This Plan is a health maintenance organization (HMO) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Sentara Health Plans holds the following accreditation: National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation, please visit the following website: www.ncqa.org.
We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. We give you a choice of enrollment in a High Option, or a High Deductible Health Plan (HDHP).
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
General features of our High Option
We have Open Access benefits
Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). Except for emergencies outside the service area, we will not pay for care or services from non-Plan providers unless it has been authorized by us. You are responsible for making sure that a provider is a Plan provider. If you use a non-Plan provider without our prior authorization, you may be responsible for charges.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, cannot exceed $7,300 for Self Only enrollment, and $14,700 for a Self Plus One or Self and Family.
General Features of our High Deductible Health Plan
HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more information about these savings features.
Preventive care services
Preventive care services are generally covered with no cost sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.
Annual deductible
The annual deductible must be met before Plan benefits are paid for care other than preventive care services.
Health Savings Account (HSA)
You are eligible for an HSA if you are enrolled in an HDHP not be covered by any other health plan that is not an HDHP (including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not received VA (except for veterans with a service-related disability) or Indian Health Services (IHS) benefits within the last three months, not covered by your own or your spouse’s flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.
- You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
- Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
- You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
- For each month that you are enrolled in a HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
- You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.
Health Reimbursement Arrangement (HRA)
If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
- An HRA does not earn interest.
- An HRA is not portable if you leave the Federal government or switch to another plan.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, to no more than $7,000 for Self Only enrollment, and $14,800 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.
Health education resources and accounts management tools
We have online, interactive health and benefits information tools to help you make more informed health decisions (see page 106).
Your rights and responsibilities
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/healthcare-insurance/) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Sentara Health Plans is a not-for-profit health maintenance organization fully licensed under the laws of the Commonwealth of Virginia to arrange for the provision of health care services to its members.
- Sentara Health Plans is one of the first HMOs in the Hampton Roads area of Virginia operating since 1984.
- Sentara Health Plans pays providers on a fee for service basis according to a fee schedule. You may find some additional information about the Plan’s providers in this brochure in Section 3, "Where You Get Covered Care". If you would like information about the Plan’s provider network, including participating hospitals, physician education, and board certification, and whether or not physicians are accepting new patients, you may check your provider directory, or the Plan’s website at www.sentarahealthplans.com/federal or call Member Services at 757-552-7550 or 800-206-1060.
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website at www.sentarahealthplans.com/federal. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 757-552-7550 or 800-206-1060, or write to Sentara Health Plans, PO Box 66189
Virginia Beach, VA 23466. You may also visit our website at www.sentarahealthplans.com/federal.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.sentarahealthplans.com/federal to obtain our Notice of Privacy Practices. You can also contact us to request that we mail a copy of the Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area in the State of Virginia:
Cities of:
Achilles, Ark, Battery Park, Bavon, Beaverlett, Bellamy, Bena, Blakes, Bohannon, Boykins, Branchville, Capron, Cardinal, Carrollton, Carrsville, Chesapeake, Claremont, Cobbs Creek, Courtland, Dendron, Diggs, Drewryville, Dutton, Elberon, Fleet, Fort Eustis, Fort Monroe, Fort Story, Foster, Franklin, Glou Point, Gloucester, Gloucester Point, Grafton, Grimstead, Gwynn, Hallieford, Hampton, Hayes, Hudgins, Isle Of Wight, Ivor, James Store, Jamestown, Lackey, Langley AFB, Lightfoot, Maryus, Mathews, Miles, Mobjack, Moon, Naval Base, Naval Weapons Station, Naxera, New Point, Newport News, Newsoms, Norfolk, Norge, North, Onemo, Ordinary, Peary, Pinero, Poquoson, Port Haywood, Portsmouth, Redart, Rescue, Schley, Seaford, Sedley, Severn, Shadow, Smithfield, Spring Grove, Suffolk, Surry, Susan, Tabb, Toano, Virginia Beach, Walters, Ware Neck, White Marsh, Wicomico, Williamsburg, Windsor, Woods Cross Roads, Yorktown, Zanoni, and Zuni.
Counties of:
Chesapeake (City), Franklin (City), Gloucester, Hampton (City), Isle Of Wight, James City, Mathews, Newport News (City), Norfolk (City), Poquoson (City), Portsmouth (City), Southampton, Suffolk (City), Surry, Virginia Beach (City), Williamsburg (City), and York.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.