Q. I'm enrolled in a fee-for-service plan. How can I get the most value for
my benefit dollar?
A. Most FEHB fee-for-service plans offer Preferred Provider Organization (PPO) arrangements. When selecting your health care practitioner, your use of PPO providers whenever possible will help reduce your out-of-pocket expenses. In addition, PPO providers will generally file your claims for you. Read your plan's FEHB brochure carefully to find out about other incentives. Contact your plan to obtain the names of PPO providers in your area. You should also visit your plan's website (identified on the front of the plan's brochure and available by link from this website). Many plans provide up-to-date lists of PPO providers on their website.
Another way to cut costs is to request generic drugs instead of brand name drugs. A generic medication is a copy of a brand name drug. It has the same active ingredients and receives the same Food and Drug Administration approval but costs less. Most plans charge you a lower copay if you use generic drugs.
Q. I don't understand what a "Plan offering a Point-of-Service (POS)"
product really is. Can you give me a more thorough explanation?
A. A Plan offering a Point of Service product (POS) has features of both a Health Maintenance Organization (HMO) and a managed Fee-for-Service (FFS) plan. A few years ago, we began permitting plans to offer POS products as part of their benefits packages. Think of it as a hybrid of the two types of plans. In an HMO, the POS product lets you choose to use providers that are not part of the network of providers affiliated with the plan. There is a cost associated with choosing non-plan providers, usually in the form of substantial deductibles and coinsurances that are higher than the copayment you would normally pay for using a plan provider. You will also need to file a claim for reimbursement, like in a FFS plan. The plan wants you to use its network of providers, but it recognizes the desire of some enrollees to see a provider of their choosing on some occasions.
In the case of a POS product of a managed Fee-for-Service (FFS) plan, the opposite is true. The plan's normal benefits include deductibles and coinsurance. But in some locations, the plan has set up a network of providers similar to that you would find in an HMO. The plan encourages you to use these providers, usually by waiving the deductibles and applying a copayment that is smaller than the normal coinsurance. Normally, there would not be any paperwork when you use a network provider. Check the FEHB Guide on this website to see where the FFS plan offers a POS product, and what you must do to elect to participate in the plan's POS product.
Q. I want to take advantage of the better benefits available by using a PPO doctor but my plan doesn't have any in my area. Why can't non-PPO's be paid as PPO's when there aren't any PPO's in my area?
A. We ensure that the plans provide the benefits described in the FEHB Program brochures. The health plans often make Preferred Provider Agreements and other arrangements with providers which are contractual arrangements between the carriers and the providers. Because of the discounts that a plan realizes through its contracts with PPO providers, the plan is able to reimburse a higher percentage of the negotiated PPO allowance when PPO providers are utilized. It would not be cost effective for the plan to reimburse at the higher level when the provider is not giving a discount. Furthermore, much of the benefit you receive from using PPO providers comes from the PPO provider's agreement not to bill you for more than the negotiated PPO allowance. Non-PPO providers are under no such obligation. In some areas of the country, it is much more difficult for a plan to arrange PPO contracts for all types of services. In areas where there are no PPO providers, you can still receive your plan's regular benefits, as opposed to the incentivized PPO benefit.
Q. My plan denied my claim and I think they should have covered the services; what can I do?
A. First, check your plan's brochure to see if the service is covered, limited or
excluded. The next step is to review the disputed claims section of your
brochure. Briefly, the disputed claims section will direct you to write to the
plan to explain why (in terms of the applicable brochure coverage provisions)
you feel the services should be covered, and to ask the plan to reconsider your
claim. If the plan again denies the claim, read the plan's decision letter
carefully and then check your plan's brochure again. If you still disagree with
the plan's decision, the disputed claims section of your brochure will show you
how to write to the Office of Personnel Management to ask us to review the claim. We can't review a denied claim unless your plan has reconsidered it first (or at least been given an opportunity to reconsider it).
Generally, we will acknowledge your request within 5 days. After we
complete the review, we will send you a final response within 60 days. If we
need more time or if you need to do more -- such as send us more information -
we will contact you within 14 work days of the time we
get your request and tell you what you still need to do, if anything. We are sorry
but we cannot give you a decision over the phone until the review has been
completed and a written copy of the final decision has been issued.
Q. I got bad information from a Plan's customer service representative and obtained medical care based on this information. Will the OPM order the plan to pay?
A. Problems arising from oral discussions are very difficult to settle later because they are impossible to prove or disprove. In contractual situations such as under the FEHB Program, oral statements can never be regarded as official and, so, we state in the brochures that oral statements made by any representative of a carrier cannot modify the benefits described in the brochure.
Q. Why can't doctor's stay with the plan a year instead of dropping out at any time? I can't keep up with who is participating and who is not?
A. The FEHB Program runs on a calendar year basis - from January through December. The carriers' provider contracts, however, which are between the provider and the carrier, are spread throughout the year, as are the carriers' policies with other employers.
Q. My plan has decided to stop participating in the FEHB Program at the end of the year. If I have to go to the doctor before the effective date of my Open Season enrollment change, who will provide coverage?
A. Your Health Plan is required to provide coverage until Open Season
enrollments are effective. Since Open Season enrollments generally become
effective the first day of the first pay period in January, your Plan will provide
coverage until that date.
Q. My plan requires that I get preauthorization for surgery. My physician told me that I need this surgery but my plan will not authorize it. What can I do?
A. First, have your doctor contact the plan to discuss the situation. You and your doctor can provide your plan with information to support your contention that the surgery should be authorized, such as medical records that indicate the need for the surgery, and ask your plan to reconsider its decision. If the plan reconsiders its decision but continues to uphold its denial, and after considering the plan's rationale you still disagree, consult the disputed claims section of your plan's brochure for specific information on how to write to the Office of Personnel Management to ask us to review the claim.
Q. Why aren't there more HMOs participating in the FEHB Program where I live?
A. Unfortunately, there are areas of the country that HMOs have simply chosen
not to participate in the FEHB Program. Reasons for this vary, but most cases
involve population size or demographics.
There is no minimum requirement for the number of HMO options available to
enrollees throughout the country. We have encouraged HMO participation in
the Program because many of our participants have asked for that choice of
health plan. In fact, under the FEHBP, the only types of health plans that can
be added to the Program are HMOs. And, HMOs have an annual opportunity to
submit their applications to participate in the Program.
If you have HMOs in your local area that do not currently participate in the
FEHBP, we encourage you to ask these HMOs to consider the FEHBP market for
their geographic areas. New plan application packages for the FEHB Program are available at www.opm.gov/insure/health/carriers/index.asp. Applications are due to OPM by January 31 of each year for the next contract term.
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 | (202) 606-1800 | TTY (202) 606-2532