HMOs in the FEHB Program

Two types of plans participate in the FEHB Program: fee-for-service plans and health maintenance organizations (HMOs).

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. 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 HMO’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. 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.

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