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 HMOs 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.
Descriptions of Plans
Each year prior to Open Season, OPM publishes an FEHB Guide 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. 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 on OPMs website at www.opm.gov. You can also get brochures from your employing office, and by contacting the plans directly at phone numbers listed in the FEHB Guide. You need to keep your selected plan’s current brochure as a continuing source of information on the benefits that your plan provides.
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 web sites. 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.
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.