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Healthcare Reference Materials

Health Plans

Types of Plans

Two types of plans participate in the FEHB Program: fee-for-service plans and health maintenance organizations (HMOs).

Fee-for-Service Plans

These plans reimburse you or your health care provider for the cost of covered services. You may choose your own physician, hospital, and other health care providers. Most fee-for-service plans have preferred provider (PPO) arrangements. If you receive services from a preferred provider, you usually have lower out-of-pocket expenses (i.e., a smaller copayment and/or a reduced or waived deductible). All fee-for-service plans require precertification of inpatient admissions and preauthorization of certain procedures.

Fee-for-service plans include:

  • The Governmentwide Service Benefit Plan, administered by the Blue Cross and Blue Shield Association on behalf of Blue Cross and Blue Shield Plans, and is open to everyone eligible to enroll under the FEHB Program.
  • Plans sponsored by unions and employee organizations. Some of these plans are open to all Federal employees who hold full or associate memberships in the organizations that sponsor the plans; others are restricted to employees in certain occupational groups and/or agencies. Generally, the employee organization requires a membership fee or dues paid directly to the employee organization, in addition to the premium. This fee is set by the employee organization and is not negotiated with OPM.

Health Maintenance Organizations

Health Maintenance Organizations (HMOs) provide or arrange for comprehensive health care services on a prepaid basis through designated plan physicians, hospitals, and other providers in particular locations. Each HMO sets a geographic area for which health care services will be available, called its service area. This area is described in the plan's brochure. You may join a particular HMO if you live within its service area. Some plans also accept enrollments from employees who work in the area even though they live elsewhere. If you have questions about whether you live or work within a HMO's service area, you should contact the plan before you enroll in it.

Generally, you must choose a primary care physician and have all care coordinated through that physician. Your physician is responsible for obtaining any pre-certification required for inpatient admissions or other procedures.

The three types of HMOs are:

  • Group Practice Plans. These plans provide care through groups of physicians who practice at medical centers.
  • Individual Practice Plans. These plans provide care through participating physicians who practice in their own offices.
  • Mixed Model Plans. These plans are a combination of Group Practice and Individual Practice plans.

Point of Service

Some fee-for-service plans and HMOs offer a point of service product. This gives you the choice of using a designated network of providers or using non-network providers at an additional cost to you. If you don't use network providers, you must pay substantial deductibles, coinsurance, and copayments.

High Deductible Health Plans

The HDHP features higher annual deductibles and annual out-of-pockets limits than other insurance plans. Depending on the HDHP you choose, you may have the choice of using in-network and out-of-network providers. There may be higher deductibles and out-of-pocket limits when you use out-of-network providers. Using in-network providers will save you money.

Some fee-for-service plans and HMOs offer a high deductible health plan (HDHP). When you enroll, your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA). The plan automatically deposits the monthly "premium pass through" into your HSA. The plan credits an amount into the HRA.

Consumer-Driven Health Plans

A consumer-driven plan provides you with freedom in spending health care dollars the way you want. The typical plan has common features: member responsibility for certain up-front medical costs, an employer-funded account that you may use to pay these up front costs, and catastrophic coverage with a high deductible. You and your family receive full coverage of in-network preventive care.

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Description of Plans

Guide to Federal Benefits

Each year prior to Open Season, OPM publishes a Guide to Federal Benefits for distribution through employing offices to enrollees and eligible persons. The Guide lists all participating plans in the FEHB Program, the premiums required, and other information, including quality indicators. You can also access the Guide to Federal Benefits from the FEHB home page.

Brochures

The benefits, cost, exclusions, limitations, and other major provisions of each participating plan are described in the brochure for that particular plan. You can get copies of the brochures for the various plans that you are eligible to join so you can make an informed choice among them. You can access all plan brochures from the FEHB home page. You can also get brochures from your employing office, and by contacting the plans directly at phone numbers listed in the Guide to Federal Benefits. You need to keep your selected plan's current brochure as a continuing source of information on the benefits that your plan provides.

Participating Provider Directories

Each HMO and each fee-for-service plan with preferred provider arrangements publishes a participating provider directory that lists its participating physicians, hospitals, and other providers. Before you enroll in a plan, you should review its participating provider directory. Every year during Open Season, you should ask for an updated directory and contact your chosen providers to see if they will continue to participate in the plan. Many plans have their provider directories on their websites. These can be accessed directly or from the FEHB home page.

Providers sometimes cease participation during an FEHB contract year; if you enroll in a fee-for-service plan, you should verify the provider's participation status before you receive services.

The continued participation of any provider with a health plan is not guaranteed. You are not eligible to change plans outside of an Open Season or other qualifying event solely because a particular health care provider stops participating with your plan.

Participating Plans

Before each Open Season begins, OPM provides agencies with an updated list of the names, addresses, and telephone numbers of all fee-for-service plans and HMOs that currently participate in the FEHB Program.

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Coordination of Benefits

If you or a covered family member are entitled to benefits from a source other than your FEHB plan, such as a spouse's health insurance coverage, Medicare, Medicaid, or no-fault automobile insurance, coordination of benefits will take place. You must disclose information about the other source of benefits to your plan's Carrier.

Coordination with health care furnished by Uniformed Services Facilities (USF) and the Department of Veterans Affairs (DVA)

These Government agencies are entitled to seek reimbursement from FEHB plans for certain services and supplies furnished to you or a family member. Generally, FEHB benefits are payable for (1) inpatient hospital costs at a Uniformed Services facility, and (2) services and supplies provided by a DVA facility for treatment of a non-service connected disability.

Coordination with TRICARE (formerly CHAMPUS)

TRICARE provides health care for active-duty military personnel whose orders do not specify a period of 30 days or less, and their dependents; retired and former military personnel currently entitled to retired or retainer pay, or equivalent pay, and their dependents; and dependents of deceased military personnel. If you are covered by both an FEHB plan and TRICARE, the FEHB plan pays benefits first as the primary payer and TRICARE is the secondary payer. (All provisions applicable to CHAMPUS now apply to TRICARE.)

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Coordination with Medicare

Basic Medicare Provisions

Medicare is generally for persons age 65 or over. It has two parts:

  • Part A (Hospital Insurance) helps pay for inpatient hospital care, skilled nursing facility care, home health care, and hospice care. You are entitled to Part A without having to pay premiums if you or your spouse worked for at least 10 years in Medicare-covered employment. (You automatically qualify if you were a Federal employee on January 1, 1983.) A percentage of your salary, up to a maximum determined by the Social Security Administration, is deducted from your pay for this coverage.
  • Part B (Medical Insurance) helps pay for doctors' services, outpatient hospital care, x-rays and laboratory tests, medical equipment and supplies, home health care (if you don't have Part A), certain preventive care, ambulance transportation, other outpatient services, and some other medical services Part A doesn't cover, such as physical and occupational therapy. You must pay premiums for Part B, which are withheld from your monthly social security payment or your Civil Service Retirement System (CSRS) annuity.

You should contact the Social Security Administration for detailed information on Medicare eligibility and benefits. You may also find information on the Medicare website at www.medicare.gov.

FEHB Plans and Medicare

Generally, plans under the FEHB Program provide protection against the same kind of expenses as Medicare, plus all FEHB plans provide prescription drug coverage, routine physicals, and a wider range of preventive services than Medicare.

Whether your FEHB plan or Medicare is the primary payer depends on your current employment or health status, as shown in the following table.

Medicare always makes the final determination as to whether they are the primary payer. The following chart illustrates whether Medicare or the FEHB Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell your plan if you or a covered family member has Medicare coverage so they can administer these requirements correctly.

A. When you - or your covered spouse - are age 65 or over and have Medicare and you...The primary payer for the individual with Medicare is...
1) Have FEHB coverage on your own as an active employee or through your spouse who is an active employee FEHB Plan
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant Medicare
3) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #1 above Medicare
4) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and ... FEHB Plan
You have FEHB coverage through your spouse who is an annuitant Medicare
5) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under who is an active employee Medicare
6) Are enrolled in Part B only, regardless of your employment status Medicare: for Part B servicesFEHB Plan: for other services
7) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that you are unable to return to duty Medicare
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and... It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period) FEHB Plan
It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD Medicare
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and... This Plan was the primary payer before eligibility due to ESRD FEHB Plan: for 30-month coordination period
Medicare was the primary payer before eligibility due to ESRD Medicare
C. When either you or a covered family member are eligible for Medicare solely due to disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee FEHB Plan
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant Medicare
D. When you are covered under the FEHB Spouse Equity provision as a former spouse
1) When you are covered under the FEHB Spouse Equity provision as a former spouse Medicare

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When Your FEHB Plan is Primary

When your FEHB Plan is primary (see the table above), you should submit claims for benefits to your FEHB plan first. If a balance remains after the FEHB plan makes payment on the claim, you can then submit the claim and a copy of the FEHB plan's explanation of benefits (EOB) to Medicare.

When Medicare is Primary

When Medicare is primary (see the table above), you should submit claims for benefits to Medicare first. If a balance remains after Medicare pays the claim, you can then submit the claim and a copy of Medicare's Medicare Summary Notice (MSN) or explanation of benefits (EOB) to your FEHB plan. As the secondary payer, the FEHB plan won't process your claim without the Medicare MSN or EOB.

FEHB plan carriers have made arrangements with Medicare that automatically transfer claims information to it once Medicare processes your claim, so you generally don't need to file with both.

Enrollment Change Permitted

You may change your FEHB enrollment to any available plan or option at any time beginning on the 30th day before you become eligible for Medicare. You may use this enrollment change opportunity only once, and is in addition to any other event (such as the annual open season) permitting enrollment changes.

You may discover that your current plan doesn't meet your needs once you start receiving Medicare benefits. You should review your plan's benefits and costs and determine if a different plan would be better for you.

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Payment of Benefits in Medically Underserved Areas

If you live in a medically underserved area and are enrolled in a fee-for-service plan, your plan must pay benefits up to its contractual limits, for covered health services provided by any medical practitioner properly licensed under applicable State law.

Each year, before the FEHB open season begins, OPM determines which states qualify as medically underserved areas for the next calendar year. OPM announces the results of this determination before each open season in a public notice in the Federal Register. The medically underserved areas are listed in each fee-for-service plan's brochure and on OPM's Plan Information page.

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Your Health Plan Choice

The right plan for you depends on many factors, including your family composition, your family's health, your ability to meet out-of-pocket medical expenses, and your ability to pay the required insurance premiums. What may be a good choice for one person may not be so for another. Only you can decide which plan is best for you.

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