- Another plan has some extra services that I can't get in my own plan. When is the next time I can change plans?
- I'm interested in changing to either a health maintenance organization (HMO) or a plan with a Point-of-Service (POS) product. How can I find out where their providers are located?
- I don't understand what a "Plan offering a Point of Service product (POS)" really is. Can you give me a more thorough explanation?
- If I join a plan because my doctor is a participating doctor or specialist and then my doctor drops out of my plan's network in the middle of the year, can I switch plans or do I need to wait until open season?
- I have a pre-existing heart condition. When I change plans, should I worry about a waiting period before I can get coverage?
- When I leave the Federal Employees Health Benefits Program, I understand I will get a certification that I had group coverage that I can use to get new coverage with my private industry employer. Will my agency or my plan certify my insurance coverage?
You can change plans at open season and whenever certain events -- such as marriage -- occur. Becoming aware of another plan that has better benefits, even if you didn't expect to want the extra benefits when you had a chance to change plans before, does not qualify as an "event" that allows you to change plans.
The plans print their provider directories and have them available during open season. Many plans also provide this information on their websites. If your agency will have an open season health fair this fall, the plans probably will be there to hand out their brochures and provider directories. You can also call the plan at the number listed in any of the Federal Employees Health Benefits Guides.
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 has 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 Federal Employees Health Benefits Guide 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.
You would need to wait for open season. It is not uncommon for providers to leave plans mid-year. Other plan providers will be available to provide care.
There are no exclusions or waiting periods for pre-existing conditions in any plan in the Federal Employees Health Benefits Program. This will also be the case after you retire.
We require FEHB carriers to issue certifications of prior coverage to enrollees. They issue certifications automatically whenever coverage terminates, whether it is termination of regular coverage, TCC coverage, or spouse equity coverage. If the plan does not certify your coverage, you should write to them and ask them to send you certification of coverage.