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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 (FFS) and health maintenance organizations (HMOs). Some of these plans offer additional plan delivery systems as described below in the “Additional Plan Delivery Systems” section. It’s important to know that not all FFS plans or HMOs offer additional plan delivery systems. Specific plan offerings are detailed on each respective plan’s brochure cover.

Fee-for-Service Plans

Fee-for-service (FFS) plans reimburse the enrollee or the health care provider for the cost of covered services. The enrollee/family member may choose his/her own physician, hospital, and other health care providers. Most FFS plans offer services through a preferred provider organization (PPO). This means that certain hospitals and other health care providers are “preferred providers.” Services received from a preferred provider usually have lower out-of-pocket expenses (i.e., a smaller copayment or coinsurance amount and/or a reduced or waived deductible). All FFS plans require precertification of inpatient admissions and preauthorization of certain procedures.

FFS plans include:

  • The Governmentwide Service Benefit Plan (also referred to as the Federal Employee Program or FEP), is administered by the Blue Cross and Blue Shield Association on behalf of Blue Cross and Blue Shield Plans nationwide, 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 and annuitants 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 and annuitants who retired from such 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. Each of these plans provide specific membership requirements on the cover of its respective brochure.

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. An individual may join an HMO if he/she lives within the HMO’s service area. Some HMOs also accept enrollments from employees who work in the service area even though they live outside of the service area. Individuals that have questions about whether they live or work within an HMO's service area should contact the plan before enrolling in it.

Generally, an enrollee and each family member must choose a primary care physician (PCP) and have all care coordinated through that PCP. The PCP 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.

Additional Plan Delivery Systems

Point of Service

Some FFS plans and HMOs offer a point of service product. This gives the enrollee and covered family members the choice of using a designated network of providers or using non-network providers at an additional cost. If network providers are not used, there are substantial out of pocket expenses.

High Deductible Health Plans

Some fee-for-service FFS and HMO plans offer a high deductible health plan (HDHP). HDHPs feature higher annual deductibles and annual out-of-pockets limits than other insurance plans. Some HDHPs offer the choice of using in-network and out-of-network providers. Enrollees who use in-network providers will save money on out-of-pocket expenses, whereas the use of out-of-network providers will result in higher deductibles and out-of-pocket limits.

When an individual enrolls in an HDHP, the health plan establishes either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for the enrollee. The plan will pass through (contribute) a portion of the health plan premium into the enrollee’s HSA or credits an amount into the HRA.

Consumer-Driven Health Plans

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

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Description of Plans

Brochures

The benefits, cost, exclusions, limitations, and other major provisions of each participating plan are described in the brochure for that particular plan. Anyone can get copies of the brochures for the various plans that they are eligible to join in order to help them make an informed choice among the available plans. Access to all plan brochures is available through the FEHB home page on the OPM website. Brochures can also be obtained from the employing office. An employee or annuitant can also contact a plan directly to receive a "hard copy" brochure. Enrollees are encouraged to keep their selected plan's current brochure as a continuing source of information on the benefits the plan provides.

Participating Provider Directories

Each HMO and FFS plan with a preferred provider organization publishes a participating provider directory that lists its participating physicians, hospitals, and other providers. Before enrolling in a plan, an individual should review its participating provider directory. Every year during Open Season, enrollees should ask for an updated directory and contact their 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 through the FEHB home page on the OPM website.

The continued participation of any provider with a health plan is not guaranteed. Providers sometimes cease participation during an FEHB contract year. Enrollees should verify provider participation status before receiving services. Enrollees are not eligible to change plans outside of an Open Season or other qualifying event solely because a particular healthcare provider stops participating with a plan.

Participating Plans

Before each Open Season begins, OPM provides employing offices with an updated list of the names, addresses, and telephone numbers of all plans that currently participate in the FEHB Program.

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Coordination of Benefits

Coordination of benefits (COB) generally occurs when an enrollee or a family member has more than one health plan covering the same benefits. Certain COB rules are used to determine which health plan pays its benefits in first (known as the primary payer) while the other plan(s) pays a reduced benefit as the secondary payor. Payment is coordinated under the COB rules to ensure that no more than 100% of any claim is paid by both plans.

If an enrollee or covered family member is entitled to health insurance coverage from a source other than his/her FEHB plan, such as a spouse's health plan, Medicare, Medicaid, or no-fault automobile insurance, coordination of benefits will take place. The enrollee must disclose information about the other source of benefits to his/her plan.

To learn more about how an FEHB plan coordinates benefits, enrollees are encouraged to review the COB section of an FEHB plan’s brochure.

Coordination with Health Care Furnished by Uniformed Services Facilities and the Department of Veterans Affairs

These Government agencies are entitled to seek reimbursement from FEHB plans for certain services and supplies furnished to an enrollee 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 Department of Veterans Affairs facility for treatment of a non-service connected disability.

Coordination with TRICARE (formerly CHAMPUS) and CHAMPVA

TRICARE provides health care for active-duty military personnel 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. CHAMPVA provides health coverage to disabled veterans and their eligible dependents. If an enrollee is covered by both an FEHB plan and TRICARE or CHAMPVA, the FEHB plan pays benefits first as the primary payer and TRICARE or CHAMPVA is the secondary payer. (All provisions applicable to CHAMPUS now apply to TRICARE.)

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Coordination with Medicare

Original Medicare Plan Provisions

Original 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. An individual is entitled to Part A without having to pay premiums if he/she or his/her spouse worked for at least 10 years in Medicare-covered employment. A percentage of his/her salary, up to a maximum determined by the Social Security Administration, is deducted from his/her 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 the individual doesn’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. Those who elect Part B coverage must pay a separate premium which is withheld from their monthly Social Security payment or their annuity.

The Social Security Administration is the point of contact for detailed information on Medicare eligibility and benefits. Information can also be found on the Medicare website.

FEHB Plans and Medicare

Generally, plans under the FEHB Program provide insurance coverage for the same kind of medical expenses as Medicare, plus a comprehensive range of preventive services and prescription drug coverage.

Medicare always makes the final determination as to whether it is the primary payer. The following chart illustrates whether Medicare or the FEHB Plan should be the primary payer according to an individual’s employment status and other factors determined by Medicare. It is critical that the enrollee tells his/her plan if he/she or a covered family member has Medicare coverage so the plan can administer these requirements correctly.

A. When an enrollee - or his/her covered spouse - is age 65 or over, has Medicare, and...The primary payer for the individual with Medicare is...
1) Has FEHB coverage on his/her own as an active employee or through his/her spouse who is an active employee FEHB Plan
2) Has FEHB coverage on his/her own as an annuitant or through his/her spouse who is an annuitant Medicare
3) Is a reemployed annuitant with the Federal government and his/her position is excluded from the FEHB (the employing office will know if this is the case) and he/she is not covered under FEHB through his/her spouse under #1 above Medicare
4) Is a reemployed annuitant with the Federal government and his/her position is not excluded from the FEHB (the employing office will know if this is the case) and ... FEHB Plan
He/she has FEHB coverage through his/her spouse who is an annuitant Medicare
5) Is 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 his/her covered spouse is this type of judge) and he/she is not covered under FEHB through his/her spouse who is an active employee Medicare
6) Is enrolled in Part B only, regardless of his/her employment status Medicare: for Part B servicesFEHB Plan: for other services
7) Is a former employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that the individual is unable to return to duty Medicare
B. When the enrollee or a covered family member...
1) Has 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 the enrollee or a family member are still entitled to Medicare due to ESRD Medicare
2) Becomes 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
3) Have Temporary Continuation of Coverage (TCC) and… Medicare based on age and disability Medicare
Medicare based on ESRD FEHB Plan for the 30-month coordination period, then Medicare
C. When either the enrollee or a covered family member is eligible for Medicare solely due to disability and he/she...
1) Has FEHB coverage on his/her own as an active employee or through a family member who is an active employee FEHB Plan
2) Has FEHB coverage on his/her own as an annuitant or through a family member who is an annuitant Medicare
D. When the enrollee is covered under the FEHB Spouse Equity provision as a former spouse
1) When he/she is covered under the FEHB Spouse Equity provision as a former spouse Medicare

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When the Enrollee's FEHB Plan is Primary

When the FEHB Plan is the primary payer (see the table above), the enrollee or covered family member should submit claims for benefits to his/her FEHB plan first. If a balance remains after the FEHB plan makes payment on the claim, he/she 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 the primary payer (see the table above), claims for benefits should be submitted to Medicare first. If a balance remains after Medicare pays the claim, the claim and a copy of the Medicare Summary Notice (MSN) or explanation of benefits (EOB) can be submitted to the FEHB plan. As the secondary payer, the FEHB plan will not process the claim without the MSN or EOB.

FEHB plan carriers and Medicare have an agreement to automatically transfer claims information from Medicare to the plan once Medicare processes a claim. In most cases, there will not be a need to file a claim to both the FEHB plan and Medicare.

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Additional Medicare Coverage

Medicare Advantage (Part C)

Individuals who are eligible for Medicare may choose to enroll in and receive Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country.

An individual may enroll in another plan’s Medicare Advantage plan and also remain enrolled in an FEHB plan. If an individual enrolls in a Medicare Advantage plan and remains enrolled in an FEHB plan, he/she must let his/her FEHB plan know. In order to correctly coordinate benefits with Medicare, the FEHB plan will need to know whether the enrollee has the Original Medicare Plan or a Medicare Advantage plan.

Annuitants and former spouses can suspend FEHB coverage to enroll in a Medicare Advantage plan thereby eliminating the FEHB premium. (OPM does not contribute to a Medicare Advantage plan premium.) For information on suspending FEHB enrollment, an individual must contact his/her retirement office. Suspending (not cancelling) FEHB enrollment is a very specific action that requires assistance from the retirement office.

An individual who later wants to re-enroll in the FEHB Program, can generally do so only at the next Open Season unless he/she involuntarily loses coverage or moves out of the Medicare Advantage plan’s service area.

FEHB plan brochures provide some information about Medicare Advantage plans. Medicare is the main point of contact for information to learn more about Medicare Advantage plans.

Medicare Prescription Drug Coverage (Part D)

The Medicare Part D program authorizes Medicare-approved private insurance companies to provide prescription drug coverage. An individual can join a standalone Prescription Drug Plan (PDP) or get prescription drug coverage as part of a Medicare Advantage plan (MA-PD). To join a Medicare Prescription Drug Plan or a Medicare Advantage plan with prescription drug coverage an individual must have Medicare Part A or Medicare Part B. He/she must also live in the service are of the plan he/she wants to join.

All FEHB plans are required to provide creditable prescription drug coverage. This means that an individual does not need to enroll in Medicare Part D and pay extra for prescription drug coverage if already enrolled in FEHB. If he/she decides to enroll in Medicare Part D later, he/she will not have to pay a penalty for late enrollment as long as he/she keeps the FEHB coverage.

If an individual chooses to enroll in Medicare Part D, he/she can keep FEHB coverage and his/her FEHB plan will coordinate benefits with Medicare.

FEHB plan brochures provide some information about Medicare Part D. Medicare is the main point of contact for information to learn more about Medicare Part D.

Enrollment Change Permitted

An enrollee may change his/her FEHB enrollment to any available plan or option at any time beginning on the 30th day before he/she becomes eligible for Medicare. Enrollees 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.

An enrollee may discover that his/her current plan will not meet his/her needs once he/she starts receiving Medicare benefits. Enrollees should review plan benefits and costs to determine if a different plan may be more beneficial.

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Health Plan Choice

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

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Control Panel