Health Maintenance Organizations (HMOs) provide or arrange for comprehensive health care services on a prepaidÂ basis through designated plan physicians, hospitals, and other providers in particular locations. Each HMO sets aÂ geographic area for which health care services will be available, called its service area. This area is described in theÂ planâ€™s brochure. You may join a particular HMO if you live within its service area. Some plans also accept enrollmentsÂ from employees who work in the area even though they live elsewhere. If you have questions about whether you liveÂ or work within a HMOâ€™s 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. YourÂ physician is responsible for obtaining any pre-certification required for inpatient admissions or other procedures.
The three types of HMOs are:
â€¢ Group Practice Plans. These plans provide care through groups of physicians who practice at medical centers.
â€¢ Individual Practice Plans. These plans provide care through participating physicians who practice in their ownÂ offices.
â€¢ 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 designatedÂ network of providers or using non-network providers at an additional cost to you. If you donâ€™t use network providers,Â 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 toÂ enrollees and eligible persons. The Guide lists all participating plans in the FEHB Program, the premiums required,Â and other information, including quality indicators. The benefits, cost, exclusions, limitations, and other majorÂ provisions of each participating plan are described in the brochure for that particular plan. You can get copies of theÂ brochures for the various plans that you are eligible to join so you can make an informed choice among them. You canÂ access all plan brochures from the FEHB home page on OPMâ€™s website at www.opm.gov. You can also get brochuresÂ from your employing office, and by contacting the plans directly at phone numbers listed in the FEHB Guide. YouÂ need to keep your selected planâ€™s current brochure as a continuing source of information on the benefits that your planÂ provides.
Each HMO and each fee-for-service plan with preferred provider arrangements publishes a participating providerÂ directory that lists its participating physicians, hospitals, and other providers. Before you enroll in a plan, you shouldÂ review its participating provider directory. Every year during Open Season, you should ask for an updated directoryÂ and contact your chosen providers to see if they will continue to participate in the plan. Many plans have their providerÂ 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, youÂ should verify the providerâ€™s participation status before you receive services. The continued participation of anyÂ provider with a health plan is not guaranteed. You are not eligible to change plans outside of an Open Season or otherÂ 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 telephoneÂ numbers of all fee-for-service plans and HMOs that currently participate in the FEHB Program.