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Insurance Services Programs

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Federal Employee Health Benefit Program

RI 70-8 For Certain Temporary Employees
Those eligible to enroll in the FEHB Program under 5 U.S.C. 8906a

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.

 

Choice of doctors, hospitals, pharmacies, and other providers

Specialty Care

Out-of-pocket costs

Paperwork

Fee-for-Service w/PPO

You must use the plan's network for full benefits. Not using PPO providers means only some or none of your benefits will be paid.

Referral not required to get benefits.

You pay fewer costs if you use a PPO provider than if you don't.

Some if you don't use network providers.

Health Maintenance Organization

You generally must use the network. You pay all costs for care outside the network.

Referral generally required from primary care doctor to get benefits.

Your out–of–pocket costs are generally limited to copayments.

Little, if any.

Point-of-Service

You must use the network for full benefits. You may go outside the network but it will cost you more.

Referral generally required to get full benefits.

You pay less if you use a network provider than if you don't.

Little if you use the network. You have to file your own claims if you don't use the network.

Consumer-Driven Plans

You may use network and non-network providers. Not using the network will cost you more.

Referral not required to get full benefits.

You will pay an annual deductible and cost-sharing. You pay less if you use the network.

Some if you don't use network providers.

High Deductible Health Plans w/HSA or HRA

Some plans are network only, others pay something even if you do not use a network provider.

Referral not required to get full benefits.

You will pay an annual deductible and cost-sharing. You pay less if you use the network.

If you have an HSA account, you may have to file a claim to obtain reimbursement.

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/archive/05/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/archive/health.

 

Health Plan________

Health Plan________

Health Plan________

Annual premium

 

 

 

Annual deductible

 

 

 

Office visit to primary care doctor

 

 

 

Hospital inpatient deductible/copayment/coinsurance

 

 

 

Hospital room & board charges

 

 

 

Generic drug (local pharmacy)

 

 

 

Brand name drug (local pharmacy)

 

 

 

Catastrophic protection limit

 

 

 

Home health care visits

 

 

 

Durable medical equipment

 

 

 

Maternity care

 

 

 

Well-child care

 

 

 

Routine physicals

 

 

 

Accreditation

 

 

 

The following information can be found in the Member Survey Results section in the benefit charts.

Overall member satisfaction with plan

 

 

 

Getting needed care

 

 

 

Getting care quickly

 

 

 

How well doctors communicate

 

 

 

Customer service

 

 

 

Claims processing

 

 

 

Step 3: Consider 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.

National Committee for Quality Assurance (www.ncqa.org)

Excellent – Levels of service and clinical quality that meet or exceed NCQA's requirements for consumer protection and quality improvement AND achieve health plan performance results that are in the highest range of national or regional performance.

Commendable – Meets or exceeds NCQA's requirements for consumer protection and quality improvement.

Accredited – Meets most of NCQA's requirements for consumer protection and quality improvement.

Provisional – Meets some but not all of NCQA's requirements for consumer protection and quality improvement.

New Health Plan –Applies to health plans that are less than two years old.

Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org)

Accreditation with Full Compliance – Demonstrates satisfactory compliance with JCAHO standards in all performance areas.

Accreditation with Requirements for Improvement – Demonstrates satisfactory compliance with JCAHO standards in most performance areas.

Provisional – Demonstrates a previously unaccredited plan's satisfactory compliance with a subset of standards.

Conditional – Demonstrates failure to meet standard(s) or specific policy requirement(s) but is believed capable to do so in a specified time period.

 

URAC (www.urac.org)

Full Accreditation – Demonstrates full compliance with standards.

Conditional – Meets most of the standards but needs some improvement before achieving full compliance.

Provisional – A plan that has otherwise complied with all standards but has been in operation for less than 6 months.

    

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. The results shown in the plan comparison sections are collected, scored, and reported by an independent organization ?not by the health plans. For each survey measure, individual plan scores are compared to a national average for all plans of the same type. Plan scores are reported as at, above, or below the national average. Here is a brief explanation of each survey category.

Overall Plan Satisfaction
  • How would you rate your overall experience with your health plan?

Getting Needed Care
  • Were you satisfied with the choices your health plan gave you to select a personal doctor?
  • Were you satisfied with the time it takes to get a referral to a specialist?

Getting Care Quickly
  • Did you get the advice or help you needed when you called your doctor during regular office hours?
  • Could you get an appointment for regular or routine care when you wanted?

How Well Doctors Communicate
  • Did your doctor listen carefully to you and explain things in a way you could understand?
  • Did your doctor spend enough time with you?

Customer Service
  • Was your plan helpful when you called its customer service department?
  • Did you have paperwork problems?
  • Were the plan's written materials understandable?

Claims Processing
  • Did your plan pay your claims correctly and in a reasonable time?

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

Case Management

Disease Management

Health Utilization Management

Health Network Accreditation

Health Plan Accreditation

APWU Health Plan

X

X

X

X

X

 

Blue Cross and Blue Shield

 

X

 

 

 

 

GEHA

 

X

X

X

X

 

Mail Handlers

 

 

X

X

 

 

NALC

X

X

 

X

 

 

PBP Health Plan

 

 

 

 

X

 

Association

 

 

 

X

X

 

Foreign Service

X

 

X

X

X

 

Panama Canal

 

 

 

 

 

X

Rural Carrier

 

 

 

X

X

 

SAMBA

 

 

 

X

 

 

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 case 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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