U.S. Office of Personnel Management - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

Appendix B: Choosing an FEHB Plan

Worksheets and Definitions

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 to reduce your out-of-pocket costs. 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 plan's network to reduce your out-of-pocket costs.	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 plan's network to reduce your out-of-pocket costs. You may go outside the network but you will pay more.	Referral generally required to get maximum 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. You will pay more by not using the network.	Referral not required to get maximum benefits from PPOs.	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/Health Savings Account or Health Reimbursement Arrangement	Some plans are network only, others pay something even if you do not use a network provider.	Referral not required to get maximum benefits from PPOs.	You will pay an annual deductible and cost-sharing. You pay less if you use the network.	If you have an HSA or HRA account, you may have to file a claim to obtain reimbursement.

Cost and benefits

Work Sheet For Picking a Health Plan

An easy-to-use tool allowing you to compare plans is available on the web at www.opm.gov/insure/health/search/plansearch.aspx. If you do not have Internet access, complete the chart below by using this Guide and the health plan’s brochures to reviewyour costs, including premiums, and estimatewhat you might spend on health care next year. Plan brochures can be obtained fromyour Human Resources Office or on the OPM website at www.opm.gov/insure/health. The side-by-side comparison can help you pick a planwith the benefits you need at a cost you can afford.

	Plan	Plan	Plan	Plan	Plan	Plan
Annual Premium
Annual Deductible (if any)
Office visit to primary care doctor (cost x estimated # of visits)
Office visit to specialist (cost x estimated # of visits)
Hospital inpatient deductible
Prescription drugs
Maximum out-of-pocket limit for year
Durable medical equipment
Preventive care
Maternity care
Well child care
Routine physicals
TOTAL COST

Think Quality

Pay attention to how a plan performs on measures of quality. We have several sources for reviewing quality information: accreditation (independent evaluations from private accrediting organizations), member survey results (evaluations by current plan members), and effectiveness of care (how the plan performs in preventing and treating common conditions). Check your health plan's brochure for its accreditation level or look for the Health Plan Accreditation link at www.opm.gov/insure/health. Member survey results are posted within the health plan benefit chart in this Guide. And a plan's effectiveness of care is measured by the Healthcare Effectiveness Data and Information Set found on our website at www.opm.gov/insure/health/hedis2008.

Enrollment Checklist

• The plans I can chose based upon where I live
• The total of all family members’ visits to primary care doctors last year
• The total of all family members’ visits to specialists last year
• The total of all family members’ visits to hospitals last year
• The total number of prescriptions for the family each month
• Do I have to choose a primary care physician
• Do I need a referral to see a specialist
• Will I receive benefits if I go outside the plan’s network
• Is there a discount prescription drug mail order service
• Prescription drugs - a flat fee or percentage
• How are routine physicals covered
• The annual deductible
• The hospital deductible, copayment, or coinsurance
• Maximum out-of-pocket costs (catastrophic protection) for the year

Review the Member Survey Results:

• Overall Plan satisfaction
• Getting needed care
• Getting care quickly
• How well doctors communicate
• Customer service
• Claims processing

Dental

• Does the health plan have a dental benefit?
• Expected # of visits to the dentist for treatment other than routine cleaning?
• Total visit of all family members to the dentist for treatment last year?
• How much did it cost for all dental expenses last year?
• Do you have higher dental expenses planned for next year?
• Compare the cost of next year’s premiums with the amount you expect to spend out of pocket on dental care next year. If the premiums are more, or equal to the amount you expect to spend, you may not need additional dental insurance.

Vision

• Are routine vision exams covered under my health plan?
• Does any family member need vision correction?
• How much did the family spend on vision correction last year?
• Does the vision plan cover the correction methods the family needs?
• Do you have higher dental expenses planned for next year?
• Is my total premium for next year more than my expected benefit? If yes, you may not need to purchase additional vision coverage.

Flexible Spending Account

• How much did the family spend on items such as: over-the-counter medicines and products, insurance co-pays and coinsurance?
• Are you or any family member planning to receive health services not covered by the health plan? How much will it cost?

Add the amount in the 2 rows above and you may consider setting that amount aside for your FSA

Definitions

Brand name drug - A prescription drug that is protected by a patent, supplied by a single company and marketed under the manufacturer's brand name.

Coinsurance - The amount you pay as your share for the medical services you receive, such as a doctor's visit. Coinsurance is a percentage of the plan's allowance for the service (you pay 20% for example).

Copayment - The amount you pay as your share for the medical services you receive, such as a doctor's visit. A copayment is a fixed dollar amount (you pay $15, for example).

Deductible - The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits. These may be separate deductibles for different types of services. For example, a plan can have a prescription drug benefit deductible separate from its calendar year deductible.

Formulary or Prescription Drug List - A list of both generic and brand name drugs, often made up of different cost-sharing levels or tiers, that are preferred by your health plan. Health plans choose drugs that are medically safe and cost-effective. A team, including pharmacists and physicians, meets to review the drug list and make changes as necessary.

Generic Drug - A generic medication is an equivalent of a brand name drug. A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (pill, liquid or injection).

In Network - You receive treatment from the doctors, clinics, health centers, hospitals, medical practices and other providers with whom your plan has an agreement to care for its members.

Out-of-Network - You receive treatment from doctors, hospitals, and medical practitioners other than those with whom the plan has an agreement at additional cost. Members in a PPO-only option who receive services outside the PPO network generally pay all charges.

Premium Conversion - A program to allow Federal employees to use pre-tax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program. Based on Federal tax rules, employees can deduct their share of health insurance premiums from their taxable income, which reduces their taxes.

Provider - A doctor, hospital, health care practitioner, pharmacy or health care facility.

Qualifying Life Events - An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season. These events also apply to employees under premium conversion and include such events as change in family status, loss of FEHB coverage due to termination or cancellation, and change in employment status.