FEHBP plans have wide range of flexibility and cost

Participants in the Federal Employees Health Benefits Program have myriad options in selecting a plan this open season. When deciding which type of coverage fits best, they should consider their preferences, such as whether they intend to see a particular physician or want the flexibility to seek care from a wide range of providers.

Walton Francis, author of the Consumers' Checkbook 2011 Guide to Health Plans for Federal Employees, said there is no right choice, as most FEHBP participants favor some plan features or cost structures over others.

A health maintenance organization offers enrollees access to a limited panel of service providers and will not cover care received outside of the plan's network. According to Francis, HMOs have generous benefits and don't require co-insurance or deductibles. Enrollees will have co-payments, or fixed-dollar costs for each physician visit or hospital stay, but low out-of-pocket expenses for in-network care. These plans are a straightforward choice for new and young federal employees who have few medical needs but may be limiting for those who want a wider range of service providers, he noted.

"You don't have to let your fingers do walking through the yellow pages to find a doctor," said Francis. "There's a modest amount of safety in the sense that the HMO manages things and performs oversight of the physicians and services in the network."

National plans, such as Blue Cross Blue Shield Standard Option, Mail Handlers Benefit Plan Standard and Value and GEHA High and Standard, have a larger list of preferred providers than HMOs but also will cover the cost of some out-of-network services. These plans have reasonable deductibles and co-payments. They offer maximum flexibility, but participants pay higher premiums in return, said Francis.

Consumer-driven and high-deductible plans require users to think more carefully about the type and cost of services they receive, according to Francis. These options have preferred providers, allow participants to seek out-of-network care and offer some type of savings account option for health care expenses. Enrollees pay several thousand dollars toward a deductible before coverage kicks in, he said.

Francis said one variable is whether plan participants prefer to visit a particular physician. But he noted employees' approach to health care and the features they want will determine the type of coverage that's right for them.

"My main advice is to look around a little bit," he said. "Don't automatically eliminate a category like HMO or high deductible. Don't assume they're not for you without looking at them."

Open season for 2011 runs from Nov. 8 to Dec. 13 and allows enrollees to alter or cancel their health, dental, vision and flexible spending account elections without penalty.

Before making any changes in health coverage, however, employees should know more than just how much their premium increased:

Co-insurance: The amount an enrollee pays for a service, such as a doctor's visit, as a percentage of the plan's allowance (20 percent of the cost of the service, for example).

Co-payments: The amount an enrollee pays for a service as a fixed dollar amount ($15 per doctor's visit, for example).

Deductibles: The dollar amount an individual or family must pay out of pocket for services before the insurance plan begins to cover expenses. There could be separate deductibles for different types of services, such as prescription drugs or outpatient care.

In-network coverage: The doctors, clinics, health centers, hospitals, medical practices and other providers with whom a plan has an agreement to care for its participants.

Out-of-network coverage: Treatment from doctors, hospitals, and medical practitioners other than those with whom a plan has an agreement. Services will cost more for out-of-network providers.

Preauthorization/prior approval requirements: Assurance from the plan that benefits will be provided and the cost of services covered.

For a more detailed glossary of terms, click here.