred by your health plan. Health plans choose formulary drugs that are medically safe and cost effective. A team including pharmacists and physicians meet to review the formulary and make changes as necessary.

Generic drug – A generic medication is an equivalent of a brand name drug. A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (pill, liquid, or injection).

Health Maintenance Organization (HMO) – A health plan that provides care through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Your eligibility to enroll in an HMO is determined by where you live or, in some plans, where you work.

Health Reimbursement Arrangements (HRA) - Health Reimbursement Arrangements are a common feature of Consumer-Driven Health Plans. They may be referred to by the health plan under a different name, such as Personal Care Account. They are also available to enrollees in High Deductible Health Plans who are ineligible foran HSA. HRAs are similar to HSAs except an enrollee cannot make deposits into an HRA, a health plan may impose a ceiling on the value of an HRA, interest is not earned on an HRA, and the amount in an HRA is not transferable if the enrollee leaves the health plan.

Health Savings Account (HSA) - A Health Savings Account allows individuals to pay for current health expenses and save for future qualified medical expenses on a tax-free basis. Funds deposited into an HSA are not taxed, the balance in the HSA grows tax- free, and that amount is available on a tax-free basis to pay medical costs. To open an HSA you must be covered under a High Deductible Health Plan and cannot be eligible for Medicare or covered by another plan that is not a High Deductible Health Plan or a general purpose HCFSA or a dependent on another person’s tax return. HSAs are subject to a number of rules and limitations established by the Department of the Treasury. Visit for more information.

High Deductible Health Plan (HDHP) - A High Deductible Health Plan is a health insurance plan in which the enrollee pays a deductible of at least $1,100(self-only coverage) or $2,200 (family coverage). The annual out-of-pocket amount (including deductibles and copayments) the enrollee pays cannot exceed $5,000 (self-only coverage) or $10,000 (family coverage). HDHPs can have first dollar coverage (no deductible)for preventive care and higher out-of-pocket copayments and coinsurance for services received from nonnetwork providers. HDHPs offered by the FEHB Program establish and partially fund HSAs for all eligible enrollees and provide a comparable HRA for enrollees who are ineligible for an HSA. The HSA premium funding or HRA credit amounts vary by plan.

In-Network – You receive treatment from the doctors, clinics, health centers, hospitals, medical practices, and other providers with whom your plan has an agreement to care for its members.

Out-of-Network – You receive treatment from doctors, hospitals, and medical practitioners other than those with whom the plan has an agreement, at additional cost. Members in a PPO-only option who receive services outside the PPO network generally pay all charges.

Point-of-Service (POS) – A product offered by a health plan that has both in-network and out-of-network features. In a POS you don't have to use the plan's network of providers for every service but you generally pay more out of network.

Preferred Provider Organization (PPO) – FFS Plans and many HDHPs use PPOs which are a network of providers. PPOs give you the choice of using doctors and other providers in the network or using non-network providers. You don’t have to use the PPO, but there are advantages if you do. (Be aware, however, that some of the services provided in a PPO hospital may not be covered by PPO arrangements. Room and board will be covered, but anesthesia and radiology, for instance, may be covered under non-PPO benefits.) Note that some FFS plans may offer an enrollment option that is "PPO­-only." You must use network providers to receive benefits from a PPO­-only plan.

Provider – A doctor, hospital, health care practitioner, pharmacy, or health care facility.

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