• FEHB and You
• Program Features
• Your Links to Information
  • 2000 FEHB Web Site - www.opm.gov/insure
  • Employee Express
  • We're Y2K OK
• Quality Indicators
  • Satisfaction Survey
  • Accreditation

FEHB and YOU

The Federal Employees Health Benefits (FEHB) Program can help you meet your health care needs. Federal employees, retirees and their survivors enjoy the widest selection of health plans in the country. You can choose from among Fee-for-Service (FFS) plans, regardless of where you live, or Plans offering a Point of Service (POS) Product and Health Maintenance Organizations (HMO) if you live (or sometimes if you work) within the area serviced by the plan.

Some FFS plans are open to all enrollees, but some require that you join the organization that sponsors the plan. Some plans limit enrollment to certain employee groups. Membership requirements and/or limitations also apply to any POS product the FFS plan may be offering.

Managed care is an important part of the FEHB Program. You will find managed care features in all the plans described on this site. Common features of managed care are pre-approval of hospital stays, the use of primary care providers as "gatekeepers" to coordinate your medical care, and networks of physicians and other providers.

You are fortunate to be able to choose from among many different health plans competing for your business. Use this site to compare the costs, benefits, and features of different plans.

We now show comparative benefit information for all plans. The benefit categories we list were chosen based on enrollee requests, differences amount plans, and simplicity. However, we urge you to consider the total benefit package, in addition to service and cost, when choosing a health plan.

The plan brochures tell you what services and supplies are covered and the level of coverage. Look over the brochures carefully, especially the Changes page of your current plan to see how benefits have changed from last year. The brochures reflect the efforts of OPM and health plan representatives to eliminate jargon and use plain language. We also formatted the brochures to ensure they are all organized alike. You can get brochures from the health plans or your human resource office. They are also available on our web site at www.opm.gov/insure. When it comes to your health care, the best surprise is no surprise.

Choosing a plan

Cost - certainly the premium you pay is an important consideration, but there are some other things you should consider. When thinking about premiums, what can you afford biweekly or monthly? Should you enroll in a High Option - and pay High Option premiums - if a Standard Option would do?

If you need to go to the hospital, how much will you have to pay? Do you know how much you will pay for an emergency room visit? If you have children, what will it cost you for a well-child care visit?

Do you have to pay a deductible for the services you might use? Your share of medical expenses is either a coinsurance (a percentage of the bill) or a copayment (a fixed dollar amount). Which option do you prefer and what does the plan require? Does the plan limit the dollar amount it will pay for certain services?

Coverage -- check to see if the plan offers the services you think you might need. If you're 65 or over, how does the plan coordinate coverage with Medicare? If you regularly see an allergist, do you pay extra for the allergy serum? Does the plan offer a prenatal program? Given the trend toward reducing hospital stays, will your plan pay for home health care? Because health care is expensive, pay attention to the plan's catastrophic coverage to see how you are protected. See if there are limits on the number of visits for the services you need.

How the plan works - if predictable cost, comprehensive benefits, no paperwork, and a coordinated approach to health care are high priorities, consider a Health Maintenance Organization (HMO). Most HMOs require you to select a doctor to act as your primary care physician, or PCP, who refers you to specialists. If you don't use a plan doctor, the plan usually will not pay for services, unless it is an emergency.

A Plan offering a Point of Service (POS) Product also has rules about what benefits are covered and doctor choice and access to specialists, but you can choose any doctor you like and see specialists without referrals if you agree to pay more.

If you are willing to pay a little more in total costs for the widest choice of doctors, a Fee-for-Service (FFS) plan might be for you. FFS plans let you choose your own doctor and allow you to see specialists without a referral. Most FFS plans have Preferred Provider Organizations (PPO) that save you money if you use these providers.

Some plans offer 24-hour medical advice lines to help you make health decisions. These programs try to keep you healthy and avoid unnecessary - and potentially costly and time consuming - medical treatment.

Satisfaction - the experience of FEHB members form the satisfaction ratings on this site. If you're considering joining a FFS plan, chances are you'll file a claim. How quickly does the plan process claims? Will the plan be responsive to your questions? As an HMO enrollee, you might be most interested in how the plan is rated in access to care and choice of doctors. Ask your doctor's office about experiences with different health plans.

Accreditations - HMO accreditations reflect the independent evaluations of nationally-recognized organizations. Plans willing to go through an accreditation review show a commitment to continuous quality improvement and accountability.

Getting the most from a plan

Within any plan, there are things you can do to minimize your out-of-pocket costs and make the plan work best for you.

Cost -- here are some ideas for getting the best value for your premium dollar:

• an easy way to save money is to use your plan's mail order drug program, if it has one.
• Request generic drugs instead of brand name drugs.
• Almost all FFS Plans have Preferred Provider Organizations. Using a PPO will reduce your out-of-pocket expenses. If you do not use a PPO provider, your plan will base its payment on an allowance that probably will be less than the actual billed charge. This means you might have to pay the difference, which may be more than the coinsurance amounts shown on this site and the plan brochure. You can reduce the chance of this happening by discussing fees in advance with your provider. Remember that plans set their own allowances.

It is also important to note that all of the services provided in a PPO hospital may not be covered by PPO arrangements. Room and board will be covered, but the anesthesia and radiology services may not be. The only way to find out is to ask ahead of time.

Quality - talk openly with your health plan and providers about the kind of quality you want. Is your HMO> rated by a national accrediting organization? Ask your surgeon how frequently he/she performs the procedure you are considering. If you're pregnant, ask your obstetrician the percentage of cases in which he/she performs a caesarean section and how that compares with the local average. Is your doctor proposing an invasive approach to treatment when a more conservative one is just as effective? Does your doctor discuss possible drug interactions with you when prescribing a new medication?

No one has a greater stake in your health than you. Understand how your plan works and don't be shy about asking questions. An informed consumer is a better decision maker.

Program Features

Some of Our Important Program Features are:

No waiting periods. Your human resource office or retirement system sets the effective date of your coverage. You can use your FEHB benefits as soon as your coverage is effective - there are no waiting periods, required medical examinations or restrictions because of age or physical condition.

A choice of coverage. You can choose self only coverage just for you, or self and family coverage for you, your spouse, and unmarried dependent children under age 22. Under certain circumstances, your FEHB enrollment may cover your disabled child 22 years old or older who is incapable of self-support.

A choice of plans and options.

• Fee-for-Service plans
• Plans offering a Point of Service product
• Health Maintenance Organizations

A Government contribution. The Government contributes toward the total cost of your premium. In 2000, the Government will pay up to $2,049.60 for each self only enrollment and $4,575.24 for each self and family enrollment, but not more than 75% of the total premium for any plan. The Government contribution for part-time employees may be different. See your human resource office to get the exact amount.

Salary deduction. You pay your share of the premium through a payroll deduction.

Annual enrollment opportunities. Each year you have the opportunity to enroll or change plans. The 1999 Open Season is from November 8 through December 13, during which you may enroll if you are eligible and not now enrolled, change plans or options, or change from self only to self and family. (You may change from self and family to self only or disenroll at any time.)

Continued group coverage. The FEHB Program offers continued FEHB coverage:

• for you and your family when you retire from Federal service (normally you need to be covered in the FEHB Program for the five years before you retire),
• for your former spouse if you divorce and he or she has a qualifying court order (see your human resource office for more information),
• for your family if you die, or
• for you and your family when you move, transfer, go on leave without pay, or enter military service (certain rules about coverage and premium amounts apply; see your human resource office).

Coverage after FEHB ends. The FEHB Program offers either temporary continuation of FEHB coverage (TCC) or conversion to non-group (private) coverage:

• for you and your family if you leave Federal service (including when you can't carry FEHB into retirement),
• for your covered dependent child if he or she marries or turns age 22, or
• for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resource office for more information).

If you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. If not, the plan must give you one on request. This certificate may be important to qualify for benefits if you join a non-FEHB plan.

Your Links to Information

1999 FEHB Web Site -- www.opm.gov/insure

Our 2000 FEHB web site gives current and valuable information to help you choose a health plan. Visit us at www.opm.gov/insure.

You will find our site even more information and easier to use than last year. You can link to most of our topics directly from the front home page this year. We still have our Health Plan Profiler (HPP) that lets you view and print summary information about health plans. This year, enrollees in all states can use our interactive decision tool to narrow your health plan search.

You can download and print plan brochures and other materials, access definitions by clicking hyperlinks, and use automated links to navigate to other sites where you can find information about the Patient's Bill of Rights, mental health, health care quality and general health care information. When you visit www.opm.gov/insure you will see these choices and more:

• 2000 Plan Information - gives you access to general information about plans, plan quality indicators (including detailed survey results which are not printed in the Guide), plan brochures, and information about how to choose a plan. You can link to other web sites with valuable information about health plans, including those plans participating in the FEHB Program. You also can view, download and print the Guides to Federal Employees Health Benefits Plans.

  PlanSmartChoice -- is a link to an interactive survey tool for help in selecting a plan. Based on individual preferences that you enter, PlanSmartChoice will rank specific health plans.

• Annuitant Information - gives you general information about Open Season for annuitants as well as new features available to retirees, including how to make Open Season changes through the Internet. You can also link to the Medicare web site.

• Patients' Bill of Rights - gives you information about the Patients' Bill of Rights and the principle areas of rights and responsibilities. You can also link to the full text of the Patients' Bill of Rights and related background information.

• Frequently Asked Questions - gives you answers to questions about premiums, Employee Express, enrollment, family members, temporary continuation of coverage (TCC), changing plans, retirement and other topics of interest.

• Rate Us -- is a new feature where you can answer specific questions about our site. We still have our section for your comments and suggestions. Let us know what you think.

Employee Express

Employee Express is a user-friendly automated system that allows some Federal employees to make changes to their health insurance, as well as Thrift Savings Plan, financial allotments, deposit of net pay, home address, and state and Federal taxes. Employees can access Employee Express using a touch-tone telephone, a personal computer or computer kiosk. This avoids the need to submit paper forms. Employee Express saves time and is accessible 24-hours a day, 7 days a week. If you are unsure whether you can use Employee Express, contact your human resource or payroll office. You may visit Employee Express at www.employeeexpress.gov or link to it from our web site.

We're Y2K OK

The United States Office of Personnel Management is prepared for the year 2000 (Y2K). Our systems are updated, tested, and ready. We have also worked hard with our participating plans to help them get ready. We want you to be ready, too. If you would like more information, we can help! Here are three ways you can get free help:

1. Call the Federal Year 2000 Information Center toll free at 1-888-USA4-Y2K (1-888-872-4925)
2. Call OPM's toll-free Fax-Back Line at 1-877-750-0177 (Select a topic from the menu and receive faxed information immediately.)
3. Visit our Y2K HELP site on the Internet at www.opm.gov/Y2K/help

Quality Indicators

Satisfaction Survey

OPM and FEHB plans and enrollees participated this year in a broad-based survey effort with other public and private employers by using the Consumer Assessment of Health Plans Survey. This survey is a widely accepted tool for obtaining customer feedback on their experiences with their health plans. Before you joint a plan, it may help to know what people who use the plan say about it. The survey results are not provided or influenced by the health plans; they are solely based on the responses of enrolled individuals like yourself. The complete questionnaire (59 questions) is on our web site but for ease of presentation we have summarized findings in the following key areas:

What the survey asked health plan enrollees:

• Getting Needed Care. Did you have problems getting a referral to a specialist? Did you experience delays in obtaining care? Did you have problems getting the care you and your doctor believed necessary?
• Getting Care Quickly. When you called during regular office hours, did you get the advice or help you needed? Could you get an appointment for regular or routine health care as soon as you wanted?
• How Well Doctors Communicate. Did the doctors or other health providers listen carefully to you? Did they explain things in a way you could understand? Did they spend enough time with you?
• Courteous and Helpful Office Staff. Did the doctor or some other provider's staff treat you with courtesy and respect? Was the staff as helpful as you thought they should be?
• Customer Service. Were you helped when you called your plan's customer service department? Did you have problems with paperwork for your plan? Was it hard to find and understand information in the plan's written materials?
• Claims Processing. Did your plan handle your claims in a reasonable time? Did they handle your claims correctly?
• Overall Plan Satisfaction. How would you rate your overall experience with your health plan?

A plan may not be rated for one of three reasons:

1. it is new to the FEHB program.
2. The plan has fewer than 500 Federal subscribers, or
3. The plan failed to administer the survey as we asked. We have identified the plans in this last category with an X.

FEHB plans also participated in a separate child's survey, but this data was not available for publication at the time this Guide went to print. Check our web site for results.

Plans that enrollees rated significantly better than average in a category have a , average ratings get a , and significantly below average get a .

Accreditation

Accreditation is a rigorous and comprehensive evaluation process where independent organizations assess the quality of the key systems and processes that managed care organizations (specifically, an HMO or POS plan) use. Accreditation also includes an assessment of the care and service plans are delivering in important areas of public concern such as immunization rates, mammography rates, and member satisfaction.

The National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are independent, private, not-for-profit organizations dedicated to assessing and reporting on the quality of health care organizations. These organizations are completely independent of the health plans and issue their accreditation results without the approval of the health plans they review. We encourage all FEHB plans to get accreditation from a national accrediting organization, who will evaluate their systems and processes and confer accreditation much like educational accrediting institutions confer accreditation to schools.

Quality includes 1) the perception of the quality of care received and 2)the quality of medical care provided.

The first is measured by annual satisfaction surveys. The second is measured in part by accreditation. As an employer, accreditation to us means accountability to a customer and validation of selected measures of a health plan's operations. Enrollees can be assured that an independent organization has performed an unbiased assessment of a health plan's systems and found them to be of a particular quality. We think an accredited plan offers value to your health plan decision making.

Note: There are various reasons why a plan is not accredited; check with the plan for an explanation.

Both NCQA and JCAHO have multiple levels of accreditation.