guide to federal benefits
TRANSCRIPT
Guide To Federal Benefits
The 2012
Healthcare and Insurance RI 70-1Revised November 2011
bull Federal Employees Health Benefits (FEHB) Program p 10
bull Federal Employees Dental and Vision Insurance Program
(FEDVIP) p14
bull Federal Flexible Spending Account Program (FSAFEDS) p18
bull Federal Employeesrsquo Group Life Insurance (FEGLI) Program p 22
bull Federal Long Term Care Insurance Program (FLTCIP) p 24
For Federal Civilian Employees
Visit us at wwwopmgovinsure
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
Table of Contents
Page
Introduction to Federal Benefits and This Guide 3
PreshyExisting Insurance Program 4
Federal Benefits Snapshot 5
Federal Benefits Open Season Snapshot 6
Thinking About Retiring 7
Federal Employees Health Benefits (FEHB) Program 10
FEHB Program Health Information Technology and PriceCost Transparency 13
Federal Employees Dental and Vision Insurance Program (FEDVIP) 14
Federal Flexible Spending Account Program (FSAFEDS) 18
Federal Employeesrsquo Group Life Insurance (FEGLI) Program 22
Federal Long Term Care Insurance Program (FLTCIP) 24
Appendix A FEHB Program Features 27
Appendix B Choosing an FEHB Plan 28
Appendix C Qualifying Life Events that May Permit a Change in Your FEHB Enrollment 31
Appendix D FEHB Member Survey Results 32
Appendix E FEHB Plan Comparison Charts 33
bull FeeshyforshyService 34
bull Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product 39
bull High Deductible and ConsumershyDriven Health Plans 64
Appendix F FEDVIP Program Features 81
Appendix G FEDVIP Definitions 82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes 83
Appendix I FEDVIP Plan Comparison Charts 84
bull Nationwide and International Dental Plans Open to All 85
bull Regional Dental Plans 86
bull Nationwide and International Vision Plans Open to All 87
Appendix J FEDVIP Dental Rating Regional Chart 88
Appendix K FEDVIP Premium Rate Charts 91
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) 94
1
This page intentionally left blank
2
Introduction to Federal Benefits and This Guide
As a Federal employee the benefits available to you represent a significant piece of your compensation package They may provide important insurance coverage to protect you and your family and in some cases offer tax advantages that reduce the burden in paying for some health products and services or dependent or elder care services
The purpose of this Guide is to provide you basic information about the benefits offered to you as a Federal employee and assist you in making informed choices about these benefits as you move through your career and prepare for retirement
Benefits Programs included in this Guide
In addition to your Civil Service or Federal Employees Retirement System benefits and the Thrift Savings Plan the Federal government offers five benefits programs to eligible employees and retirees This Guide includes information on the five programs
bull Federal Employees Health Benefits Program bull Federal Employees Dental and Vision Insurance Program bull Federal Flexible Spending Account Program bull Federal Employeesrsquo Group Life Insurance Program bull Federal Long Term Care Insurance Program
If you are a new Federal employee or have recently become eligible for benefits this Guide will walk you through the benefits offered and provide information on how and when to make your choices If you are a current employee it will provide the most current information regarding the benefit programs and will support you as you make decisions during the annual Federal Benefits Open Season or experience life events that cause you to reconsider previous choices
This Guide also contains some tips on what to consider as you make your decisions For instance did you know that the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) can potentially provide you with greater benefits without costing you much more As a Federal employee you can choose to pay the FEDVIP and FEHB premiums with preshytax dollars and you can use preshytax FSA dollars to pay for eligible expenses including FEDVIP and FEHB copays and deductibles Dental and vision care are also eligible FSA expenses whether combined with FEDVIP coverage or not Please take a moment to review the information in this Guide and decide upon the right choices for you
Additional Information
You will find references throughout this Guide to websites or other locations to obtain more detailed information than is available here We encourage you to access these sites to become a more educated decisionshymaker and consumer of Federal benefit programs
3
Preshyexisting Condition Insurance Program (PCIP)
Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help
An individual is eligible to buy coverage in PCIP if
bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition
bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)
bull He or she is a citizen or national of the United States or resides in the US legally
The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)
4
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
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26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
Table of Contents
Page
Introduction to Federal Benefits and This Guide 3
PreshyExisting Insurance Program 4
Federal Benefits Snapshot 5
Federal Benefits Open Season Snapshot 6
Thinking About Retiring 7
Federal Employees Health Benefits (FEHB) Program 10
FEHB Program Health Information Technology and PriceCost Transparency 13
Federal Employees Dental and Vision Insurance Program (FEDVIP) 14
Federal Flexible Spending Account Program (FSAFEDS) 18
Federal Employeesrsquo Group Life Insurance (FEGLI) Program 22
Federal Long Term Care Insurance Program (FLTCIP) 24
Appendix A FEHB Program Features 27
Appendix B Choosing an FEHB Plan 28
Appendix C Qualifying Life Events that May Permit a Change in Your FEHB Enrollment 31
Appendix D FEHB Member Survey Results 32
Appendix E FEHB Plan Comparison Charts 33
bull FeeshyforshyService 34
bull Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product 39
bull High Deductible and ConsumershyDriven Health Plans 64
Appendix F FEDVIP Program Features 81
Appendix G FEDVIP Definitions 82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes 83
Appendix I FEDVIP Plan Comparison Charts 84
bull Nationwide and International Dental Plans Open to All 85
bull Regional Dental Plans 86
bull Nationwide and International Vision Plans Open to All 87
Appendix J FEDVIP Dental Rating Regional Chart 88
Appendix K FEDVIP Premium Rate Charts 91
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) 94
1
This page intentionally left blank
2
Introduction to Federal Benefits and This Guide
As a Federal employee the benefits available to you represent a significant piece of your compensation package They may provide important insurance coverage to protect you and your family and in some cases offer tax advantages that reduce the burden in paying for some health products and services or dependent or elder care services
The purpose of this Guide is to provide you basic information about the benefits offered to you as a Federal employee and assist you in making informed choices about these benefits as you move through your career and prepare for retirement
Benefits Programs included in this Guide
In addition to your Civil Service or Federal Employees Retirement System benefits and the Thrift Savings Plan the Federal government offers five benefits programs to eligible employees and retirees This Guide includes information on the five programs
bull Federal Employees Health Benefits Program bull Federal Employees Dental and Vision Insurance Program bull Federal Flexible Spending Account Program bull Federal Employeesrsquo Group Life Insurance Program bull Federal Long Term Care Insurance Program
If you are a new Federal employee or have recently become eligible for benefits this Guide will walk you through the benefits offered and provide information on how and when to make your choices If you are a current employee it will provide the most current information regarding the benefit programs and will support you as you make decisions during the annual Federal Benefits Open Season or experience life events that cause you to reconsider previous choices
This Guide also contains some tips on what to consider as you make your decisions For instance did you know that the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) can potentially provide you with greater benefits without costing you much more As a Federal employee you can choose to pay the FEDVIP and FEHB premiums with preshytax dollars and you can use preshytax FSA dollars to pay for eligible expenses including FEDVIP and FEHB copays and deductibles Dental and vision care are also eligible FSA expenses whether combined with FEDVIP coverage or not Please take a moment to review the information in this Guide and decide upon the right choices for you
Additional Information
You will find references throughout this Guide to websites or other locations to obtain more detailed information than is available here We encourage you to access these sites to become a more educated decisionshymaker and consumer of Federal benefit programs
3
Preshyexisting Condition Insurance Program (PCIP)
Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help
An individual is eligible to buy coverage in PCIP if
bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition
bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)
bull He or she is a citizen or national of the United States or resides in the US legally
The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)
4
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
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26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Table of Contents
Page
Introduction to Federal Benefits and This Guide 3
PreshyExisting Insurance Program 4
Federal Benefits Snapshot 5
Federal Benefits Open Season Snapshot 6
Thinking About Retiring 7
Federal Employees Health Benefits (FEHB) Program 10
FEHB Program Health Information Technology and PriceCost Transparency 13
Federal Employees Dental and Vision Insurance Program (FEDVIP) 14
Federal Flexible Spending Account Program (FSAFEDS) 18
Federal Employeesrsquo Group Life Insurance (FEGLI) Program 22
Federal Long Term Care Insurance Program (FLTCIP) 24
Appendix A FEHB Program Features 27
Appendix B Choosing an FEHB Plan 28
Appendix C Qualifying Life Events that May Permit a Change in Your FEHB Enrollment 31
Appendix D FEHB Member Survey Results 32
Appendix E FEHB Plan Comparison Charts 33
bull FeeshyforshyService 34
bull Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product 39
bull High Deductible and ConsumershyDriven Health Plans 64
Appendix F FEDVIP Program Features 81
Appendix G FEDVIP Definitions 82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes 83
Appendix I FEDVIP Plan Comparison Charts 84
bull Nationwide and International Dental Plans Open to All 85
bull Regional Dental Plans 86
bull Nationwide and International Vision Plans Open to All 87
Appendix J FEDVIP Dental Rating Regional Chart 88
Appendix K FEDVIP Premium Rate Charts 91
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) 94
1
This page intentionally left blank
2
Introduction to Federal Benefits and This Guide
As a Federal employee the benefits available to you represent a significant piece of your compensation package They may provide important insurance coverage to protect you and your family and in some cases offer tax advantages that reduce the burden in paying for some health products and services or dependent or elder care services
The purpose of this Guide is to provide you basic information about the benefits offered to you as a Federal employee and assist you in making informed choices about these benefits as you move through your career and prepare for retirement
Benefits Programs included in this Guide
In addition to your Civil Service or Federal Employees Retirement System benefits and the Thrift Savings Plan the Federal government offers five benefits programs to eligible employees and retirees This Guide includes information on the five programs
bull Federal Employees Health Benefits Program bull Federal Employees Dental and Vision Insurance Program bull Federal Flexible Spending Account Program bull Federal Employeesrsquo Group Life Insurance Program bull Federal Long Term Care Insurance Program
If you are a new Federal employee or have recently become eligible for benefits this Guide will walk you through the benefits offered and provide information on how and when to make your choices If you are a current employee it will provide the most current information regarding the benefit programs and will support you as you make decisions during the annual Federal Benefits Open Season or experience life events that cause you to reconsider previous choices
This Guide also contains some tips on what to consider as you make your decisions For instance did you know that the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) can potentially provide you with greater benefits without costing you much more As a Federal employee you can choose to pay the FEDVIP and FEHB premiums with preshytax dollars and you can use preshytax FSA dollars to pay for eligible expenses including FEDVIP and FEHB copays and deductibles Dental and vision care are also eligible FSA expenses whether combined with FEDVIP coverage or not Please take a moment to review the information in this Guide and decide upon the right choices for you
Additional Information
You will find references throughout this Guide to websites or other locations to obtain more detailed information than is available here We encourage you to access these sites to become a more educated decisionshymaker and consumer of Federal benefit programs
3
Preshyexisting Condition Insurance Program (PCIP)
Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help
An individual is eligible to buy coverage in PCIP if
bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition
bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)
bull He or she is a citizen or national of the United States or resides in the US legally
The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)
4
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
This page intentionally left blank
26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
This page intentionally left blank
2
Introduction to Federal Benefits and This Guide
As a Federal employee the benefits available to you represent a significant piece of your compensation package They may provide important insurance coverage to protect you and your family and in some cases offer tax advantages that reduce the burden in paying for some health products and services or dependent or elder care services
The purpose of this Guide is to provide you basic information about the benefits offered to you as a Federal employee and assist you in making informed choices about these benefits as you move through your career and prepare for retirement
Benefits Programs included in this Guide
In addition to your Civil Service or Federal Employees Retirement System benefits and the Thrift Savings Plan the Federal government offers five benefits programs to eligible employees and retirees This Guide includes information on the five programs
bull Federal Employees Health Benefits Program bull Federal Employees Dental and Vision Insurance Program bull Federal Flexible Spending Account Program bull Federal Employeesrsquo Group Life Insurance Program bull Federal Long Term Care Insurance Program
If you are a new Federal employee or have recently become eligible for benefits this Guide will walk you through the benefits offered and provide information on how and when to make your choices If you are a current employee it will provide the most current information regarding the benefit programs and will support you as you make decisions during the annual Federal Benefits Open Season or experience life events that cause you to reconsider previous choices
This Guide also contains some tips on what to consider as you make your decisions For instance did you know that the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) can potentially provide you with greater benefits without costing you much more As a Federal employee you can choose to pay the FEDVIP and FEHB premiums with preshytax dollars and you can use preshytax FSA dollars to pay for eligible expenses including FEDVIP and FEHB copays and deductibles Dental and vision care are also eligible FSA expenses whether combined with FEDVIP coverage or not Please take a moment to review the information in this Guide and decide upon the right choices for you
Additional Information
You will find references throughout this Guide to websites or other locations to obtain more detailed information than is available here We encourage you to access these sites to become a more educated decisionshymaker and consumer of Federal benefit programs
3
Preshyexisting Condition Insurance Program (PCIP)
Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help
An individual is eligible to buy coverage in PCIP if
bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition
bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)
bull He or she is a citizen or national of the United States or resides in the US legally
The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)
4
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
This page intentionally left blank
26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Introduction to Federal Benefits and This Guide
As a Federal employee the benefits available to you represent a significant piece of your compensation package They may provide important insurance coverage to protect you and your family and in some cases offer tax advantages that reduce the burden in paying for some health products and services or dependent or elder care services
The purpose of this Guide is to provide you basic information about the benefits offered to you as a Federal employee and assist you in making informed choices about these benefits as you move through your career and prepare for retirement
Benefits Programs included in this Guide
In addition to your Civil Service or Federal Employees Retirement System benefits and the Thrift Savings Plan the Federal government offers five benefits programs to eligible employees and retirees This Guide includes information on the five programs
bull Federal Employees Health Benefits Program bull Federal Employees Dental and Vision Insurance Program bull Federal Flexible Spending Account Program bull Federal Employeesrsquo Group Life Insurance Program bull Federal Long Term Care Insurance Program
If you are a new Federal employee or have recently become eligible for benefits this Guide will walk you through the benefits offered and provide information on how and when to make your choices If you are a current employee it will provide the most current information regarding the benefit programs and will support you as you make decisions during the annual Federal Benefits Open Season or experience life events that cause you to reconsider previous choices
This Guide also contains some tips on what to consider as you make your decisions For instance did you know that the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) can potentially provide you with greater benefits without costing you much more As a Federal employee you can choose to pay the FEDVIP and FEHB premiums with preshytax dollars and you can use preshytax FSA dollars to pay for eligible expenses including FEDVIP and FEHB copays and deductibles Dental and vision care are also eligible FSA expenses whether combined with FEDVIP coverage or not Please take a moment to review the information in this Guide and decide upon the right choices for you
Additional Information
You will find references throughout this Guide to websites or other locations to obtain more detailed information than is available here We encourage you to access these sites to become a more educated decisionshymaker and consumer of Federal benefit programs
3
Preshyexisting Condition Insurance Program (PCIP)
Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help
An individual is eligible to buy coverage in PCIP if
bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition
bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)
bull He or she is a citizen or national of the United States or resides in the US legally
The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)
4
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
This page intentionally left blank
26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Preshyexisting Condition Insurance Program (PCIP)
Do you know someone who needs health insurance but canrsquot get it The PreshyExisting Condition Insurance Plan (PCIP) may help
An individual is eligible to buy coverage in PCIP if
bull He or she has a preshyexisting medical condition or has been denied coverage because of the health condition
bull He or she has been without health coverage for at least the last six months (If the individual currently has insurance coverage that does not cover the preshyexisting condition or is enrolled in a state high risk pool then that person is not eligible for PCIP)
bull He or she is a citizen or national of the United States or resides in the US legally
The Federal government administers PCIP in the following states Alabama Arizona District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Kentucky Louisiana Massachusetts Minnesota Mississippi North Dakota Nebraska Nevada South Carolina Tennessee Texas Vermont Virginia West Virginia and Wyoming To find out about eligibility visit wwwpcipgov andor wwwhealthcaregov or call 1shy866shy717shy5826 (TTY 1shy866shy561shy1604)
4
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
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26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Federal Benefits Snapshot
New or Newly Eligible Employees
As a new or newly eligible employee you may have the opportunity to enroll in the benefit programs noted below Use this chart to assist you with the decisionshymaking process of selecting and enrolling in the benefit programs below that meet your needs The chart gives you things to consider as you make your decisions
FEHB 1 See page 10 for general information on FEHB (including eligibility) and for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 See page 14 for general information on FEDVIP (including eligibility) and guidance on choosing a FEDVIP dental plan andor vision plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 See page 16 for information on how to enroll
FSAFEDS 1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
FEGLI 1 See page 22 for general information on FEGLI (including eligibility) and for guidance on making a decision whether to select optional insurance (Basic FEGLI is automatic)
2 See page 23 for information on how to enroll
1 See page 24 for general information on FLTCIP (including eligibility) and for guidance FLTCIP on making a decision whether to apply
2 See page 25 for information on how to apply for coverage
5
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
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26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Federal Benefits Open Season Snapshot
Current Employees
During Open Season you have the opportunity to make changes in the Federal Employees Health Benefits (FEHB) Program the Federal Employees Dental and Vision Insurance Program (FEDVIP) and the Federal Flexible Spending Account Program (FSAFEDS) You can use this chart to assist you with the decisionshymaking process of selecting plans and enrolling in these benefit programs
If Currently Enrolled in the Program If Not Enrolled in the Program
FEHB 1 Check your planrsquos 2012 premiums and satisfaction survey results in Appendix E
2 Examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
3 Check Appendix E for any new plans and plan options available to you
4 If satisfied with your planrsquos rates survey results and benefits for 2012 do nothing ndash your enrollment will continue automatically
5 If not satisfied with your current plan for 2012 see Appendix B for guidance on choosing another plan
6 See page 7 for information on FEHB and retirement
1 See page 10 for general information on FEHB (including eligibility) and Appendix B for guidance on choosing a plan
2 If you decide to enroll examine the 2012 brochure of each plan you consider to ensure the benefits and premiums meet your needs and the plan is available in your area
3 Contact the human resources office of your agency for information on how to enroll
FEDVIP 1 Check your planrsquos 2012 premiums in Appendix K and examine your planrsquos 2012 brochure for benefit and enrollmentservice area changes
2 If also enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
3 If satisfied with your planrsquos rates and benefits for 2012 do nothing ndash your enrollment will continue automatically
4 If not satisfied with your current plan for 2012 see page 14 for guidance on choosing another plan and for information on how to change your enrollment
5 If you no longer want FEDVIP you must cancel during Open Season by contacting BENEFEDS After Open Season you cannot cancel see Appendix H for details
6 See page 7 for information on FEDVIP and retirement
1 See page 14 for general information on FEDVIP (including eligibility) and for guidance on choosing a FEDVIP plan
2 If you decide to enroll examine the 2012 brochure of the plans in which you are interested to ensure the benefits and premiums meet your needs and the plan is available in your area
3 If enrolled in FEHB check your 2012 FEHB brochure for any changes in dental andor vision benefits
4 See page 16 for information on how to enroll
FSAFEDS 1 If you want to participate in 2012 you must make a new election Keep in mind your election and enrollment do not carry over from year to year see page 21 for information on how to enroll
2 Check your 2012 FEHB and 2012 FEDVIP plan brochures to see how any benefit changes may affect your outshyofshypocket health care expenses
3 See page 18 for any updated information about the Program
1 See page 18 for general information on FSAFEDS (including eligibility) and for guidance on making a decision whether to participate
2 See page 21 for information on how to enroll
6
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
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26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96
Thinking About Retiring
Federal Benefits Facts
FEHB bull When you retire you are eligible to continue health benefits coverage if you meet all of the following requirements
ndash you are entitled to retire on an immediate annuity under a retirement system for civilian employees (including the Federal Employees Retirement System (FERS) Minimum Retirement Age (MRA) + 10 retirement) and
ndash you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
bull The 5 year requirement period can include the following
ndash the time you are covered as a family member under another persons FEHB enrollment or
ndash the time you are covered under the Uniformed Services Health Benefits Program (also known as TRICARE) as long as you were covered under an FEHB enrollment at the time of your retirement
bull As an annuitant you are entitled to the same benefits and Government contributions as Federal employees enrolled in the same plan
bull The event of retirement is not a qualifying life event (QLE) however there are other opportunities to change FEHB enrollment including during Open Season or when you experience a QLE
bull If you retire with a Self Only enrollment and later want to cover eligible family members you can change to a Self and Family enrollment during the annual Open Season or when you experience certain QLEs
bull If you are not enrolled in FEHB (or covered as a family member) at the time of your retirement you cannot enroll when you retire
bull If you are enrolled in a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA) at the time of your retirement you can still contribute to your HSA provided you have no other insurance coverage other than those specifically allowed and are not claimed as a dependent on someone elsersquos tax return Some examples of other coverage that would cause ineligibility are Medicare TRICARE other nonshyhigh deductible health insurance or having received VA benefits within the previous three months If you donrsquot qualify for an HSA your plan will enroll you in a Health Reimbursement Arrangement (HRA)
bull If you cancel your FEHB enrollment as an annuitant you will never be able to reshyenroll in FEHB unless you had suspended your FEHB enrollment because you are now covered by a Medicare Advantage plan TRICARE or CHAMPVA Medicaid or similar Stateshysponsored program of medical assistance or Peace Corps Volunteer coverage
bull If you want your surviving family members to continue your health benefits enrollment after your death you must be enrolled for Self and Family at the time of your death and at least one family member must be entitled to an annuity as your survivor
bull Consider whether you need to signshyup for Medicare when you become eligible
7
Thinking About Retiring
Federal Benefits Facts continued
FEDVIP bull There is no 5 year requirement for continuing FEDVIP coverage into retirement
bull Your coverage will continue as a retiree Retirees may also enroll during the annual Federal Benefits Open Season or when you experience a qualifying life event (QLE) Keep in mind that retirement is not a QLE
bull In most cases changing from payroll deduction to annuity deduction is automatic but may take one to three months to occur It is advised that you contact BENEFEDS at 1shy877shy888shy3337 prior to retirement in order to eliminate any suspension in coverage
bull BENEFEDS cannot deduct premiums from your annuity while you are receiving ldquospecialrdquo or ldquointerimrdquo pay Once your annuity is finalized premium deductions will begin If you miss one or more premium payments before your annuity is final BENEFEDS will make double deductions until any balance due is paid They will notify you before deducting this additional premium amount Once there is no past due balance the amount of premium deducted will return to the regular monthly premium
FSAFEDS
bull When you retire you will no longer be able to participate in FSAFEDS Your FSA will terminate as of the date of your retirement and you will not be eligible to enroll as an annuitant When you make your annual election for the year that you plan to retire keep in mind that any remaining funds for which you have not incurred eligible expenses while employed will be forfeited
bull You can still submit claims for eligible medical expenses incurred prior to the date of your retirement
bull You can continue to use the remaining balance in your Dependent Care Flexible Spending Account (DCFSA) to pay for eligible dependent care expenses until the end of the Benefit Period or until your account balance is used up whichever comes first
8
Thinking About Retiring
Federal Benefits Facts continued
FEGLI
bull When you retire you are eligible to continue your FEGLI life insurance coverage(s) if you retire on an immediate annuity and had the coverage for
ndash the five years of service immediately before the starting date of your annuity or for annuitants retiring under FERS who postpone receiving their annuity the five years immediately before their separation date for annuity purposes or
ndash all period(s) of service during which that coverage was available to you if it is less than five years and
ndash you (or your assignees) do not convert the coverage to a private policy
bull If you are eligible you will choose via Standard Form (SF) 2818 how you wish your coverage(s) to continue during your retirement
bull If you are not enrolled in FEGLI at the time of your retirement you cannot enroll when you retire
bull You cannot newly elect or increase existing coverage after you retire You may only reduce or cancel coverage
bull Your premiums are subject to change in the future Your premium could change based on your age and the experience of the Program You will be notified if there is any change in your deductions from your annuity
FLTCIP bull Your coverage continues into retirement provided you continue to pay premiums
bull If you pay premiums via payroll deduction then shortly before you retire you should notify Long Term Care Partners (LTCP) at 1shy800shy582shy3337 to make other arrangements for premium payment
bull You may elect annuity deduction if you desire LTCP cannot deduct your premium from ldquospecialrdquo or ldquointerimrdquo pay LTCP will send you a direct bill during this time Premium deduction will begin from your annuity once it is finalized
9
Federal Employees Health Benefits (FEHB) Program
What does this Program offer
The FEHB Program offers a wide variety of plans and coverage to help you meet your health care needs It is group coverage available to employees retirees and their eligible family members If you continuously maintain your FEHB enrollment or are covered by another FEHB enrollment as a family member or a combination of both for the five years of service immediately preceding your retirement and you retire on an immediate annuity you can continue to participate in the FEHB Program after retirement The benefits you receive as a retiree are the same coverage Federal employees receive and at the same cost If you leave government employment before retiring the Program offers temporary continuation of coverage (TCC) and an opportunity to convert your enrollment to nonshygroup (private) coverage
If you are currently enrolled in the FEHB and do not want to change plans or enrollment type you do not need to do anything Your enrollment will continue automatically
Appendix E includes a comparison chart of all the plans in the FEHB with information comparing basic benefits and costs
Key FEHB facts
bull The FEHB Program is part of the annual Federal Benefits Open Season
bull FEHB coverage continues each year You do not need to reshyenroll each year If you are happy with your current coverage do nothing Please note that your premiums and benefits may change
bull You can choose from ConsumershyDriven and High Deductible plans that offer catastrophic risk protection with higher deductibles health savingsreimbursable accounts and lower premiums or Health Maintenance Organizations or FeeshyforshyService plans with comprehensive coverage and higher premiums
bull There are no waiting periods and no preshyexisting condition limitations even if you change plans
bull If you are an active Federal employee you can use your Health Care Flexible Spending Account or Limited Expense Health Care Flexible Spending Account with your FEHB plan
bull If you participate in premium conversion enrollment changes can only be made during Open Season or if you experience a qualifying life event Premium conversion allows Federal employees to use preshytax dollars to pay their FEHB premiums
bull All nationwide FEHB plans offer international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
What enrollment types are available
bull Self Only which covers only the enrolled employee
bull Self and Family which covers the enrolled employee and all eligible family members
10
Federal Employees Health Benefits (FEHB) Program
Which family members are eligible
Family Members covered under your Self and Family enrollment are
bull Your spouse (including a valid common law marriage) and
bull Children under age 26 including legally adopted children recognized natural (born out of wedlock) children and stepchildren
Foster children are included if they meet certain requirements A child age 26 or over that is incapable of selfshysupport because of a mental or physical disability that existed before age 26 is also an eligible family member
In determining whether the child is a covered family member your employing office will look at the childrsquos relationship to you as an enrollee
How much does it cost
The premiums for your enrollment are shared by you and your Federal agency or retirement system The government pays the lesser of 72 of the average total premium of all plans weighted by the number of enrollees in each or 75 of the premium for the specific plan you choose If you are an employee you automatically pay your share of the premium through a payroll deduction using preshytax dollars unless you elect not to participate in Premium Conversion The charts in Appendix E provide cost information for all plans in the FEHB Program
Am I eligible to enroll
Most employees are eligible those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you have an appointment other than a career or career conditional appointment and your agency has not provided you information about enrollment you should contact your human resources office for information
When you retire you are eligible to continue health benefits coverage if you retire on an immediate annuity under a retirement system for civilian employees (including FERS MRA + 10 retirement) and you have been continuously enrolled (or covered as a family member) in any FEHB plan(s) for the 5 years of service immediately before the date your annuity starts or for the full period(s) of service since your first opportunity to enroll (if less than 5 years)
If you suspend your FEHB coverage as a retiree because you are covered by TRICARE or CHAMPVA a Medicare Advantage Plan Medicaid or Peace Corps volunteer coverage you may reenroll under certain conditions (You should contact your retirement system for information on your eligibility) If you are not enrolled in or covered as a family member under FEHB when you retire you will not be able to enroll after retirement
11
Federal Employees Health Benefits (FEHB) Program
When can I enroll
If you are a new employee who is eligible for FEHB or an employee who has become newly eligible to enroll you may enroll within 60 days of becoming eligible You may also enroll during the annual Open Season held from the Monday of the second full work week in November through the Monday of the second full work week in December Furthermore you may enroll change your enrollment type or change plans outside of Open Season if you experience a qualifying life event such as a change in family or other insurance coverage status Appendix C contains more specific information about qualifying life events that permit employees to enroll or change enrollment in the FEHB Program
For new or newly eligible employees who elect to enroll coverage will be effective on the first day of the first pay period that begins after your agency receives your enrollment An Open Season enrollment or change is effective on the first day of the first full pay period that begins in January
How do I enroll
You may be able to enroll using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay Employee Personal Page or EBIS Contact the human resources office of your employing agency for details
How do I get more information about this Program
Visit the FEHB Program online at wwwopmgovinsurehealth for information including bull How to compare and choose among health plans bull Health plan websites and plan brochures bull How to file a disputed claim request bull Getting quality healthcare bull Medicare and FEHB
12
Federal Employees Health Benefits (FEHB) Program
Did You Knowhellip Health Information Technology can improve your health
What is Health Information Technology Health Information Technology (HIT) allows doctors and hospitals to manage medical information and to securely exchange information among patients and providers In a variety of ways HIT has a demonstrated benefit in improving health care quality preventing medical errors reducing costs and decreasing paperwork
What are examples of HIT at work
bull You can go online to review your medical pharmacy and laboratory claims information
bull If you complete a Health Risk Assessment (HRA) your health plan can identify you as a candidate for case management or disease management and offer suggestions on healthy lifestyle strategies and how to reduce or eliminate health risks Health plans can provide you with tips and educational material about good health habits information about routine care that is age and gender appropriate
bull Physicians can have the very best clinical guidelines at their fingertips for managing and treating diseases
bull While with a patient a physician can enter a prescription on a computer where potential allergies and adverse reactions are shown immediately
bull Computer alerts are sent to physicians to remind them of a patientrsquos preventive care needs and to track referrals and test results
One feature of HIT is the Personal Health Record (PHR) The electronic version of your medical records allows you to maintain and manage health information for yourself and your family in a private and secure electronic environment Some health plans include your medical claims data in your PHR which gives a more complete picture of your health status and history
You can also find a PHR on OPMrsquos website at wwwopmgovinsurehealthphrtoolsasp This PHR is a fillable and downloadable form that you complete yourself and save on your home computer We encourage you to take a look at this PHR option and if you determine it will fulfill your recordshykeeping needs take advantage of this opportunity
Pricecost transparency is another element of health information technology For example many health plans allow you to use online tools that will show what the plan will pay on average for a specific procedure or for a specific prescription drug You can also review healthcare quality indicators for physician and hospital services
The health plans listed on our HIT website at wwwopmgovinsurehealthreferencehittransparencyasp have taken steps to help you become a better consumer of health care and have met OPMrsquos HIT quality and pricecost transparency standards
No one is more responsible for your health care than you ndash HIT tools can help
13
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What does this Program offer
The Federal Employees Dental and Vision Insurance Program provides comprehensive dental and vision insurance at competitive group rates There are seven dental plans and three vision plans from which to choose FEDVIP features nationwide international and regional plans
A dental or vision insurance plan is much like a health insurance plan you may be required to meet a deductible and provide a copay or coinsurance payments for your dental or vision services With any plan choice you should look at all the information and find a plan that will best fit your needs You should also review your FEHB plan brochure to determine what dental andor vision coverage the FEHB plan provides
If you are currently enrolled in FEDVIP and you take no action during Open Season your current coverage will continue in 2012 provided you remain eligible for the program Enrollment continues year to year automatically Please Note your premiums and benefits may change for 2012
Key FEDVIP facts
bull FEDVIP is part of the annual Federal Benefits Open Season
bull FEDVIP is separate and different from the FEHB Program
bull The health care law does not change the age or unmarried requirement for dependents in FEDVIP
bull FEDVIP coverage continues each year You do not need to reshyenroll each year If you do not want to change plans or enrollment type do nothing
bull You can only cancel FEDVIP coverage during Open Season upon deployment to active military duty or upon transfer to another agency where you enroll in their dental andor vision plan and the agency pays at least 50 of the premium You cannot cancel just because you retire or because you can no longer afford the premiums
bull If you are enrolled in an FEHB plan it is a requirement under the FEDVIP law that your FEHB plan function as the first payer The FEDVIP plan is always the secondary payer to the FEHB plan
bull You can use your Flexible Spending Account (FSA) with FEDVIP You can submit your FEDVIP copayments and deductibles as eligible expenses against your FSA account
bull Cancellation of coverage can only be made during Open Season upon deployment to active military duty or upon transferring to an eligible position
bull All nationwide FEDVIP plans provide international coverage
bull There are separate andor different provider networks for each plan
bull Utilizing an inshynetwork provider will reduce your outshyofshypocket costs
bull There are no preshyexisting condition limitations for enrollment
bull There is no opportunity to convert to a private plan when your FEDVIP coverage ends There is no 31shyday extension of coverage Temporary Continuation of Coverage (TCC) Spouse Equity coverage or right to convert to an individual policy (conversion policy)
14
Federal Employees Dental and Vision Insurance Program (FEDVIP)
What enrollment types are available
bull Self Only which covers only the enrolled employee or retiree
bull Self Plus One which covers the enrolled employee or retiree plus one eligible family member specified by the enrollee and
bull Self and Family which covers the enrolled employee or retiree and all eligible family members
Appendix I lists the available dental and vision insurance plans along with basic benefit information
Which family members are eligible
Eligible family members include your spouse and unmarried dependent children under age 22 This includes legally adopted children and recognized natural children who meet certain dependency requirements This also includes stepchildren and foster children who live with you in a regular parentshychild relationship Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport
FEDVIP rules and FEHB rules for family member eligibility are NOT the same
Changes in dependent eligibility under healthcare reform (Affordable Care Act) do not affect eligibility for children under FEDVIP
How much does it cost
You pay the entire premium There is no government contribution to the premium If you are an active employee your premiums are taken from your salary on a preshytax basis if your salary is sufficient to make the premium withholding When you retire premiums are withheld from your monthly annuity check on a postshytax basis if your annuity is sufficient
Premiums for the nationwide dental plans and one regional dental plan are based on where you live This is called your rating region Your home ZIP code is used to find your rating region Rating regions vary by carrier The vision plans do not have rating regions Enrolling in a FEDVIP plan will not reduce your FEHB premium
See Appendices J and K to find 1) the rating region assigned to the area where you live by the different dental plans and 2) the related premium you will pay You may also go to our website at wwwopmgovinsuredental and wwwopmgovinsurevision for premium and rating region information
Am I eligible to enroll
In general Federal employees eligible for FEHB coverage (whether or not actually enrolled) and retirees (regardless of FEHB status) are eligible to enroll in a dental andor vision plan Former spouses and deferred annuitants are NOT eligible to enroll Anyone receiving an insurable interest annuity who is not also an eligible family member is NOT eligible to enroll
15
Federal Employees Dental and Vision Insurance Program (FEDVIP)
When can I enroll
If you are a new employee eligible for FEDVIP or an employee who has become newly eligible to enroll you may enroll within 60 days of first becoming eligible This is a oneshytime opportunity outside of Open Season to enroll There is a separate 60shyday enrollment period for dental and vision For example you may enroll in a dental plan on day 30 and a vision plan on day 59 Once you enroll your 60shyday opportunity for that type of plan ends
An eligible employee or retiree may also enroll during the annual Federal Benefits Open Season which runs from the Monday of the second full work week in November through the Monday of the second full work week in December An eligible employee or retiree may enroll cancel or change enrollment type or options during Open Season They may enroll or make changes outside of Open Season if they experience a qualifying life event (QLE) such as a change in family or other insurance coverage status Please see Appendix H for more information about QLEs that permit employees and retirees to enroll or make changes in FEDVIP
If you enroll during Open Season premiums are deducted beginning the first full pay period on or after January 1 For new or newly eligible employees who elect to enroll coverage is effective the first day of the pay period following the one in which BENEFEDS receives your enrollment An Open Season enrollment or change is effective January 1
How do I enroll
You may enroll on the Internet at wwwBENEFEDScom BENEFEDS is a secure enrollment website sponsored by OPM For those without access to a computer please call 1shy877shy888shyFEDS (1shy877shy888shy3337) (TTY number 1shy877shy889shy5680)
You cannot enroll in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency selfshyservice system such as Employee Express MyPay or Employee Personal Page However those sites may provide a link to BENEFEDS
What should I consider in making my decision to participate in this Program
There are questions you should ask yourself when deciding to enroll in FEDVIP or selecting a FEDVIP plan By considering these questions thoroughly you will be able to determine if FEDVIP is a good option for you
1 Does my FEHB plan provide dental or vision coverage
2 Does the FEDVIP plan coordinate benefits with the FEHB plan and how is the coordination of benefits calculated
3 How affordable is the plan bull How much will it cost me on a bishyweekly or monthly basis Can I afford that for the entire year bull Must I pay a deductible bull If I use a FEDVIP provider outside of the network how much will I pay to get care bull How frequently can I visit the dentist and how much do I have to pay at each visit bull Will the plan provide benefits if I am also covered by another dental or vision plan
16
Federal Employees Dental and Vision Insurance Program (FEDVIP)
4 Do I have access to any provider bull Does the plan give me the freedom to choose my own dentist or am I restricted to a panel of dentists selected by the plan
bull Are there enough of the kinds of dentists I want to see bull Where will I go for care Are these places near where I work or live bull Do I need to get permission before I see a dental specialist bull Will the plan allow referrals to specialists Will my dentist and I be able to choose the specialist
5 Does the plan provide coverage for specialty services bull Are dentures orthodontics implants or replacement of missing teeth covered bull What are the planrsquos limitations or exclusions bull Are there annual limits on the types of services included
How do I find my premium rate
If you live outside the United States Go to Appendix K for your dental and vision premium rates
If you live inside the United States Go to Appendix K for your vision premium rate To find your bishyweekly or monthly dental premium you must first find your rating area on the chart in Appendix J Some plans may have changed their rating regions for the upcoming plan year
Please Note If you are currently enrolled and have moved or your postal service has assigned you a new ZIP code your rating region may have changed
1 To find your dental rating area a Go to the chart in Appendix J b Find your state and your corresponding Zip code (1st 3 digits) c Look under the plan name and you will find your rating area
2 To find your bishyweekly or monthly dental premium match your rating area with your desired FEDVIP plan on the chart in Appendix K
Making an informed choice
bull Before selecting a plan that best suits your needs ask your carrier or access the OPM website for a copy of the plan brochure
bull If you have questions about coverage exclusions limitations or payment of benefits ask the plan before making your plan selection
bull Find out which plan your provider participates in and why Keep in mind that if your provider leaves the plan this is not a qualifying life event allowing a change or cancellation
How do I get more information about this Program
Visit FEDVIP online at wwwopmgovinsuredental and wwwopmgovinsurevision for information including
bull How to enroll bull Dental premium rates bull FEDVIP plan websites brochures and provider searches bull Vision premium rates
17
Federal Flexible Spending Account Program (FSAFEDS)
What does this Program offer
A way to SAVE MONEY The Federal Flexible Spending Account Program known as FSAFEDS is a benefit that can save you money It offers accounts where you contribute money from your salary BEFORE taxes are withheld incur eligible expenses and get reimbursed Itrsquos a way to save money on dependent care and health care services and items for you and your family Itrsquos a way to pay less tax and save money
The money contributed to your FSAFEDS account is set aside before taxes are deducted so in most cases you save about 30 on your Federal taxes The average tax savings for a person earning $50000 who contributes $2000 into an FSA account is approximately $600 That means you get $2000 worth of FSA eligible purchasing power PLUS pay about $600 LESS in Federal taxes
Key FSAFEDS facts
bull FSAFEDS is part of the annual Federal Benefits Open Season
bull Retirees cannot enroll in FSAFEDS
bull Employees MUST reshyenroll each year ndash coverage does not automatically carry over to the next benefit period
bull If you enroll during Open Season you will have 14shy12 months to spend your annual election
bull Enrollees must incur eligible expenses for their current benefit period by March 15th of the following year
bull Enrollees must file claims for their current benefit period by April 30th of the following year
bull Enrollees can use FSAFEDS accounts for copayments and deductibles from their FEHB andor FEDVIP enrollments
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
bull Eligible health care expenses of an employeersquos child are covered through the end of the year in which the child turns 26
Recent changes to FSAFEDS
bull Coverage for OvershytheshyCounter Medicines or Drugs shy Overshytheshycounter (OTC) products that are medicines or drugs are not eligible for reimbursement from your Health Care FSA ndash unless ndash you have a prescription for that item written by your physician The only exception is insulin ndash you will not need a prescription Other currently eligible OTC items that are not medicines or drugs will not require a prescription
bull Expanded Coverage for Your Childrsquos Eligible Health Care Expenses shy An employee enrolled in FSAFEDS may request reimbursement for eligible health care expenses incurred by a natural child stepchild adopted child eligible foster child or a child who is placed with the employee for legal adoption The child does not need to reside with the employee or qualify as the employeersquos tax dependent
18
Federal Flexible Spending Account Program (FSAFEDS)
What enrollment types are available
There are three types of FSAs Each type has a minimum annual election of $250 and a maximum of $5000
bull Dependent Care FSA (DCFSA) ndash Used for eligible dependent care (nonshymedical) expenses that allow you and your spouse (if married) to work look for work (as long as you have earned income at some point during the year) or attend school fullshytime Eligible expenses include child care before and after school care late pickshyup fees and adult daycare Dependents covered under a DCFSA include your children before their 13th birthday and may also include any person you claim as a dependent on your Federal Income Tax return who is mentally or physically incapable of self care
bull Health Care FSA (HCFSA) ndash Used for eligible health care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance Common expenses that are reimbursable by an HCFSA include
shy Chiropractic services shy Coinsurance copays and deductibles (but not insurance premiums) shy Contact lenses solutions and cleaners and cases shy Dental care and procedures shy Eye surgery shy Eyeglasses and prescription sunglasses shy Hearing aids and batteries shy Infertility treatments
An HCFSA is not health insurance and does not replace your insurance plan It is a separate program that reimburses you for eligible outshyofshypocket health care expenses
bull Limited Expense Health Care FSA (LEX HCFSA) ndash Designed for employees enrolled in or covered by a High Deductible Health Plan with a Health Savings Account Eligible expenses are limited to dental and vision care expenses for you your spouse your tax dependents and your adult children through the end of the calendar year in which they turn age 26 that are not covered or reimbursed by FEHB FEDVIP or other insurance By opening a Limited Expense Health Care FSA you can save money on taxes by using your LEX HCFSA dollars for dental and vision care while preserving your Health Savings Account funds for other purposes
Eligible expenses include your outshyofshypocket costs for services and products related to
ndash Dental care (eg cleanings fillings crowns orthodontics etc) ndash Vision care (eg contact lenses eyeglasses refractions vision correction procedures etc)
Am I eligible to enroll
Most Federal employees in the Executive branch and many in nonshyExecutive branch agencies are eligible For specifics on eligibility visit wwwFSAFEDScom or call an FSAFEDS Benefits Counselor tollshyfree at 1shy877shyFSAFEDS (1shy877shy372shy3337) TTY 1shy800shy952shy0450 Monday through Friday 9 am until 9 pm Eastern Time Retirees cannot enroll
19
Federal Flexible Spending Account Program (FSAFEDS)
Which family members are eligible
Enrollees in FSAFEDS may request reimbursement for eligible health care expenses incurred by a spouse tax dependent natural child stepchild adopted child eligible foster child or a child who is placed with the enrollee for legal adoption
When can I enroll
If you are a new or newly eligible employee or experience a qualifying life event (QLE) such as a change in family status you have 60 days from your hire date (QLE date) to enroll in a HCFSA or LEX HCFSA andor DCFSA but you must enroll before October 1 If you are hired or become eligible or experience a QLE on or after October 1 you must wait and enroll during the Federal Benefits Open Season held each fall which runs from the Monday of the second full work week in November to the Monday of the second full work week in December You can find more information about qualifying life events at wwwFSAFEDScom
Enrollment does not carry over from year to year ndash you must make an election every year to participate
An election made during Open Season is effective on January 1 of the benefit year If you are a newly hired or newly eligible employee enrolling outside of Open Season your effective date is the day after your election is accepted by FSAFEDS
Qualifying Life Events (QLEs) that May Permit a Change in Your Flexible Spending Account Participation
The following QLEs may allow you to enroll cancel increase or even decrease your election amount
bull A change in your legal marital status (ie marriage legal separation divorce or death of your spouse)
bull The birth or adoption of your child or placement for adoption bull The death of a dependent bull Other changes in the number of your tax dependents (eg parents now reside with you because they are incapable of selfshycare )
bull A change in employment status (for you your spouse or your dependent) that affects eligibility for health insurance benefits
bull Leave Without Pay (LWOP) due to military deployment bull A change in your dependentrsquos eligibility (eg your child reaches age 13 when heshe is no longer eligible for coverage under a Dependent Care Flexible Spending Account)
bull A change in cost or coverage for daycare or elder care (eg a significant cost increase charged by your current daycare provider or a change in your provider ndash for Dependent Care Flexible Spending Account only)
20
Federal Flexible Spending Account Program (FSAFEDS)
How do I enroll
You enroll at wwwFSAFEDScom or by calling 1shy877shy372shy3337
What should I consider in making my decision to participate in this Program
bull Do I want to participate this year You must make a new election every year Enrollment does not carry over from year to year
bull What do my annual medicaldependent care outshyofshypocket expenses run each year
bull Will my health dental or vision insurance coverage be different this year Am I changing plans or adding other coverage Are my copayments changing
bull Will I still have the same number of dependents
bull Plan your contribution carefully and conservatively ndash you will lose any money in your account(s) for which you do not incur eligible expenses and timely file claims
How do I get more information about this Program
Call 1shy877shy372shy3337 TTY 1shy800shy952shy0450 or visit wwwFSAFEDScom
21
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
What does this Program offer
The FEGLI Program offers group term life insurance
Key FEGLI facts
bull The FEGLI Program is not part of the annual Federal Benefits Open Season
bull Employees in eligible positions are automatically covered under Basic life insurance unless they choose to waive that coverage
bull Employees must have Basic insurance in order to have or elect Optional insurance
bull Employees must take action within strict time limits to elect Optional insurance Coverage is not automatic
bull The Government pays oneshythird of the cost of Basic insurance Enrollees pay 100 of the cost of Optional insurance
bull FEGLI does not have any cash or paidshyup value You cannot get a loan by borrowing from this insurance
bull Retirees may be able to continue their FEGLI coverage into retirement but they cannot newly elect FEGLI coverage as a retiree
bull Living benefits are life insurance benefits paid to you while you are still living rather than paid to a beneficiary or survivor when you die You are eligible to elect a living benefit if you are an employee retiree or compensationer covered under the FEGLI Program who has been diagnosed as terminally ill with a life expectancy of nine months or less and you have not assigned your insurance
What coverage is available
Basic insurance ndash your annual salary rounded up to the next even $1000 plus $2000 Basic insurance includes accidental death and dismemberment coverage for employees (not for retirees)
Optional insurance bull Option A shy Standard ndash $10000 of insurance Option A includes accidental death and dismemberment coverage for employees (not for retirees)
bull Option B shy Additional ndash 1 2 3 4 or 5 times your annual rate of basic pay after rounding it up to the next even $1000
bull Option C shy Family ndash coverage for your spouse and all of your eligible dependent children You can elect 1 2 3 4 or 5 multiples Each multiple is equal to $5000 for your spouse and $2500 for each eligible child
How much does it cost
You pay twoshythirds of the premium for Basic life insurance and the Government pays oneshythird Your cost for Basic life insurance is $015 biweekly per $1000 of coverage Your age does not affect the cost of Basic insurance
You pay 100 of the premium for Optional insurance The cost depends on your age based on 5shyyear age groups
Am I eligible to enroll
Most Federal employees are eligible to enroll in FEGLI unless they are excluded by law or regulation Federal retirees are eligible to carry their FEGLI into retirement if they meet the following requirements eligible to retire on an immediate annuity (including FERS MRA+10 retirement) have not converted the coverage to a private plan and have been insured under FEGLI for the five years immediately preceding retirement or for all periods of service during which FEGLI was available to them if they have been covered for less than five years There is no waiver of this fiveshyyear rule
22
Federal Employeesrsquo Group Life Insurance (FEGLI) Program
Which family members are eligible
Eligible FEGLI family members include a spouse and eligible dependent children Eligible dependent children must be unmarried and under age 22 or if age 22 or over incapable of selfshysupport because of a mental or physical disability that existed before the child reached age 22 Eligible dependent children include your natural children adopted children stepchildren (if they live with you in a regular parentshychild relationship) recognized natural children and foster children (if they live with you in a regular parentshychild relationship) Stillborn children are not covered
When can I enroll
The FEGLI Program is not part of the annual Federal Benefits Open Season
If you are a new employee who is eligible for FEGLI or an employee who has become newly eligible to enroll you will be automatically enrolled in Basic If you do not want Basic you must file a waiver with your agency
As a new or newly eligible employee you may enroll in Optional insurance within 60 days of becoming eligible If you take no action you will have Basic and will not have any Optional insurance
If you are not a new employee or newly eligible you may enroll in Basic life insurance and if you wish Option A andor Option B coverage by providing satisfactory medical information at your own expense using the Request for Life Insurance (Standard Form 2822) You cannot enroll in Option C this way
You may elect Basic Option A Option B and Option C within 60 days of a FEGLI qualifying life event In addition you may increase the number of multiples of Option B andor Option C You may elect any number of multiples for Option B and Option C as long as the total number of multiples for each option does not exceed 5
You may also enroll during a FEGLI Open Season which is held infrequently You will receive plenty of notice when there is a FEGLI Open Season The most recent FEGLI Open Seasons were held in 2004 and in 1999
How do I enroll
You may be able to enroll using the Life Insurance Election Form (Standard Form 2817) or through an agency selfshyservice system such as EBIS Contact the human resources office of your employing agency for details on how you can enroll
Who gets the benefits paid after my death
When you die the Office of Federal Employeesrsquo Group Life Insurance (OFEGLI) an administrative unit of Metropolitan Life Insurance Company (MetLife) will pay life insurance benefits in a particular order set by law The FEGLI Program Booklet available from your human resources office and at wwwopmgovinsurelife contains more details
How does my beneficiary file a claim
He or she must use a specific form (FEshy6) to claim FEGLI benefits available from your human resources office or retirement system or at wwwopmgovinsurelife
How do I get more information about this Program
Contact your agency human resources office If you are retired contact OPMrsquos Retirement Operations Center at retireopmgov or by calling 1shy888shy767shy6738 Neither OFEGLI nor OPMrsquos Insurance Operations offices maintain records for active Federal employees or retirees
23
Federal Long Term Care Insurance Program (FLTCIP)
What does this Program offer
The FLTCIP offers insurance that helps cover the costs of certain long term care services Long term care is the assistance you receive to perform activities of daily living ndash such as bathing or dressing yourself ndash or supervision you receive because of a severe cognitive impairment such as Alzheimerrsquos disease Long term care can be provided in a facility like a nursing home but is most often provided at home
Key FLTCIP facts
bull The FLTCIP is not part of the annual Federal Benefits Open Season
bull You must apply and answer questions about your health to find out if you are approved to enroll
bull You can apply for coverage at any time using the full underwriting application you do not have to wait for an Open Season
bull Newnewly eligible employees and their spouses and newly married spouses of employees can apply with abbreviated underwriting (fewer questions about their health) within 60 days of becoming eligible
bull Qualified family members including sameshysex domestic partners can also apply with full underwriting
bull Once enrolled you can keep your coverage even if you are no longer in an eligible group (for example you leave your job with the Federal Government)
How much does it cost
If you are approved for coverage your premium is based on your age on the date your application is received and on the benefit options you select You may pay your premiums through deductions from pay or annuity by automatic bank withdrawal or by direct bill
PLEASE NOTE Your premiums do not change because you get older or your health changes after your coverage becomes effective However premiums are not guaranteed We may only increase premiums if you are among a group of enrollees whose premium is determined to be inadequate
Am I eligible to apply
Most Federal employees are eligible to apply for coverage those who are not eligible usually have limited appointments of short duration or work sporadically only during certain seasons or when needed by their Federal agency If you are eligible for the FEHB Program you are eligible to apply for coverage under the FLTCIP even if you are not enrolled in the FEHB Program Retirees are eligible to apply
24
Federal Long Term Care Insurance Program (FLTCIP)
Which family members are eligible
Enrollment in the FLTCIP is on an individual basis If you are eligible as a Federal employee or annuitant your spouse sameshysex domestic partner and your adult children at least 18 years old are eligible to apply for coverage If you are a Federal employee your parents parentsshyinshylaw and step parents are also eligible to apply
For more information on eligibility visit wwwltcfedscomeligibility
How do I apply
You apply by completing an application found at wwwltcfedscom or by calling 1shy800shyLTCshyFEDS You must pass a medical screening (called underwriting) Certain medical conditions or combinations of conditions will prevent some people from being approved for coverage By applying while yoursquore in good health you could avoid the risk of having a future change in your health disqualify you from obtaining coverage Also the younger you are when you apply the lower your premiums
If you are a new or newly eligible employee you (and your spouse if applicable) have 60 days to apply using the abbreviated underwriting application which asks fewer questions about your health Newly married spouses of employees also have 60 days to apply using abbreviated underwriting You and your qualified relatives including sameshysex domestic partners may apply anytime using the full underwriting application
What should I consider in making my decision to participate in this Program
Remember that FEHB plans do not cover the cost of long term care While Medicare covers some care in nursing homes and at home it does so only for a limited time subject to restrictions The need for long term care can strike anyone at any age and the cost of care can be substantial
Be sure to visit wwwltcfedscom for the most upshytoshydate information about the FLTCIP before deciding whether to apply
How do I get more information about this Program
Call 1shy800shyLTCshyFEDS (1shy800shy582shy3337) (TTY 1shy800shy843shy3557) or visit wwwltcfedscom
25
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26
Appendix A FEHB Program Features
No waiting periods You can use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations even if you change plans
A choice of coverage You can choose Self Only coverage just for you or Self and Family coverage for you your spouse and children under age 26 Under certain circumstances your FEHB enrollment may cover your disabled child 26 years old or older who is incapable of selfshysupport
A choice of plans and options The FEHB Program offers FeeshyforshyService plans plans offering a PointshyofshyService product Health Maintenance Organizations High Deductible Health Plans and ConsumershyDriven Health Plans
A Government contribution The Government pays 72 percent of the average premium of all plans toward the total cost of your premium but not more than 75 percent of the total premium for any plan
Salary deduction You pay your share of the premium through a payroll deduction and have the choice of doing so using preshytax dollars
Annual enrollment opportunities Each year you can enroll or change your health plan enrollment during Open Season Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year see your human resources office or retirement system for details
Continued group coverage The FEHB Program offers continued FEHB coverage
for you and your family when you retire from Federal service (normally you need to be covered under the FEHB Program for the five years of service immediately before you retire)
for your former spouse if you divorce and he or she has a qualifying court order (see your human resources office for more information)
for your family if you die or
for you and your family when you move transfer go on leave without pay or enter military service (certain rules about coverage and premium amounts apply see your human resources office)
Coverage after FEHB ends The FEHB Program offers temporary continuation of coverage (TCC) and conversion to nonshygroup (private) coverage
for you and your family if you leave Federal service (including when you are not eligible to carry FEHB into retirement)
for your covered child if he or she turns age 26 or
for your former spouse if you divorce and he or she does not have a qualifying court order (see your human resources office for more information)
If you lose coverage under the FEHB Program you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB plan to cover you If not the plan must give you one on request This certificate may be important to qualify for benefits if you join a nonshyFEHB plan
27
Appendix B Choosing an FEHB Plan
What type of health plan is best for you You have some basic questions to answer about how you pay for and access medical care Here are the different types of plans from which to choose
Choice of doctors Specialty care Outshyofshypocket costs Paperwork hospitals pharmacies and other providers
FeeshyforshyService wPPO (Preferred Provider Organization)
You must use the planrsquos network to reduce your outshyofshypocket costs For BCBS Basic Option you
Referral not required to get benefits
You pay fewer costs if you use a PPO provider than if you donrsquot
Some if you donrsquot use network providers
must use Preferred providers for your care to be eligible for benefits
Health Maintenance You generally must Referral generally Your outshyofshypocket Little if any Organization use the planrsquos network required from primary costs are generally
to reduce your outshyofshy care doctor to get limited to copayments pocket costs benefits
PointshyofshyService You must use the planrsquos network to reduce your outshyofshypocket costs You may go outside the network but you will
Referral generally required to get maximum benefits
You pay less if you use a network provider than if you donrsquot
Little if you use the network You have to file your own claims if you donrsquot use the network
pay more
ConsumershyDriven Plans
You may use network and nonshynetwork
Referral not required to get maximum
You will pay an annual deductible and
Some if you donrsquot use network providers
providers You will pay benefits from PPOs costshysharing You pay more by not using the less if you use the network network
High Deductible Some plans are Referral not required You will pay an If you have an HSA or Health Plans wHealth network only others to get maximum annual deductible and HRA account you may Savings Account (HSA) pay something even if benefits from PPOs costshysharing You pay have to file a claim to or Health you do not use a less if you use the obtain reimbursement Reimbursement network provider network Arrangement (HRA)
28
Appendix B Choosing an FEHB Plan
What should you consider when choosing a plan Having a variety of plans to choose from is a good thing but it can make the process confusing We have a tool on our website that will help you narrow your plan choice based on the benefits that are important to you go to wwwopmgovinsurehealthsearchplansearchaspx You can also find help in selecting a plan using tools provided by PlanSmartChoice and Consumerrsquos Checkbook at wwwopmgovinsurehealthplaninfoindexasp
Ask yourself these questions
1 How much does the plan cost This includes the premium you pay
2 What benefits does the plan cover Make sure the plan covers the services or supplies that are important to you and know its limitations and exclusions
3 What are my out of pocket costs Does the plan charge a deductible (the amount you must first pay before the plan begins to pay benefits) What is the copayment or coinsurance (the amount you share in the cost of the service or supply)
4 Who are the doctors hospitals and other care providers I can use Your costs are lower when you use providers who are part of the plan these are ldquoinshynetworkrdquo providers
5 How well does my plan provide quality care Quality care varies from plan to plan and here are three sources for reviewing quality
Member survey results ndash evaluations by current plan members are posted within the health plan benefit charts in this Guide
Effectiveness of care ndash how a plan performs in preventing or treating common conditions is measured by the Healthcare Effectiveness Data and Information Set and is found at wwwopmgovinsurehealthplaninfoqualityhedisaspx
Accreditation ndash evaluations of health plans by independent accrediting organizations Check the cover of your health planrsquos brochure for its accreditation level or go to httpreportcardncqaorgplanexternalplansearchaspx
29
Appendix B Choosing an FEHB Plan
Definitions
Brand name drug shy A prescription drug that is protected by a patent supplied by a single company and marketed under the manufacturerrsquos brand name
Coinsurance shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit Coinsurance is a percentage of the planrsquos allowance for the service (you pay 20 for example)
Copayment shy The amount you pay as your share for the medical services you receive such as a doctorrsquos visit A copayment is a fixed dollar amount (you pay $15 for example)
Deductible shy The dollar amount of covered expenses an individual or family must pay before the plan begins to pay benefits There may be separate deductibles for different types of services For example a plan can have a prescription drug benefit deductible separate from its calendar year deductible
Formulary or Prescription Drug List shy A list of both generic and brand name drugs often made up of different costshysharing levels or tiers that are preferred by your health plan Health plans choose drugs that are medically safe and cost effective A team including pharmacists and physicians determines the drugs to include in the formulary
Generic Drug shy A generic medication is an equivalent of a brand name drug A generic drug provides the same effectiveness and safety as a brand name drug and usually costs less A generic drug may have a different color or shape than the brand name but it must have the same active ingredients strength and dosage form (pill liquid or injection)
InshyNetwork shy You receive treatment from the doctors clinics health centers hospitals medical practices and other providers with whom your plan has an agreement to care for its members
OutshyofshyNetwork shy You receive treatment from doctors clinics health centers hospitals and medical practices other than those with whom the plan has an agreement at additional cost Members who receive services outside the network may pay all charges
Premium Conversion shy A program to allow Federal employees to use preshytax dollars to pay health insurance premiums to the Federal Employees Health Benefits (FEHB) Program Based on Federal tax rules employees can deduct their share of health insurance premiums from their taxable income which reduces their taxes
Provider shy A doctor hospital health care practitioner pharmacy or health care facility
Qualifying Life Events shy An event that may allow participants in the FEHB Program to change their health benefits enrollment outside of an Open Season These events also apply to employees under premium conversion and include such events as change in family status loss of FEHB coverage due to termination or cancellation and change in employment status
Additional definitions are located at the beginning of the sections introducing the different types of health plans
30
Appendix C Qualifying Life Events (QLEs)
that May Permit a Change in Your FEHB Enrollment
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay their share of FEHB premiums with preshytax dollars Premium conversion plans are governed by the Internal Revenue Code and IRS rules govern when a participant may change his or her enrollment outside of the annual Open Season When an employee experiences a qualifying life event changes to the employeersquos FEHB enrollment may be permitted Individuals who donrsquot participate in Premium Conversion (retirees and employees who waived participation) may cancel their enrollment or change to Self Only at any time
Below is a brief list of the more common QLEs Be aware that time limits apply for requesting changes A complete listing of QLEs can be found at wwwopmgovformspdf_fillsf2809pdf For more details about these and other QLEs contact the human resources office of your employing agency
From Not Enrolled to Enrolled
From Self Only to Self and Family
From One Plan or Option to Another
Cancel or Change to Self Only
Change in family status that results in increase or decrease in number of eligible family members
Any change in employeersquos employment status that could result in entitlement to coverage
Employee restored to civilian position after serving in uniformed services
Employee (or covered family member) enrolled in an FEHB health maintenance organization (HMO) moves or becomes employed outside the geographic area from which the FEHB carrier accepts enrollment or if already outside the area moves further from this area
Employee or eligible family member loses coverage under FEHB or another group insurance plan
Enrolled employee or eligible family member gains coverage under FEHB or another group insurance plan
Yes
Yes
Yes
Not Applicable
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes
Not Applicable
Yes
Yes
Yes
No
Yes1
Not Applicable
Yes
Not Applicable
Yes
Yes2
1 Employees may change to Self Only outside of Open Season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
2 Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage
31
Appendix D FEHB Member Survey Results
Each year Federal Employees Health Benefits plans with 500 or more subscribers mail the Consumers Assessment of Healthcare Providers and Systems (CAHPS)1 to a random sample of plan members For Health Maintenance Organizations (HMO)PointshyofshyService (POS) and High Deductible Health Plans (HDHP) and ConsumershyDriven Health Plans (CDHP) the sample includes all commercial plan members including nonshyFederal members For FeeshyforshyService (FFS)Preferred Provider Organization (PPO) plans the sample includes Federal members only The CAHPS survey asks questions to evaluate membersrsquo satisfaction with their health plans Independent vendors certified by the National Committee for Quality Assurance administer the surveys
OPM reports each planrsquos scores on the various survey measures by showing the percentage of satisfied members on a scale of 0 to 100 Also we list the national average for each measure Since we offer HMO plans FFSPPO plans HDHP and CDHP plans we compute a separate national average for each plan type
Survey findings and member ratings are provided for the following key measures of member satisfaction
bull Overall Plan Satisfaction ndash This measure is based on the question ldquoUsing any number from 0 to 10 where 0 is the worst health plan possible and 10 is the best health plan possible what number would you use to rate your health planrdquo We report the percentage of respondents who rated their plan 8 or higher
bull Getting Needed Care ndash How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
bull Getting Care Quickly ndash When you needed care right away how often did you get care as soon as you thought you needed Not counting the times you needed care right away how often did you get an appointment at a doctors office or clinic as soon as you thought you needed
bull How Well Doctors Communicate ndash How often did your personal doctor explain things in a way that was easy to understand How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
bull Customer Service ndash How often did the written materials or the Internet provide the information you needed about how your health plan works How often did your health planrsquos customer service give you the information or help you needed How often were the forms from your health plan easy to fill out
bull Claims Processing ndash How often did your health plan handle your claims quickly and correctly
bull Plan Information on Costs ndash How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
In evaluating plan scores you can compare individual plan scores against other plans and against the national averages Generally new plans and those with fewer than 500 FEHB subscribers do not conduct CAHPS Therefore some of the plans listed in the Guide will not have survey data
1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
32
Appendix E FEHB Plan Comparison Charts
Nationwide FeeshyforshyService Plans (Pages 34 through 37)
FeeshyforshyService (FFS) plans with a Preferred Provider Organization (PPO) ndash A FeeshyforshyService plan provides flexibility in using medical providers of your choice You may choose medical providers who have contracted with the health plan to offer discounted charges You may also choose medical providers who do not contract with the plan but you will pay more of the cost
Medical providers who have contracts with the health plan (Preferred Provider Organization or PPO) have agreed to accept the health planrsquos reimbursement You usually pay a copayment or a coinsurance amount and do not file claims or other paperwork Going to a PPO hospital does not guarantee PPO benefits for all services received in the hospital however Lab work radiology and other services from independent practitioners within the hospital are frequently not covered by the hospitalrsquos PPO agreement If you receive treatment from medical providers who are not contracted with the health plan you either pay them directly and submit a claim for reimbursement to the health plan or the health plan pays the provider directly according to plan coverage and you pay a deductible coinsurance or the balance of the billed charge In any case you pay a greater amount in outshyofshypocket costs
PPOshyonly ndash A PPOshyonly plan provides medical services only through medical providers that have contracts with the plan With few exceptions there is no medical coverage if you or your family members receive care from providers not contracted with the plan
FeeshyforshyService plans open only to specific groups ndash Several FeeshyforshyService plans that are sponsored or underwritten by an employee organization strictly limit enrollment to persons who are members of that organization If you are not certain if you are eligible check with your human resource office first
The Health Maintenance Organization (HMO) and PointshyofshyService (POS) section begins on page 39
The High Deductible Health Plan (HDHP) and ConsumershyDriven Health Plan (CDHP) section begins on page 64
33
Nationwide FeeshyforshyService Plans
How to read this chart
The table below highlights selected features that may help you narrow your choice of health plans Always consult plan brochures before making your final decision The chart does not show all of your possible outshyofshypocket costs
The Deductibles shown are the amount of covered expenses that you pay before your health plan begins to pay
Calendar Year deductibles for families are two or more times the per person amount shown
In some plans your combined Prescription Drug purchases from Mail Order and local pharmacies count toward the deductible In other plans only purchases from local pharmacies count Some plans require each family member to meet a per person deductible
The Hospital Inpatient deductible is what you pay each time you are admitted to a hospital
Doctors shows what you pay for inpatient surgical services and for office visits
Your share of Hospital Inpatient Room and Board covered charges is shown
Plan Name Open to All Telephone Number
Enrollment Code
Your Share of Premium
Monthly Biweekly
Self Self amp only family
Self Self amp Self Self amp only family only family
APWU Health Plan (APWU) shyhigh 800shy222shy2798 471 472 12762 28856 5890 13318
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shystd Local phone 104 105 18542 43004 8558 19848
Blue Cross and Blue Shield Service Benefit Plan (BCBS) shybasic Local phone 111 112 12188 28542 5625 13173
GEHA Benefit Plan (GEHA) shyhigh 800shy821shy6136 311 312 18503 43838 8540 20233
GEHA Benefit Plan (GEHA) shystd 800shy821shy6136 314 315 9272 21086 4279 9732
MHBP shystd 800shy410shy7778 454 455 20874 50100 9634 23123
MHBP shy Value Plan 800shy410shy7778 414 415 8577 20449 3959 9438
NALC shyhigh 888shy636shy6252 321 322 16178 32760 7467 15120
SAMBA shyhigh 800shy638shy6589 441 442 25922 66049 11964 30484
SAMBA shystd 800shy638shy6589 444 445 13171 30550 6079 14100
Compass Rose Health Plan (CRHP) shyhigh 800shy769shy6953
Plan Name Open Only to Specific Groups
421 422 13272 32275 6126 14896
Foreign Service Benefit Plan (FSBP) shyhigh 202shy833shy4910 401 402 12349 30734 5699 14185
Panama Canal Area Benefit Plan (PCABP) shyhigh 800shy424shy8196 431 432 10538 21996 4864 10152
Rural Carrier Benefit Plan (Rural) shyhigh 800shy638shy8432 381 382 18319 29905 8455 13802
34
Prescription Drug Payment Levels Plans use a variety of terms to define what you pay for prescription drugs such as generic brand name Tier I Tier II Level I etc The 2 to 3 payment levels that plans use follow Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs Many plans are basing how much you pay for prescription drugs on what they are charged
Mail Order Discounts If your plan has a Mail Order progrram and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through Mail Order) your planrsquos response is ldquoyesrdquo If the plan does not have a Mail Order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
The prescription drug copayments or coinsurances described in this chart do not represent the complete range of costshysharing under these plans Many plans have variations in their prescription drug benefits (eg you pay the greater of a dollar amount or a percentage or you pay one amount for your first prescription and then a different amount for refills) You must read the plan brochure for a complete description of prescription drug and all other benefits
Plan
Benefit Type
MedicalshySurgical ndash You Pay
Deductible Copay ($)Coinsurance ()
Per Person Hospital Inpatient
Doctors Hospital Inpatient
RampB
Prescription Drugs
Level I Level II Level III Mail Order Discounts
Office Visits
Inpatient Surgical Services
Calendar Year
Prescription Drug
APWU shyhigh
BCBS shystd
BCBS shybasic
GEHA shyhigh
GEHA shystd
MHBP shystd
MHBP shyValue
NALC shyhigh
SAMBA shyhigh
SAMBA shystd
CRHP
FSBP
PCABP
Rural
PPO NonshyPPO
PPO NonshyPPO
PPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
PPO NonshyPPO
POS FFS
PPO NonshyPPO
$275 None $500 None
$350 None $350 None
None None
$350 None $350 None
$350 None $350 None
$400 None $600 None
$600 None $900 Not Covered
$300 None $300 None
$300 None $300 None
$350 None $350 None
$300 None $350 None
$300 None $300 None
None None None None
$350 $200 $400 $200
FFS National Average
None $300
$250 $350
$150day x 5
$100 $300
None None
$200 $500
None None
$200 $350
$200 $300
$150 up to $450 $200 up to $600
$150 $350
Nothing $200
$100 $25
$100 $300
$18 10 30+diff 30+diff
$20 15 35 35
$25 $150
$20 10 25 25
$10 15 35 35
$20 10 30 30
$30 20 40 40
$20 15 30 30
$20 10 30 30
$20 15 35 35
$10 Nothing 30 30
10 10 30 30
50 50 $5 Nothing
$20 10 25 25
10 30
Nothing 35
Nothing
Nothing Nothing
15 35
Nothing 30
20 40
Nothing 30
Nothing 30
Nothing 35
Nothing 30
Nothing 20
50 Nothing
Nothing 20
$8 2525 Yes 50 5050 Yes
20 (15MCare B) 3030 Yes 45 + 45+45+ Yes
$10 $50$150 NA
$5 25 Max $150NA Yes $5 25 Max $150 +NA Yes
$5 50 Max $200NA Yes $5 50 Max $200 +NA Yes
$10 30($200 max)50($200 max) Yes 50 5050 Yes
$10 4575 Yes Not Covered Not CoveredNot Covered Yes
20 3030 Yes 45 45+ 45+45+ Yes
$10 15($55 max)30($90 max) Yes $10 15($55 max)30($90 max) Yes
$10 25($70 max)35($100 max) Yes $10 25($70 max)35($100 max) Yes
$5 $3030 or $45 Yes $5 $3030 or $45 Yes
$10 25$50 minNA Yes $10 25$50 minNA Yes
20 2020 No 20 2020 No
30 3030 Yes 30 3030 Yes
The Panama Canal Area Plan provides a PointshyofshyService product within the Republic of Panama
35
Nationwide FeeshyforshyService Plans
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic
as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
Plan Name Open to All
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
APWU Health Plan shyhigh
FFS National A
47
verage 774
78
916
898
91
921
948
938
897
837
929
898
725
737 47
Blue Cross and Blue Shield Service Benefit Plan shystd 10 788 924 884 944 888 945 719 10
Blue Cross and Blue Shield Service Benefit Plan shybasic 11 717 907 876 939 885 932 725
GEHA Benefit Plan shyhigh 31 855 928 911 943 928 966 74 31
GEHA Benefit Plan shystd 31 773 894 88 934 901 939 73 31
MHBP shystd 45 706 916 917 943 898 927 713 45
MHBP shy Value Plan 41 564 879 877 955 857 849 638 41
NALC shyhigh 32 811 934 914 951 923 951 766 32
SAMBA shyhigh 44 893 946 937 968 901 973 791 44
SAMBA shystd 44 745 923 933 952 903 925 74
Compass Rose Health Plan
Plan Name Open Only to Specific GFFS National
44
42
roups Average 774 916 91 948 897 929 725
42
Foreign Service Benefit Plan 40 788 90 928 951 902 883 698 40
Panama Canal Area Benefit Plan 43 43
Rural Carrier Benefit Plan 38 845 945 944 96 934 964 77 38
36
FeeshyforshyService Plans ndash Blue Cross and Blue Shield Service Benefit Plan ndash Member Survey Results for Select States
Again this year we are providing more detailed information regarding the quality of services provided by our health plans We are including the results of the Member Satisfaction survey at the state level for eight local Blue Cross Blue Shield (BCBS) Plans
Location Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
FFS National Average 774 916 91 948 897 929 725
Blue Cross and Blue Shield Service shy Standard Arizona 10 819 93 898 947 914 962 743 Benefit Plan shy Basic 11 752 895 895 929 883 939 642
Blue Cross and Blue Shield Service shy Standard California 10 771 93 94 947 899 955 673 Benefit Plan shy Basic 11 656 885 818 927 871 894 659
Blue Cross and Blue Shield Service shy Standard District of Columbia 10 794 914 897 931 883 912 708 Benefit Plan shy Basic 11 646 843 838 902 862 933 626
Blue Cross and Blue Shield Service shy Standard Florida 10 864 936 943 934 888 957 763 Benefit Plan shy Basic 11 764 922 895 92 883 935 671
Blue Cross and Blue Shield Service shy Standard Illinois 10 829 928 904 945 928 963 70 Benefit Plan shy Basic 11 759 913 89 94 823 933 672
Blue Cross and Blue Shield Service shy Standard Maryland 10 832 941 914 941 864 937 743 Benefit Plan shy Basic 11 713 883 911 928 878 924 667
Blue Cross and Blue Shield Service shy Standard Texas 10 835 933 908 94 89 959 726 Benefit Plan shy Basic 11 803 921 872 924 91 969 686
Blue Cross and Blue Shield Service shy Standard Virginia 10 863 943 928 956 906 965 745 Benefit Plan shy Basic 11 758 903 919 935 877 955 679
37
This page intentionally left blank
38
Appendix E FEHB Plan Comparison Charts
Health Maintenance Organization Plans and Plans Offering a PointshyofshyService Product
(Pages 40 through 63)
Health Maintenance Organization (HMO) ndash A Health Maintenance Organization provides care through a network of physicians and hospitals in particular geographic or service areas HMOs coordinate the health care service you receive and free you from completing paperwork or being billed for covered services Your eligibility to enroll in an HMO is determined by where you live or for some plans where you work
bull The HMO provides a comprehensive set of services ndash as long as you use the doctors and hospitals affiliated with the HMO HMOs charge a copayment for primary physician and specialist visits and sometimes a copayment for inshyhospital care
bull Most HMOs ask you to choose a doctor or medical group as your primary care physician (PCP) Your PCP provides your general medical care In many HMOs you must get authorization or a ldquoreferralrdquo from your PCP to see other providers The referral is a recommendation by your physician for you to be evaluated andor treated by a different physician or medical professional The referral ensures that you see the right provider for the care appropriate to your condition
bull Medical care from a provider not in the planrsquos network is not covered unless itrsquos emergency care or your plan has an arrangement with another plan
Plans Offering a PointshyofshyService (POS) Product ndash A PointshyofshyService plan is like having two plans in one ndash an HMO and an FFS plan A POS allows you and your family members to choose between using (1) a network of providers in a designated service area (like an HMO) or (2) OutshyofshyNetwork providers (like an FFS plan) When you use the POS network of providers you usually pay a copayment for services and do not have to file claims or other paperwork If you use nonshyHMO or nonshyPOS providers you pay a deductible coinsurance or the balance of the billed charge In any case your outshyofshypocket costs are higher and you file your own claims for reimbursement
The tables on the following pages highlight what you are expected to pay for selected features under each plan Always consult plan brochures before making your final decision
Primary careSpecialist office visit copay ndash Shows what you pay for each office visit to your primary care doctor and specialist Contact your plan to find out what providers it considers specialists
Hospital per stay deductible ndash Shows the amount you pay when you are admitted into a hospital
Prescription drugs ndash Plans use a variety of terms to define what you pay for prescription drugs such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
Mail Order Discount ndash If your plan has a mail order program and that program is superior to the purchase of medications at the pharmacy (eg you get a greater quantity or pay less through mail order) your planrsquos response is ldquoyesrdquo If the plan does not have a mail order program or it is not superior to its pharmacy benefit the planrsquos response is ldquonordquo
Member Survey Results ndash See Appendix D for a description
39
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Arizona
Aetna Open Access shyhighshy Phoenix and Tucson Areas 877shy459shy6604 WQ1 WQ2 23237 63735 10725 29416
Health Net of Arizona Inc shyhighshy MaricopaPimaOther AZ counties 800shy289shy2818 A71 A72 15119 50381 6978 23253
Health Net of Arizona Inc shystdshy MaricopaPimaOther AZ counties 800shy289shy2818 A74 A75 12370 35483 5709 16377
Arkansas
QualChoice shy high shy All of Arkansas 800shy235shy7111 DH1 DH2 16857 43946 7780 20283
QualChoice shy std shy All of Arkansas 800shy235shy7111 DH4 DH5 11134 26073 5139 12034
California
Aetna Open Access shyhighshy Los Angeles and San Diego Areas 877shy459shy6604 2X1 2X2 12307 31486 5680 14532
Blue Shield of CA Access+HMO shyhighshy Southern Region 800shy880shy8086 SI1 SI2 13414 31488 6191 14533
Health Net of California shyhighshy Northern Region 800shy522shy0088 LB1 LB2 52715 125157 24330 57765
Health Net of California shystdshy Northern Region 800shy522shy0088 LB4 LB5 48447 115288 22360 53210
Health Net of California shyhighshy Southern Region 800shy522shy0088 LP1 LP2 19277 47844 8897 22082
Health Net of California shystdshy Southern Region 800shy522shy0088 LP4 LP5 15661 39487 7228 18225
Kaiser Foundation Health Plan of California shyhighshy Northern California 800shy464shy4000 591 592 25944 68220 11974 31486
Kaiser Foundation Health Plan of California shystdshy Northern California 800shy464shy4000 594 595 15195 39953 7013 18440
Kaiser Foundation Health Plan of California shyhighshy Southern California 800shy464shy4000 621 622 12608 29139 5819 13449
Kaiser Foundation Health Plan of California shystdshy Southern California 800shy464shy4000 624 625 8076 18665 3727 8614
United Healthcare of California shyhighshy Most of California 866shy546shy0510 CY1 CY2 12810 29285 5912 13516
Colorado
Kaiser Foundation Health Plan of Colorado shyhighshy DenverBoulderSouthern Colorado areas 800shy632shy9700 651 652 17398 40506 8030 18695
Kaiser Foundation Health Plan of Colorado shystdshy DenverBoulderSouthern Colorado areas 800shy632shy9700 654 655 8185 18498 3778 8537
Delaware Aetna Open Access shyhighshy KentNew CastleSussex areas 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy KentNew CastleSussex areas 877shy459shy6604 P34 P35 33995 81655 15690 37687
40
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Arizona
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
583
855
842
855
864
935
883
839
858
876
884
664
636
Health Net of Arizona IncshyHigh $15$30 $200day x 3 $10 $30$50 Yes 702 878 868 921 863 946 675
Health Net of Arizona IncshyStd
Arkansas
QualChoiceshy InshyNetwork
$15$40
$20$30
$250day x 3
$100max$500
$10
$0
$40$70
$40$60
Yes
Yes
702
61
878
845
868
873
921
935
863
877
946
887
675
652 QualChoiceshy OutshyNetwork 4040 40 NA NA NA NA 61 845 873 935 877 887 652
QualChoiceshy InshyNetwork
California
Aetna Open AccessshyHigh
$20$40
$20$35
$200max$1000
$250day x 4
$5
$10
$40$60
$35$65
Yes
Yes
61
612
845
808
873
822
935
922
877
813
887
882
652
608
Blue Shield of CA Access+HMOshyHigh $20$30 $150 day x 3 $10 $35$50 Yes 709 874 876 938 824 878 665
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyHigh $15$30 $100day x 5 $10 $35$60 Yes 662 833 819 90 794 885 591
Health Net of CaliforniashyStd $30$50 $500 $15 $35$60 Yes 662 833 819 90 794 885 591
Kaiser Foundation HP of California shyHigh $15$25 $250 $10 $30$30 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyStd $30$40 $500 $15 $35$35 Yes 764 846 83 91 826 754 597
Kaiser Foundation HP of California shyHigh $10$20 $250 $10 $30$30 Yes 818 845 807 934 853 763 681
Kaiser Foundation HP of California shyStd $20$40 $500 $15 $35$35 Yes 818 845 807 934 853 763 681
United Healthcare of California shyHigh
Colorado
Kaiser Foundation HP of Colorado shyHigh
$20$35
$20$40
$150day x 4
$250
$10
$10
$35$60
$35$60
Yes
Yes
692
716
787
833
824
862
935
918
761
77
88
876
588
684
Kaiser Foundation HP of Colorado shyStd
Delaware Aetna Open AccessshyHigh
$25$45
$20$35
$250day x 3
$150day x 5
$15
$10
$40$80
$35$65
Yes
Yes
716
616
833
884
862
88
918
943
77
857
876
932
684
631
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 616 884 88 943 857 932 631
41
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
District of Columbia Aetna Open Access shyhighshy Washington DC Area 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy Washington DC Area 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Washington DC Metro Area 888shy789shy9065 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Option shystdshy Washington DC Metro Area 888shy789shy9065 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Washington DC area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Washington DC area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy Washington DC area 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Florida AvshyMed Health Plan shyhighshy Broward Dade and Palm Beach 800shy882shy8633 ML1 ML2 18274 50680 8434 23391
AvshyMed Health Plan shystdshy Broward Dade and Palm Beach 800shy882shy8633 ML4 ML5 12265 29438 5661 13587
Capital Health Plan shyhighshy Tallahassee area 850shy383shy3311 EA1 EA2 10227 27101 4720 12508
Coventry Health Plan of Florida shyhighshy Southern Florida 800shy441shy5501 5E1 5E2 12185 36227 5624 16720
Coventry Health Plan of Florida shystdshy Southern Florida 800shy441shy5501 5E4 5E5 11028 28494 5090 13151
Humana Medical Plan Inc shyhighshy South Florida 888shy393shy6765 EE1 EE2 16490 37882 7611 17484
Humana Medical Plan Inc shystdshy South Florida 888shy393shy6765 EE4 EE5 12083 27187 5577 12548
Humana Medical Plan Inc shyhighshy Tampa 888shy393shy6765 LL1 LL2 34027 77341 15705 35696
Humana Medical Plan Inc shystdshy Tampa 888shy393shy6765 LL4 LL5 13457 31059 6211 14335
Georgia Aetna Open Access shyhighshy Atlanta and Athens Areas 877shy459shy6604 2U1 2U2 28232 67349 13030 31084
Humana Employers Health of Georgia Inc shyhighshy Columbus 888shy393shy6765 CB1 CB2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Columbus 888shy393shy6765 CB4 CB5 12755 28698 5887 13245
Humana Employers Health of Georgia Inc shyhighshy Atlanta 888shy393shy6765 DG1 DG2 12915 29058 5961 13411
Humana Employers Health of Georgia Inc shystdshy Atlanta 888shy393shy6765 DG4 DG5 12419 27942 5732 12896
Humana Employers Health of Georgia Inc shyhighshy Macon 888shy393shy6765 DN1 DN2 13459 31061 6212 14336
Humana Employers Health of Georgia Inc shystdshy Macon 888shy393shy6765 DN4 DN5 12755 28698 5887 13245
Kaiser Foundation Health Plan of Georgia shyhighshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F81 F82 16038 38835 7402 17924
Kaiser Foundation Health Plan of Georgia shystdshy Atlanta Athens Columbus Macon Savananah 888shy865shy5813 F84 F85 9746 22270 4498 10278
42
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
District of Columbia Aetna Open AccessshyHigh $15$30 $150day x 3 $5
HMO
$35$65
POS National
Yes
Average 659
659
855
871
855
87
935
918
839
901
876
874
664
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Florida AvshyMed Health PlanshyHigh
$25$40
$15$40
$150day x 3
$150day x 5
$7
$5
$30$150$250
$30$5030
Yes
No
632
724
838
869
871
855
925
913
841
894
90
853
65
648
AvshyMed Health PlanshyStd $25$45 $175day x 5 $10 $40$6030 No 724 869 855 913 894 853 648
Capital Health PlanshyHigh $15$25 $250 $15 $30$50 No 862 862 896 942 909 978 778
Coventry Health Plan of FloridashyHigh $15$30 Ded+$150x3 $3$20 $40$6020 No 502 812 822 899 787 873 647
Coventry Health Plan of FloridashyStandard $20$50 Ded+$100x5 $10 $50$7020 No 502 812 822 899 787 873 647
Humana Medical Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan IncshyStandard $25$40 $500day x 3 $10 $40$60 Yes 524 828 866 926 828 849 628
Humana Medical Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Medical Plan Inc shyStandard
Georgia Aetna Open AccessshyHigh
$25$40
$20$35
$500day x 3
$250day x 4
$10
$10
$40$60
$35$65
Yes
Yes 569 888 835 927 882 873 589
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 504 824 83 956 806 812 642
Humana Employers Health of Georgia IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Employers Health of Georgia IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
Kaiser Foundation HP of Georgia shyHigh $10$25 $350 $10$20 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
Kaiser Foundation HP of Georgia shyStd $20$30 $250day x 3 $15$25 Comm $30$40 Comm $30$40 Comm Yes 768 845 84 922 818 822 614
43
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Guam
TakeCare shyhighshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK1 JK2 12447 41060 5745 18951
TakeCare shystdshy GuamNMariana IslandsBelau(Palau) 671shy647shy3526 JK4 JK5 11043 29162 5097 13459
Hawaii HMSA shyhighshy All of Hawaii 808shy948shy6499 871 872 11847 26372 5468 12172
Kaiser Foundation Health Plan of Hawaii shyhighshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 631 632 13685 28987 6316 13378
Kaiser Foundation Health Plan of Hawaii shystdshy HawaiiKauaiLanaiMauiMolokaiOahu 808shy432shy5955 634 635 6162 13250 2844 6115
Idaho
Altius Health Plans shyhighshy Southern Region 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Southern Region 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
Group Health Cooperative shyhighshy Kootenai and Latah 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Kootenai and Latah 888shy901shy4636 544 545 9559 21579 4412 9959
Illinois
Aetna Open Access shyhighshy Chicago Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Blue Preferred Plus POS shyhighshy Madison and St Clair counties 888shy811shy2092 9G1 9G2 26208 54102 12096 24970
Health Alliance HMO shyhighshy CentralECentralN CentSouthWest 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Benefit Plan of Illinois Inc shyhighshy Central and Northwestern 888shy393shy6765 9F1 9F2 39583 89839 18269 41464
Humana Benefit Plan of Illinois Inc shystdshy Central and Northwestern 888shy393shy6765 AB4 AB5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Chicago 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy Chicago 888shy393shy6765 754 755 13457 31059 6211 14335
Union Health Service shyhighshy Chicago area 312shy829shy4224 761 762 12827 29794 5920 13751
United Healthcare of the Midwest shyhighshy Southwest llinois 877shy835shy9861 B91 B92 19353 43374 8932 20019
United Healthcare Plan of the River Valley Inc shyhighshy West Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
44
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Guam
TakeCareshyHigh $20$40 $100day for 5 days $10
HMOP
$15$25$50
OS Nationa
No
l Average 659
642
855
726
855
626
935
895
839
694
876
664
664
563
TakeCareshyStd
Hawaii HMSAshy InshyNetwork
$25$40
$15$15
$150day for 5 days
$100
$15
$7
$20$40$80
$30$65
No
Yes
642
833
726
924
626
91
895
959
694
837
664
941
563
666 HMSAshy OutshyNetwork 3030 30 $7 + 20 $30+20
$65+20 No 833 924 91 959 837 941 666
Kaiser Foundation HP of Hawaii shyHigh $20$20 $100 $15 $15$15 Yes 751 821 797 935 792 853 707
Kaiser Foundation HP of Hawaii shyStd
Idaho
Altius Health PlansshyHigh
$30$30
$20$30
10
$200
$20
$7
$20$20
$25$50
Yes
Yes
751
556
821
86
797
88
935
948
792
817
853
853
707
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
Group Health CooperativeshyHigh $25$25 $350day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
Group Health CooperativeshyStd
Illinois
Aetna Open AccessshyHigh
$25+20$25+20
$20$35
$500day x 3
$250day x 4
$20
$10
$40$60
$35$65
Yes
Yes
691
615
839
826
844
82
926
909
867
866
896
823
711
642
Blue Preferred Plus POS InshyNetwork $25$35 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded NA NA NA 718 897 85 915 857 913 659
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana BP of Illinois Inc shyHigh $20$35 $250 x 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana BP of Illinois Inc shyStd $25$40 $400 X 3 $10 $40$60 Yes 606 879 861 954 774 735 719
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Union Health Service shyHigh $15$15 None $15 $30$35 No
UHC of the Midwest Inc shyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
UHC Plan of the River Valley Inc shyHigh $20$45 Nothing $10 $35$50 Yes 524 873 853 956 798 886 622
45
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Plan Name ndash Location Telephone Self Number only
Self amp Self family only
Self amp Self family only
Self amp family
Indiana
Aetna Open Access shyhighshy Northern Indiana Area 877shy459shy6604 IK1 IK2 34233 89563 15800 41337
Health Alliance HMO shyhighshy Western Indiana 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
Humana Health Plan Inc shyhighshy LakePorterLaPorte Counties 888shy393shy6765 751 752 29971 68215 13833 31484
Humana Health Plan Inc shystdshy LakePorterLaPorte Counties 888shy393shy6765 754 755 13457 31059 6211 14335
Humana Health Plan Inc shyhighshy Southern Indiana 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Southern Indiana 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Physicians Health Plan of Northern Indiana shyhighshy Northeast Indiana 260shy432shy6690 DQ1 DQ2 19103 42326 8817 19535
Iowa
Coventry Health Care of Iowa shyhighshy CentralEasternWestern Iowa 800shy257shy4692 SV1 SV2 11864 31973 5476 14757
Coventry Health Care of Iowa shystdshy CentralEasternWestern Iowa 800shy257shy4692 SY4 SY5 9243 21722 4266 10026
Health Alliance HMO shyhighshy Central Iowa 800shy851shy3379 FX1 FX2 21846 54966 10083 25369
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy Northwestern Iowa 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy Northwestern Iowa 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
UnitedHealthcare Plan of the River Valley Inc shyhighshy Eastern Iowa W Central Illinois 800shy747shy1446 YH1 YH2 13276 37085 6127 17116
Kansas
Aetna Open Access shyhighshy Kansas City Area 877shy459shy6604 HY1 HY2 11817 36274 5454 16742
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA1 HA2 12196 32723 5629 15103
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO) 800shy969shy3343 HA4 HA5 10096 23722 4660 10948
Humana Health Plan Inc shyhighshy Kansas City area 888shy393shy6765 MS1 MS2 45714 103636 21099 47832
Humana Health Plan Inc shystdshy Kansas City area 888shy393shy6765 MS4 MS5 13457 31059 6211 14335
46
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Indiana
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
615
855
826
855
82
935
909
839
866
876
823
664
642
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 651 853 871 926 806 843 702
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 475 86 864 923 871 901 694
Physicians Health Plan of Northern IndianashyHigh
Iowa
Coventry Health Care of IowashyHigh
$15$15
$20$45
20
15
$10
$3$10
$25$50
$40$65
Yes
Yes
583
567
879
857
88
867
952
966
905
824
944
907
603
675
Coventry Health Care of IowashyStd $20$45 20 $3$10 305000Max 305000Max No 567 857 867 966 824 907 675
Health Alliance HMOshyHigh $20$30 $2005 days $15 $30$50 Yes 849 897 884 96 927 902 726
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then 20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703
Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA No 53 831 861 963 905 907 703
UHC Plan of the River Valley IncshyHigh
Kansas
Aetna Open AccessshyHigh
$25$45
$20$35
Nothing
$250day x 4
$10
$10
$35$50
$35$65
Yes
Yes
524 873 853 956 798 886 622
Coventry Health Care of KansasshyHigh $20$60 None $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 None $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
47
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Kentucky
Humana Health Plan Inc shyhighshy Louisville Area 888shy393shy6765 MH1 MH2 17459 40062 8058 18490
Humana Health Plan Inc shystdshy Louisville Area 888shy393shy6765 MH4 MH5 13459 31061 6212 14336
Humana Health Plan Inc shyhighshy Lexington Area 888shy393shy6765 MI1 MI2 13398 30812 6184 14221
Humana Health Plan Inc shystdshy Lexington Area 888shy393shy6765 MI4 MI5 11412 25677 5267 11851
Louisiana
Coventry Health Care of Louisiana shyhighshy New Orleans area 800shy341shy6613 BJ1 BJ2 19017 47855 8777 22087
Coventry Health Care of Louisiana shystdshy New Orleans area 800shy341shy6613 BJ4 BJ5 13035 31308 6016 14450
Maryland
Aetna Open Access shyhighshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralSouthern Maryland Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy All of Maryland 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy All of Maryland 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Coventry Health Care shyhighshy All of Maryland 800shy833shy7423 IG1 IG2 10806 27119 4987 12516
Coventry Health Care shystdshy All of Maryland 800shy833shy7423 IG4 IG5 10049 25121 4638 11594
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy BaltimoreWashington DC areas 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy BaltimoreWashington DC areas 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy All of Maryland 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Massachusetts
Fallon Community Health Plan shybasicshy CentralEastern Massachusetts 800shy868shy5200 JG1 JG2 21173 59490 9772 27457
48
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
6
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Kentucky
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10
HMO
$40$60
POS National
Yes
Average 659 855 855 935 839 876 664
Humana Health Plan Inc shyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan Inc shyStd
Louisiana
Coventry Health Care of LouisianashyHigh
$25$40
$25$45
$500day x 3
$100
$10
$5
$40$60
$40$75
Yes
Yes 579 866 853 964 793 843 677
Coventry Health Care of LouisianashyStd
Maryland
Aetna Open AccessshyHigh
$30$55
$15$30
30
$150day x3
$5
$5
$40$75
$35$65
Yes
Yes
579
659
866
871
853
87
964
918
793
901
843
874
677
667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoice InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoice OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Coventry Health CareshyHigh $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Coventry Health CareshyStd $20$40 $200day x 3 $3$15 $30$60 Yes 477 81 811 935 708 818 553
Kaiser Foundation HP MidshyAtlantic States shyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HP MidshyAtlantic States shyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh
Massachusetts
Fallon Community Health PlanshyBasic
$25$40
$25$35
$150day x 3
$150 to $750max
$7
$10
$30$150$250
$30$60
Yes
Yes
632
61
838
862
871
883
925
95
841
828
90
799
65
627
49
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Plan Name ndash Location
Bluecare Network of MI shyhighshy Traverse City
Bluecare Network of MI shyhighshy Grand Rapids
Bluecare Network of MI shyhighshy East Region
Bluecare Network of MI shyhighshy Southeast Region
Grand Valley Health Plan shyhighshy Grand Rapids area
Grand Valley Health Plan shystdshy Grand Rapids area
Health Alliance Plan shyhighshy Southeastern MichiganFlint area
Health Alliance Plan shystdshy Southeastern MichiganFlint area
HealthPlus MI shyhighshy East Michigan
Physicians Health Plan shystdshy MidshyMichigan
HealthPartners shyhighshy
HealthPartners shystdshy
Aetna Open Access shyhighshy Kansas City Area
Blue Preferred Plus POS shyhighshy St LouisCentralSW areas
Coventry Health Care of Kansas shyhighshy Kansas City Metro Area (KS and MO)
Coventry Health Care of Kansas shystdshy Kansas City Metro Area (KS and MO)
Humana Health Plan Inc shyhighshy Kansas City area
Humana Health Plan Inc shystdshy Kansas City area
United Healthcare of the Midwest shyhighshy St Louis Area
Enrollment Code
Self Self amp only family
Michigan
H61 H62
J31 J32
K51 K52
LX1 LX2
RL1 RL2
RL4 RL5
521 522
GY4 GY5
X51 X52
9U4 9U5
Minnesota
V31 V32
V34 V35
Missouri HY1 HY2
9G1 9G2
HA1 HA2
HA4 HA5
MS1 MS2
MS4 MS5
B91 B92
Telephone Number
800shy662shy6667
800shy662shy6667
800shy662shy6667
800shy662shy6667
616shy949shy2410
616shy949shy2410
800shy556shy9765
800shy556shy9765
800shy332shy9161
866shy539shy3342
952shy883shy5000
952shy883shy5000
877shy459shy6604
888shy811shy2092
800shy969shy3343
800shy969shy3343
888shy393shy6765
888shy393shy6765
877shy835shy9861
50
Monthly
Self Self amp only family
17455 60199
20874 69088
15762 37947
12930 44648
19006 64274
12973 45145
15511 44042
12822 33321
12002 34959
20141 55759
32886 78427
8987 20671
11817 36274
26208 54102
12196 32723
10096 23722
45714 103636
13457 31059
19353 43374
Biweekly
Self Self amp only family
8056 27784
9634 31887
7275 17514
5968 20607
8772 29665
5987 20836
7159 20327
5918 15379
5539 16135
9296 25735
15178 36197
4148 9540
5454 16742
12096 24970
5629 15103
4660 10948
21099 47832
6211 14335
8932 20019
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Michigan
Bluecare Network of MIshyHigh $15$25 Nothing $5
HMO
$50NA
POS National
Yes
Average 659 855 855 935 839 876 664
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Bluecare Network of MIshyHigh $15$25 Nothing $5 $50NA Yes 61 844 87 911 852 887 613
Grand Valley Health PlanshyHigh $10$10 Nothing $5 $15$15 No 796 869 919 939 89 864 778
Grand Valley Health PlanshyStd $20$20 $500 x 3 $10 $40$40 No 796 869 919 939 89 864 778
Health Alliance PlanshyHigh $10$20 Nothing $5 $25$25 Yes 748 876 842 957 849 869 653
Health Alliance PlanshyStd $15$30 Nothing $10 $40$40 Yes
HealthPlus MIshyHigh $10$20 None $8 $40$60 Yes 763 902 904 953 873 90 724
Physicians Health PlanshyStd
Minnesota
HealthPartnersshyHigh
$20Nothing
$25$45
20
Nothing
$15
$12
$25$50
$45$90
Yes
Yes
774
641
906
873
886
897
964
951
893
888
887
912
69
66
HealthPartnersshyStd
Missouri Aetna Open AccessshyHigh $20$35
$0 for 3 then 20 $0 for 3 then 20 20 in40 out
$250day x 4
$9
$10
$40$70
$35$65
Yes
Yes
641 873 897 951 888 912 66
Blue Preferred Plus POS InshyNetwork $25$25 $500 $10 $30$5025 $5025 Yes 718 897 85 915 857 913 659
Blue Preferred Plus POS OutshyNetwork 30 after ded 30 after ded 30 after ded NA NA NA NA 718 897 85 915 857 913 659
Coventry Health Care of KansasshyHigh $20$60 20 $3$12 $40$65 Yes 501 871 88 95 853 868 624
Coventry Health Care of KansasshyStd $30$60 20 $3$12 $50$75 Yes 501 871 88 95 853 868 624
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes 646 872 868 928 874 927 725
United Healthcare of the Midwest IncshyHigh $25$40 $450 $7 $30$60 Yes 569 863 866 949 815 894 617
51
Plan Name ndash Location
Aetna Open Access shyhighshy Clark County and Las Vegas areas
Health Plan of Nevada shyhighshy Las Vegas area
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Self Self amp Self Self amp Self Self amp only family only family only family
Nevada
HF1 HF2 10582 33646 4884 15529
NM1 NM2 10448 24635 4822 11370
Telephone Number
877shy459shy6604
800shy777shy1840
New Jersey
Aetna Open Access shyhighshy Northern New Jersey 877shy459shy6604 JR1 JR2 41628 98562 19213 45490
Aetna Open Access shybasicshy Northern New Jersey 877shy459shy6604 JR4 JR5 24416 59488 11269 27456
Aetna Open Access shyhighshy Southern NJ 877shy459shy6604 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Southern NJ 877shy459shy6604 P34 P35 33995 81655 15690 37687
GHI Health Plan shyhighshy Northern New Jersey 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Northern New Jersey 212shy501shy4444 804 805 11681 27270 5391 12586
New Mexico
Lovelace Health Plan shyhighshy All of New Mexico 800shy808shy7363
Presbyterian Health Plan shyhighshy All counties in New Mexico 800shy356shy2219
52
Q11 Q12 22873 58561 10557 27028
P21 P22 17370 41076 8017 18958
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Nevada
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMO
$35$65
POS National
Yes
Average 659 855 855 935 839 876 664
Health Plan of NevadashyHigh
New Jersey
Aetna Open AccessshyHigh
$10$20
$20$35
$150
$150day x 5
$5
$10
$35$55
$35$65
Yes
Yes
567
617
709
855
706
886
898
937
78
852
845
861
561
605
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 617 855 886 937 852 861 605
Aetna Open AccessshyHigh $20$35 $150day x 5 $10 $35$65 Yes 729 89 91 948 902 902 741
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 729 89 91 948 902 902 741
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd
New Mexico
Lovelace Health PlanshyHigh
$25$25
$20$35
$250day x 3
$250 after ded
$5
$5
$25$50
$35$6050
Yes
Yes
604
623
856
807
861
786
926
896
763
807
772
862
572
746
Presbyterian Health PlanshyHigh $25$35 $100 x 5 days $10 $40$7525 Yes 653 831 814 918 823 876 673
53
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
New York Aetna Open Access shyhighshy NYC AreaUpstate NY 877shy459shy6604 JC1 JC2 32251 88675 14885 40927
Aetna Open Access shybasicshy NYC AreaUpstate NY 877shy459shy6604 JC4 JC5 18521 53023 8548 24472
Blue Choice shyhighshy Rochester area 800shy462shy0108 MK1 MK2 22050 54639 10177 25218
Blue Choice shystdshy Rochester area 800shy462shy0108 MK4 MK5 13332 43643 6153 20143
CDPHP Universal Benefits shyhighshy Upstate Hudson Valley Central New York 877shy269shy2134 SG1 SG2 17270 55893 7971 25797
CDPHP Universal Benefits shystdshy Upstate Hudson Valley Central New York 877shy269shy2134 SG4 SG5 10761 27761 4966 12813
GHI HMO shyhighshy BrnxBrklynManhatQueenRichmonWestche 877shy244shy4466 6V1 6V2 37834 109100 17462 50354
GHI HMO shyhighshy CapitalHudson Valley Regions 877shy244shy4466 X41 X42 27148 80953 12530 37363
GHI Health Plan shyhighshy All of New York 212shy501shy4444 801 802 25441 74455 11742 34364
GHI Health Plan shystdshy Most of New York City 212shy501shy4444 804 805 11681 27270 5391 12586
HIP of Greater New York shyhighshy New York City area 800shyHIPshyTALK 511 512 20414 70973 9422 32757
HIP of Greater New York shystdshy New York City area 800shyHIPshyTALK 514 515 13724 53244 6334 24574
Independent Health Assoc shyhighshy Western New York 800shy501shy3439 QA1 QA2 14928 48169 6890 22232
MVP Health Care shyhighshy Eastern Region 888shy687shy6277 GA1 GA2 13362 43962 6167 20290
MVP Health Care shystdshy Eastern Region 888shy687shy6277 GA4 GA5 11930 29849 5506 13776
MVP Health Care shyhighshy Western Region 888shy687shy6277 GV1 GV2 13096 41303 6044 19063
MVP Health Care shystdshy Western Region 888shy687shy6277 GV4 GV5 11424 28584 5273 13192
MVP Health Care shyhighshy Central Region 888shy687shy6277 M91 M92 16048 51079 7407 23575
MVP Health Care shystdshy Central Region 888shy687shy6277 M94 M95 12526 35596 5781 16429
MVP Health Care shyhighshy Northern Region 888shy687shy6277 MF1 MF2 23939 70828 11049 32690
MVP Health Care shystdshy Northern Region 888shy687shy6277 MF4 MF5 16701 52700 7708 24323
MVP Health Care shyhighshy MidshyHudson Region 888shy687shy6277 MX1 MX2 16902 53174 7801 24542
MVP Health Care shystdshy MidshyHudson Region 888shy687shy6277 MX4 MX5 12638 36569 5833 16878
54
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
New York Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
651
855
828
855
853
935
927
839
873
876
875
664
60
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 651 828 853 927 873 875 60
Blue ChoiceshyHigh $20$20 $240 $10 $30$100 No 724 921 924 947 86 931 71
Blue ChoiceshyStd $25$40 $500 $7 $50$100 No 724 921 924 947 86 931 71
CDPHP Universal Benefits IncshyHigh $20$30 $100 x 5 25 2525 No 71 911 882 957 909 903 739
CDPHP Universal Benefits IncshyStd $25$40 $500+10 30 3030 No 71 911 882 957 909 903 739
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI HMO SelectshyHigh $25$40 $500 $10 $30$50 Yes 513 806 859 945 814 817 65
GHI Health Planshy InshyNetwork $15$15 $100 $15 $25$50 Yes 604 856 861 926 763 772 572 GHI Health Planshy OutshyNetwork +50 of sch +50 of sch NA NA NA No 604 856 861 926 763 772 572
GHI Health PlanshyStd $25$25 $250day x 3 $5 $25$50 Yes 604 856 861 926 763 772 572
HIP of Greater New YorkshyHigh $10$20 None $15 $30$50 Yes 701 843 813 898 79 844 561
HIP of Greater New YorkshyStd $20$40 $500 $15 $30$50 Yes 701 843 813 898 79 844 561
Independent Health Assocshy InshyNetwork $20$20 $250 $10 $20$35 No 741 905 915 953 892 935 784 Independent Health Assocshy OutshyNetwork 2525 25 NA NA NA No 741 905 915 953 892 935 784
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
MVP Health CareshyHigh $25$25 $500 $5 $35$70 Yes 69 905 889 959 862 94 786
MVP Health CareshyStd $30$50 $750 $5 $45$90 Yes 69 905 889 959 862 94 786
55
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
North Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Heart of America Health Plan shyhighshy Northcentral North Dakota 800shy525shy5661 RU1 RU2 11236 28876 5186 13327
Ohio
AultCare HMO shyhighshy StarkCarrollHolmesTuscarawasWayne Co 330shy363shy6360 3A1 3A2 17728 52557 8182 24257
HMO Health Ohio shyhighshy Northeast Ohio 800shy522shy2066 L41 L42 36224 89930 16719 41506
Kaiser Foundation Health Plan of Ohio shyhighshy ClevelandAkron areas 800shy686shy7100 641 642 25023 60344 11549 27851
Kaiser Foundation Health Plan of Ohio shystdshy ClevelandAkron areas 800shy686shy7100 644 645 10804 24849 4986 11469
The Health Plan of the Upper Ohio Valley shyhighshyEastern Ohio 800shy624shy6961 U41 U42 15195 35529 7013 16398
Oklahoma
Globalhealth Inc shyhighshy Oklahoma 877shy280shy2990 IM1 IM2 9779 23566 4513 10877
Oregon
Kaiser Foundation Health Plan of Northwest shyhighshy PortlandSalem areas 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy PortlandSalem areas 800shy813shy2000 574 575 11677 26824 5389 12380
56
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
North Dakota
HealthPartnersshyHigh $25$45 Nothing $12
HMO
$45$90
POS National
Yes
Average 659
641
855
873
855
897
935
951
839
888
876
912
664
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Heart of America Health PlanshyHigh InshyNetwork $15$25 None 50 5050 None Heart of America Health PlanshyHigh OutshyNetwork
Ohio
AultCare HMOshyHigh
2020
$15$20
20
$150
NA
$15
NA
$30$45
NA
No 865 935 926 946 946 958 863
HMO Health OhioshyHigh $20$20 $250 $20 $30$40 Yes 679 871 875 961 84 912 701
Kaiser Foundation HP of OhioshyHigh $20$20 $250 $10 $30$30 Yes 736 857 85 907 835 858 724
Kaiser Foundation HP of OhioshyStd $30$40 $500 $15 $40$40 Yes 736 857 85 907 835 858 724
The Health Plan of the Upper Ohio ValleyshyHigh
Oklahoma
Globalhealth IncshyHigh
Oregon
Kaiser Foundation HP of NorthwestshyHigh
$10$20
$15$35
$15$25
$250
$150day x 3
$200
$15
$10
$15
$30$50
$30$40
$40$40
Yes
Yes
Yes
739
56
677
905
731
769
89
812
778
963
941
893
927
715
864
957
883
848
758
626
679
Kaiser Foundation HP of NorthwestshyStd $25$35 $500 $20 $40$40 Yes 677 769 778 893 864 848 679
57
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Pennsylvania
Aetna Open Access shyhighshy Philadelphia 800shy392shy9137 P31 P32 62387 157861 28794 72859
Aetna Open Access shybasicshy Philadelphia 800shy392shy9137 P34 P35 33995 81655 15690 37687
Aetna Open Access shyhighshy Pittsburgh and Western PA Areas 877shy459shy6604 YE1 YE2 12215 37849 5638 17469
Geisinger Health Plan shystdshy NortheasternCentralSouth Central areas 800shy447shy4000 GG4 GG5 24219 58498 11178 26999
HealthAmerica Pennsylvania shyhighshy Greater Pittsburgh area 866shy351shy5946 261 262 16956 44653 7826 20609
HealthAmerica Pennsylvania shystdshy Central Pennsylvania 866shy351shy5946 SW4 SW5 15645 35977 7221 16605
UPMC Health Plan shyhighshy Western Pennsylvania 888shy876shy2756 8W1 8W2 19435 47493 8970 21920
UPMC Health Plan shystdshy Western Pennsylvania 888shy876shy2756 UW4 UW5 15251 37871 7039 17479
Puerto Rico Humana Health Plans of Puerto Rico Inc shyhighshy Puerto Rico 800shy314shy3121 ZJ1 ZJ2 8177 18399 3774 8492
TripleshyS Salud Inc shyhighshy All of Puerto Rico 787shy774shy6060 891 892 8389 18875 3872 8712
South Dakota
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
Sanford Health Plan shyhighshy EasternCentralRapid City Areas 800shy752shy5863 AU1 AU2 25421 61310 11733 28297
Sanford Health Plan shystdshy EasternCentralRapid City Areas 800shy752shy5863 AU4 AU5 22906 55477 10572 25605
Tennessee
Aetna Open Access shyhighshy Memphis Area 877shy459shy6604 UB1 UB2 15845 53244 7313 24574
Humana Health Plan Inc shyhighshy Knoxville 888shy393shy6765 GJ1 GJ2 13459 31061 6212 14336
Humana Health Plan Inc shystdshy Knoxville 888shy393shy6765 GJ4 GJ5 11479 25828 5298 11921
58
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Pennsylvania
Aetna Open AccessshyHigh $20$35 $150day x 5 $10
HMO
$35$65
POS National
Yes
Average 659
567
855
873
855
885
935
946
839
752
876
886
664
682
Aetna Open AccessshyBasic $15$35 20 Plan Allow $5 $35$65 Yes 567 873 885 946 752 886 682
Aetna Open AccessshyHigh $20$35 $250day x 4 $10 $35$65 Yes 567 873 885 946 752 886 682
Geisinger Health PlanshyStd $20$35 20aftrDeduct 30 $5$15 40 $40$12050 $60$180 Yes 704 889 899 959 841 896 713
HealthAmerica PennsylvaniashyHigh $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
HealthAmerica PennsylvaniashyStd $25$50 15 $5 $35$60 Yes 695 864 888 946 836 919 709
UPMC Health PlanshyHigh $20$35 None $5 $35$70 Yes 764 903 871 959 87 885 716
UPMC Health PlanshyStd
Puerto Rico Humana HP of Puerto Rico shy InshyNetwork
$20$35
$5$5
None
None
$5
$250
$35$70
$10$15
Yes
Yes
764
753
903
807
871
815
959
936
87
834
885
811
716
591 Humana HP of Puerto Rico shy OutshyNetwork $10$10 $50 NA NA NA No 753 807 815 936 834 811 591
TripleshyS Salud Incshy InshyNetwork $750$10 None $5 or $12 Greater of $15 or 20
25 up to $100$175 max Yes 716 857 796 968 683 695 514 TripleshyS Salud Incshy OutshyNetwork
South Dakota
HealthPartnersshyHigh
$750+10$10+10
$25$45
10 +
Nothing
NA
$12
NA NA
$45$90
No
Yes
716
641
857
873
796
897
968
951
683
888
695
912
514
66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then 20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
Sanford Health Planshy InshyNetwork $20$30 $100day x 5 $15 $30$50 NA 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork 4040 40 NA NA NA NA 53 831 861 963 905 907 703
Sanford Health Planshy InshyNetwork $25$25 $100day x 5 $15 $30$50 No 53 831 861 963 905 907 703 Sanford Health Planshy OutshyNetwork
Tennessee
Aetna Open AccessshyHigh
4040
$20$35
40
$250day x 4
NA
$10
NA NA
$35$65
No
Yes
53
639
831
877
861
842
963
936
905
85
907
919
703
708
Humana Health Plan IncshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan IncshyStd $25$40 $500day x 3 $10 $40$60 Yes
59
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Texas
Aetna Open Access shyhighshy Austin and San Antonio Areas 877shy459shy6604 P11 P12 34790 99255 16057 45810
Firstcare shyhighshy West Texas 800shy884shy4901 CK1 CK2 12270 57475 5663 26527
Humana Health Plan of Texas shyhighshy Corpus Christi 888shy393shy6765 UC1 UC2 18345 42055 8467 19410
Humana Health Plan of Texas shystdshy Corpus Christi 888shy393shy6765 UC4 UC5 13459 31059 6212 14335
Humana Health Plan of Texas shyhighshy San Antonio 888shy393shy6765 UR1 UR2 44696 101346 20629 46775
Humana Health Plan of Texas shystdshy San Antonio 888shy393shy6765 UR4 UR5 13457 31059 6211 14335
Humana Health Plan of Texas shyhighshy Austin 888shy393shy6765 UU1 UU2 19558 44783 9027 20669
Humana Health Plan of Texas shystdshy Austin 888shy393shy6765 UU4 UU5 13459 31061 6212 14336
UnitedHealthcare Benefits of Texas Inc shyhighshy San Antonio 866shy546shy0510 GF1 GF2 19474 47638 8988 21987
Utah
Altius Health Plans shyhighshy Wasatch Front 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Wasatch Front 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
SelectHealth shyhighshy Urban and Suburban Utah 800shy538shy5038 SF1 SF2 21966 47129 10138 21752
Virgin Islands
TripleshyS Salud Inc shyhighshy US Virgin Islands 800shy981shy3241 851 852 10305 23402 4756 10801
Virginia Aetna Open Access shyhighshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN1 JN2 33796 76072 15598 35110
Aetna Open Access shybasicshy NorthernCentralRichmond Virginia Areas 877shy459shy6604 JN4 JN5 12446 29128 5744 13444
CareFirst BlueChoice shyhighshy Northern Virginia 866shy296shy7363 2G1 2G2 13999 32255 6461 14887
CareFirst BlueChoice Healthy Blue Optionshystdshy Northern Virginia 866shy296shy7363 2G4 2G5 12883 28982 5946 13376
Kaiser Foundation Health Plan MidshyAtlantic States shyhighshy Northern VirginiaFredericksburg area 877shy574shy3337 E31 E32 14800 36835 6831 17001
Kaiser Foundation Health Plan MidshyAtlantic States shystdshy Northern VirginiaFredericksburg area 877shy574shy3337 E34 E35 8969 20629 4139 9521
MD IPA shyhighshy NVACntrl VARichmond 877shy835shy9861 JP1 JP2 16579 41260 7652 19043
Optima Health Plan shyhighshy Hampton Roads and Richmond areas 800shy206shy1060 9R1 9R2 16681 44919 7699 20732
Optima Health Plan shystdshy Hampton Roads and Richmond areas 800shy206shy1060 9R4 9R5 9333 22083 4307 10192
Piedmont Community Healthcare shyhighshy Lynchburg area 888shy674shy3368 2C1 2C2 12771 29243 5894 13497
60
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Texas
Aetna Open AccessshyHigh $20$35 $250day x 4 $10
HMOP
$35$65
OS Nationa
Yes
l Average 659
698
855
833
855
793
935
896
839
829
876
886
664
652
FirstcareshyHigh $20$55 $200day x 5 $15 $35$65 No 597 846 875 946 781 865 637
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 587 86 795 91 805 87 621
Humana Health Plan of TexasshyHigh $20$35 $250day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
Humana Health Plan of TexasshyStd $25$40 $500day x 3 $10 $40$60 Yes 627 859 866 94 821 922 653
UnitedHealthcare Benefits of TexasshyHigh
Utah
Altius Health PlansshyHigh
$20$40
$20$30
$250day x 5
$200
$10
$7
$35$60
$25$50
Yes
Yes
654
556
864
86
842
88
936
948
797
817
905
853
646
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
SelectHealthshyHigh
Virgin Islands
TripleshyS Salud Incshy InshyNetwork
$15$25
$750$10
$100
None
$5
$5 or $12
$2550
Greater of $15 or 20 25 up to $100$175 ma
NA
Yes x
553 834 823 93 935 92 712
TripleshyS Salud Incshy OutshyNetwork $750 amp 10+ 10+ NA NANA No
Virginia Aetna Open AccessshyHigh $15$30
$10 amp 10+
$150day x3 $5 $35$65 Yes 659 871 87 918 901 874 667
Aetna Open AccessshyBasic $20$35 10 Plan Allow $10 $35$65 Yes 659 871 87 918 901 874 667
CareFirst BlueChoiceshyHigh $25$35 $200 Nothing $30$50 Yes 618 862 846 917 722 846 532
CareFirst BlueChoiceshyHigh InshyNetwork Nothing$35 $200 Nothing $30$50 Yes
CareFirst BlueChoiceshyHigh OutshyNetwork $70$70 $500 Nothing $30$50 Yes
Kaiser Foundation HPshyHigh $10$20 $100 $7$17 Net $30$50$45$65 Yes 767 847 874 922 816 873 716
Kaiser Foundation HPshyStd $20$30 $250day x 3 $12$22Net $35$55$50$70 Yes 767 847 874 922 816 873 716
MD IPAshyHigh $25$35 $150day x 3 $7 $25$150$250 Yes 632 838 871 925 841 90 65
Optima Health PlanshyHigh $15$0 childlt13$30 $200 $10 $25$50$75 Yes 689 90 849 934 917 933 719
Optima Health PlanshyStd $20$30 None $5 $2550up to $3000 No 689 90 849 934 917 933 719
Piedmont Community HCshyHigh $35$35 20 $15 $30$55 Yes
61
Health Maintenance Organization (HMO) and PointshyofshyService (POS) Plans See page 39 for an explanation of the columns on these pages
Your Share of Premium
Monthly Biweekly Enrollment Code
Telephone Self Self amp Self Self amp Self Self amp Plan Name ndash Location Number only family only family only family
Washington
Group Health Cooperative shyhighshyWestern WACentral WASpokanePullman 888shy901shy4636 541 542 19699 39110 9092 18051
Group Health Cooperative shystdshy Western WACentral WASpokanePullman 888shy901shy4636 544 545 9559 21579 4412 9959
KPS Health Plans shystdshy All of Washington 800shy552shy7114 L11 L12 10650 22988 4915 10610
KPS Health Plans shyhighshy All of Washington 800shy552shy7114 VT1 VT2 26338 55718 12156 25716
Kaiser Foundation Health Plan of Northwest shyhighshy VancouverLongview 800shy813shy2000 571 572 20921 48379 9656 22329
Kaiser Foundation Health Plan of Northwest shystdshy VancouverLongview 800shy813shy2000 574 575 11677 26824 5389 12380
West Virginia
The Health Plan of the Upper Ohio Valley shyhighshy NorthernCentral West Virginia 800shy624shy6961 U41 U42 15195 35529 7013 16398
Wisconsin
Dean Health Plan shyhighshy South Central Wisconsin 800shy279shy1301 WD1 WD2 15028 48410 6936 22343
Group Health Cooperative shyhighshy South Central Wisconsin 608shy828shy4827 WJ1 WJ2 12504 35304 5771 16294
HealthPartners shyhighshy 952shy883shy5000 V31 V32 32886 78427 15178 36197
HealthPartners shystdshy 952shy883shy5000 V34 V35 8987 20671 4148 9540
MercyCare HMO shyhighshy South Central Wisconsin 800shy895shy2421 EY1 EY2 12765 37875 5891 17481
Physicians Plus shyhighshy Dane County 800shy545shy5015 LW1 LW2 12539 38142 5787 17604
Wyoming
Altius Health Plans shyhighshy Uinta County 800shy377shy4161 9K1 9K2 19786 42302 9132 19524
Altius Health Plans shystdshy Uinta County 800shy377shy4161 DK4 DK5 10651 23431 4916 10814
62
Plan Name ndash Location
Primary care
Specialist office copay
Hospital per stay deductible
Prescription Drugs
Member Survey Results
Level I Level II Level III
Mail order
discount
Ove
rall plan
satisfaction
Gettin
g nee
ded
care
Gettin
g care
quickly
How
well
doctors
communicate
Customer
service
Claim
sproce
ssing
Plan
Inform
ation
on
Costs
Washington
Group Health CooperativeshyHigh $25$25 $350day x 3 $20
HMOP
$40$60
OS National
Yes
Average 659
691
855
839
855
844
935
926
839
867
876
896
664
711
Group Health CooperativeshyStd $25+20 $25+20 $500day x 3 $20 $40$60 Yes 691 839 844 926 867 896 711
KPS Health Plansshy InshyNetwork $153 or 2020 Nothing $10 $3550
$40 max $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $153 +40+diff
40+diff Nothing Not Covered Not Covered No 775 934 929 948 91 937 718
KPS Health Plansshy InshyNetwork $30$30 None $5 $2550 or $100 Yes 775 934 929 948 91 937 718 KPS Health Plansshy OutshyNetwork $30+40+diff
$30+40+diff None Not covered NA NA No 775 934 929 948 91 937 718
Kaiser Foundation HP of NorthwestshyHigh $15$25 $200 $15 $40$40 Yes 677 769 778 893 864 848 679
Kaiser Foundation HP of NorthwestshyStd
West Virginia
The HP of the Upper Ohio ValleyshyHigh
Wisconsin
Dean Health PlanshyHigh
$25$35
$10$20
$10$10
$500
$250
None
$20
$15
$10
$40$40
$30$50
30$75max30
Yes
Yes
No
677
739
77
769
905
871
778
89
883
893
963
962
864
927
854
848
957
921
679
758
689
Group Health CooperativeshyHigh $10 $10 None $5 $20$20 Yes 796 788 847 961 893 916 756
HealthPartnersshyHigh $25$45 Nothing $12 $45$90 Yes 641 873 897 951 888 912 66
HealthPartnersshyStd $0 for 3 then20 $0 for 3 then20 20 in40 out $9 $40$70 Yes 641 873 897 951 888 912 66
MercyCare HMOshyHigh $10$10 Nothing $10 $20$50 Yes
Physicians PlusshyHigh
Wyoming
Altius Health PlansshyHigh
$10$10
$20$30
Nothing
$200
$10
$7
3050
$25$50
No
Yes
766
556
86
86
889
88
95
948
901
817
912
853
723
625
Altius Health PlansshyStd $20$35 None $7 $35$60 Yes 556 86 88 948 817 853 625
63
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
(Pages 68 through 79)
A High Deductible Health Plan (HDHP) provides comprehensive coverage for highshycost medical events and a taxshyadvantaged way to help you build savings for future medical expenses The HDHP gives you greater flexibility and discretion over how you use your health care benefits
When you enroll your health plan establishes for you either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) The plan automatically deposits the monthly ldquopremium pass throughrdquo into your HSA The plan credits an amount into the HRA (This is the ldquoPremium Contribution to HSAHRArdquo column in the following charts)
Preventive care is often covered in full usually with no or only a small deductible or copayment Preventive care expenses may also be payable up to an annual maximum dollar amount (up to $300 for instance) As you receive other nonshypreventive medical care you must meet the plan deductible before the health plan pays benefits You can choose to pay your deductible with funds from your HSA or you can choose instead to pay for your deductible outshyofshypocket allowing your savings to continue to grow
The HDHP features higher annual deductibles (a minimum of $1200 for Self and $2400 for Family coverage) and annual outshyofshypocket limits (not to exceed $6050 for Self and $12100 for Family coverage) than other insurance plans Depending on the HDHP you choose you may have the choice of using InshyNetwork and OutshyofshyNetwork providers There may be higher deductibles and outshyofshypocket limits when you use OutshyofshyNetwork providers Using InshyNetwork providers will save you money
Health Savings Account (HSA)
A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a preshytax basis Funds deposited into an HSA are not taxed the balance in the HSA grows tax free and that amount is available on a tax free basis to pay medical costs You are eligible for an HSA if you are enrolled in an HDHP not covered by any other health plan that is not an HDHP (including a spousersquos health plan but does not include specific injury insurance and accident disability dental care vision care or longshyterm coverage) not enrolled in Medicare not received VA benefits within the last three months not covered by your own or your spousersquos flexible spending account (FSA) and are not claimed as a dependent on someone elsersquos tax return If you are enrolled in a High Deductible Health Plan with an HSA you may not participate in a Health Care Flexible Spending Account (HCFSA) but you are permitted to participate in a Limited Expense (LEX) HCFSA HSArsquos are subject to a number of rules and limitations established by the Department of the Treasury
Visit wwwustreasgovofficespublicshyaffairshsa for more information The 2012 maximum contribution limits are $3100 for Self Only coverage and $6250 for Self and Family coverage If you are over 55 you can make an additional ldquocatch uprdquo contribution You can use funds in your account to help pay your health plan deductible
64
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
Features of an HSA include
bull Taxshydeductible deposits you make to the HSA Your own HSA contributions are either taxshydeductible or preshytax (if made by payroll deduction) See IRS Publication 969
bull Taxshydeferred interest earned on the account
bull Taxshyfree withdrawals for qualified medical expenses
bull Carryover of unused funds and interest from year to year
bull Portability the account is owned by you and is yours to keep ndash even when you retire leave government service or change plans
Health Reimbursement Arrangement (HRA)
Health Reimbursement Arrangements are a common feature of ConsumershyDriven Health Plans They may be referred to by the health plan under a different name such as personal care account They are also available to enrollees in High Deductible Health Plans who are not eligible for an HSA HRAs are similar to HSAs except
bull An enrollee cannot make deposits into an HRA
bull A health plan may impose a ceiling on the value of an HRA
bull Interest is not earned on an HRA and
bull The amount in an HRA is not transferable if the enrollee leaves the health plan
If you are enrolled in a High Deductible Health Plan with an HRA you may participate in a Health Care Flexible Spending Account (HCFSA)
The plan will credit the HRA different amounts depending on whether you have a Self Only or a Self and Family enrollment You can use funds in your account to help pay your health plan deductible
Features of an HRA include
bull Taxshyfree withdrawals for qualified medical expenses bull Carryover of unused credits from year to year bull Credits in an HRA do not earn interest bull Credits in the HRA are forfeited if you leave federal employment or switch health
insurance plans
65
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
ELIGIBILITY
FUNDING
Health Savings Account (HSA)
You must enroll in a High Deductible Health Plan (HDHP) No other general medical insurance coverage is permitted You cannot be enrolled in Medicare Part A or Part B You cannot be claimed as a dependent on someone elsersquos tax returns
The plan deposits a monthly ldquopremium pass throughrdquo into your account
Health Reimbursement Arrangement (HRA)
You must enroll in a High Deductible Health Plan (HDHP)
The plan deposits the credit amount directly into your account
CONTRIBUTIONS
DISTRIBUTIONS
The maximum allowed is a combination of the health plan ldquopremium pass throughrdquo and the member contribution up to the maximum contribution amount set by the IRS each year
May be used to pay the outshyofshypocket medical expenses for yourself your spouse or your dependents (even if they are not covered by the HDHP) or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
Only that portion of the premium specified by the health plan will be contributed You cannot add your own money to an HRA
May be used to pay the outshyofshypocket expenses for qualified medical expenses for individuals covered under the HDHP or to pay the planrsquos deductible
See IRS Publication 502 for a complete list of eligible expenses
ANNUAL ROLLOVER
PORTABLE Yes you can take this account with you when you change plans separate from service or retire
Yes funds accumulate without a maximum cap
If you retire and remain in your HDHP you may continue to use and accumulate credits in your HRA
If you terminate employment or change health plans only eligible expenses incurred while covered under that HDHP will be eligible for reimbursement subject to timely filing requirements Unused credits are forfeited
Yes credits accumulate without a maximum cap
IMPORTANT REMINDER This is only a summary of the features of the HDHPHSA or HRA Refer to the specific Plan brochure for the complete details covering Plan design operation and administration as each Plan will have differences
66
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
A ConsumershyDriven plan provides you with freedom in spending health care dollars the way you want The typical plan has features such as member responsibility for certain upshyfront medical costs an employershyfunded account that you may use to pay these upshyfront costs and catastrophic coverage with a high deductible You and your family receive full coverage for InshyNetwork preventive care
67
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
The tables on the following pages highlight what you are expected to pay for selected features under each plan The charts are not a complete statement of your outshyofshypocket obligations in every individual circumstance Unlike many regular medical plans the covered outshyofshypocket expenses under a High Deductible Health Plan including office visit copayments and prescription drug copayments count toward the calendar year deductible and the catastrophic limit You must read the planrsquos brochure for details
Premium Contribution (pass through) to HSAHRA (or personal care account) shows the amount your health plan automatically deposits or credits into your account on a monthly basis for Self OnlySelf and Family enrollments (ConsumershyDriven Health Plans credit accounts annually) The amount credited under ldquoPremium Contributionrdquo is shown as a monthly amount for comparison purposes only
Calendar Year (CY) Deductible SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles coinsurance and copayments before the plan pays catastrophic benefits
Catastrophic (Cat) Limit SelfFamily is the maximum amount of covered expenses an individual or family must pay outshyofshypocket including deductibles and coinsurance and copays before the Plan pays catastrophic benefits
Office Visit shows what you pay for a visit to a primary care physician after the deductible is met for other than preventive care
Inpatient Hospital shows what you pay after the deductible is met for hospital services when an inpatient The amount could be a daily copayment up to a specified amount (eg $50 a day up to three days) a coinsurance amount such as
Your Share of Premium
Plan Name Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
APWU Health Plan shyCDHP shy Nationwide
GEHA High Deductible Health Plan shyHDHP shy Nationwide
MHBP Consumer Option shyHDHPshy Nationwide
866shy833shy3463
800shy821shy6136
800shy694shy9901
474 475
341 342
481 482
8923 20072
9996 22832
11557 26186
4118 9264
4614 10538
5334 12086
68
Appendix E FEHB Plan Comparison Charts
High Deductible and ConsumershyDriven Health Plans With a Health Savings Account or Health Reimbursement Arrangement
20 or a flat deductible amount (eg $200 per admission) This amount does not include charges from physicians or for services that may not be charged by the hospital such as laboratory or radiology
Outpatient Surgery shows what you pay the doctor for surgery performed on an outpatient basis
Preventive Services are often covered in full usually with no or only a small deductible or copayment Preventive services may also be payable up to an annual maximum dollar amount (eg up to $300 per person per year)
Prescription Drugs are catagorized using a variety of terms to define what you pay such as generic brand Level I Level II Tier I Tier II etc In capturing these differences we use the following Level I includes most generic drugs but may include some preferred brands Level II may include generics and preferred brands not included in Level I Level III includes all other covered drugs with some exceptions for specialty drugs The level in which a medication is placed and what you pay for prescription drugs is often based on what the plan is charged
High Deductible Health Plans and Consumer Driven Health Plans are much different from the other types of plans shown in this Guide You can use inshynetwork providers to save money If you use outshyofshynetwork providers however you not only pay more of the costs but you are also usually responsible for any difference between the amount billed for a service and what the plan actually allows (For example you receive a bill from an outshyofshynetwork provider for $100 but the plan allows $85 for the service You pay the higher copayment for outshyofshynetwork care plus the $15 difference between $100 ndash the billed amount ndash and the planrsquos allowance of $85) In addition the difference you pay between the billed amount and the planrsquos allowance does not count toward satisfying the catastrophic limit
Plan Name Benefit Premium CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Type Contribution SelfFamily SelfFamily Visit Hospital Surgery Services Drugs
SelfFamily Levels I II III
APWU Health Planshy InshyNetwork $1200$2400 $600$1200 $3000$4500 15 None 15 Nothing 252525 APWU Health Planshy OutshyNetwork $1200$2400 $600$1200 $9000$9000 40+diff None 40+diff Nothing up to $1200 Not Covered
GEHA HDHPshy InshyNetwork $6250$125 $1500$3000 $5000$10000 5 5 5 Nothing 252525 GEHA HDHPshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 25 25 25 Ded25 25+25+25+
MHBP Consumer Optionshy InshyNetwork $70$141 $2000$4000 $5000$10000 $15 $75 dayshy$750 Nothing Nothing $10$25$40 MHBP Consumer Optionshy OutshyNetwork $70$141 $2000$4000 $7500$15000 40 40 40 Not Covered Not Covered
69
High Deductible Health Plans and ConsumershyDriven Health Plan Member Survey Results
Member Survey results are collected scored and reported by an independent organization ndash not by the health plans See Appendix D for a fuller explanation of each survey category
Overall Plan Satisfaction bull How would you rate your overall experience with your health plan
Getting Needed Care bull How often was it easy to get an appointment the care tests or treatment you thought you needed through your health plan
Getting Care Quickly bull When you needed care right away how often did you get care as soon as you thought you needed bull Not counting the times you needed care right away how often did you get an appointment at a doctorrsquos office or clinic as soon as you thought you needed
How Well Doctors bull How often did your personal doctor explain things in a way that was easy to understand Communicate bull How often did your personal doctor listen carefully to you show respect for what you had to say and spend enough time with you
Customer Service bull How often did written materials or the Internet provide the information you needed about how your health plan works bull How often did your health planrsquos customer service give you the information or help you needed bull How often were the forms from your health plan easy to fill out
Claims Processing bull How often did your health plan handle your claims quickly and correctly
Plan Information on Costs bull How often were you able to find out from your health plan how much you would have to pay for a health care service or equipment or for specific prescription drug medicines
High Deductible Health Plans Plan Name
Member Survey Results
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
HDHP National Average 592 863 885 931 85 889 577
Aetna Health Fund shy Nationwide
GEHA High Deductible Health Plan shy Nationwide
MHBP Consumer Option shy Nationwide
22
34
48
60
637
54
856
864
868
893
885
877
935
923
936
859
852
839
90
876
892
592
593
547
ConsumershyDriven Health Plans Plan Name
Plan Code
Overall plan satisfaction
Getting needed care
Getting care quickly
How well doctors
communicate Customer service
Claims processing
Plan Information on Costs
CDHP National Average 577 849 868 929 833 867 619
Aetna Health Fund shy Nationwide
APWU Health Fund shy Nationwide
Humana Coverage First shyTX
22
47
TU TV
60
643
489
856
884
806
893
868
841
935
924
929
859
803
839
90
809
891
592
657
609
70
This page intentionally left blank
71
A Aetna HealthFundshy
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
The Aetna Healthfund is available in all or part of the following states AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS
Your Share of Premium
Plan Name
Telephone Number
Enrollment Code Monthly Biweekly
Self only
Self amp family
Self only
Self amp family
Self only
Self amp family
Aetna HealthFund shyCDHP
Aetna HealthFund shyHDHP
877shy459shy6604
877shy459shy6604
221 222
224 225
15604 37056
9412 20613
7202 17103
4344 9514
Your Share of Premium
Florida
Coventry Health Care of Flordia shyHDHPshySouthern Florida
Humana CoverageFirst shyCDHPshy Tampa Area
Humana CoverageFirst shyCDHPshy South Florida Area
Georgia Humana CoverageFirst shyCDHPshy Atlanta Area
Humana CoverageFirst shyCDHPshy Macon Area
Guam TakeCare shyHDHPshy GuamN Mariana IslandsBelau (Palau)
Idaho
Altius Health Plans shyHDHPshy Southern Region
Plan Name
800shy441shy5501
888shy393shy6765
888shy393shy6765
888shy393shy6765
888shy393shy6765
671shy647shy3526
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
J41
MJ1
QP1
AD1
LM1
KX1
9K4
Self only
J42
MJ2
QP2
AD2
LM2
KX2
9K5
Self amp family
11570
12685
10873
11477
11840
8138
8704
Self only
28710
28542
24465
25824
26639
21442
18033
Self amp family
5340
5855
5018
5297
5464
3756
4017
Self only
13251
13173
11291
11919
12295
9896
8323
Self amp family
72
OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+
MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV and WY
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III Plan Name
Aetna HealthFundshy InshyNetwork $833316666 $1000$2000 $4000$8000 15 15 15 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $833316666 $1000$2000 $5000$10000 40 40 40 FundDed40 40+40+40+
Aetna HealthFundshy InshyNetwork $6250$125 $1500$3000 $4000$8000 10 10 10 Nothing $10$35$60 Aetna HealthFundshy OutshyNetwork $6250$125 $2500$5000 $5000$10000 30 30 30 Ded30 30+30+30+
Benefit Type
Premium Contribution to HSAHRA
CY Ded SelfFamily
Cat Limit SelfFamily
Office Visit
Inpatient Hospital
Outpatient Surgery
Preventive Services
Prescription Drugs
Levels I II III
Florida
Coventry Health Care of Florida
Plan Name
$8334$16667 $2500$5000 $5000$10000 $10 20 20 Nothing $5$35$5020
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60
Humana CoverageFirstshy
Georgia Humana CoverageFirstshy
OutshyNetwork
InshyNetwork
NA
$8333
$3000$6000
$1000$2000
$4000$8000
$3000$6000
30
$25
30
$300day x 5
30
$150
30
Nothing
$10+$40+$60+
$10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy
Guam TakeCareshy
OutshyNetwork
InshyNetwork
NA
$8666$22208
$3000$6000
$3000$6000
$4000$8000
$5000$10000
30
20afterDed
30
20 after Ded
30
20 after Ded
30
Nothing
$10+$40+$60+
$20$40$150 TakeCareshy
Idaho
Altius Health Plans
OutshyNetwork $8666$22208
$4583$9166
$3000$6000
$1200$2400
$10000$20000
$5000$10000 $20
30 afterDed
10
30 after Ded 30 after Ded
10
1st $300ded
Nothing
30 after Ded
$7$25$50
73
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Illinois Humana CoverageFirst shyCDHPshy CentralNorthwestern Illinois
Humana CoverageFirst shyCDHPshy Chicago Area
Indiana Humana CoverageFirst shyCDHPshy LakePorterLaPorte Counties
Iowa Coventry Health Care of Iowa shyHDHPshy CentralEasternWestern Iowa
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
Kentucky Humana CoverageFirst shyCDHPshy Lexington Area
Maryland Coventry Health Care shyHDHPshy All of Maryland
Plan Name
888shy393shy6765
888shy393shy6765
888shy393shy6765
800shy257shy4692
800shy969shy3343
888shy393shy6765
888shy393shy6765
800shy833shy7423
Telephone Number
Enrollment Code Monthly Biweekly
GB1
MW1
MW1
SV4
9H1
PH1
6N1
GZ1
Self only
GB2
MW2
MW2
SV5
9H2
PH2
6N2
GZ2
Self amp family
12685
12081
12081
8608
9721
10873
10064
9834
Self only
28542
27182
27182
20544
22845
24464
22644
22508
Self amp family
5855
5576
5576
3973
4486
5018
4645
4539
Self only
13173
12546
12546
9482
10544
11291
10451
10388
Self amp family
74
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Illinois Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Indiana Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Iowa Coventry Health Care of Iowa $6667$13334 $2000$4000 $5000$10000 $20 15 15 Nothing $3$10$40$65
Kansas Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 Nothing Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Kentucky Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Maryland Coventry Health Care HDHP InshyNetwork $4167$8334 $2000$4000 $4000$8000 $15 Nothing Nothing Nothing $15$30$60 Coventry Health Care HDHP OutshyNetwork $4167$8334 $2000$4000 $4000$8000 30 30 30 30 NA
75
A
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHPshy
Kansas City Metro Area (KS and MO)
Humana CoverageFirst shyCDHPshy Kansas City Area
New York Independent Health Assoc shyHDHPshy Western New York
Ohio AultCare HMO shyHDHPshy StarkCarrollHolmesTuscarawasWayne Co
Pennsylvania
HealthAmerica PennsylvaniashyHDHPshy Greater Pittsburgh Area
HealthAmerica PennsylvaniashyHDHPshy Central Pennsylvania
UPMC Health Plan shyHDHPshy Western Pennsylvania
Texas Humana CoverageFirst shyCDHPshy Corpus Christi Area
Humana CoverageFirst shyCDHPshy San Antonio Area
Humana CoverageFirst shyCDHPshy Austin Area
Plan Name
800shy969shy3343
888shy393shy6765
800shy501shy3439
330shy363shy6360
866shy351shy5946
866shy351shy5946
888shy876shy2756
888shy393shy6765
888shy393shy6765
888shy393shy6765
Telephone Number
Enrollment Code Monthly Biweekly
9H1
PH1
QA4
3A4
Y61
YW1
8W4
TP1
TU1
TV1
Self only
9H2
PH2
QA5
3A5
Y62
YW2
8W5
TP2
TU2
TV2
Self amp family
9721
10873
9633
7760
11914
14046
11884
11840
12081
12284
Self only
22845
24464
24717
15548
27430
30756
26620
26640
27182
27639
Self amp family
4486
5018
4446
3581
5499
6483
5485
5464
5576
5669
Self only
10544
11291
11408
7176
12660
14195
12286
12295
12546
12756
Self amp family
76
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Missouri Coventry Health Care of Kansas (Kansas City)shyHDHP $6666$13333 $2500$5000 $3500$7000 20 20 20 $20$350 Nothing
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
New York Independent Health Assocshy InshyNetwork $6641$16667 $2000$4000 $5000$10000 $15 Nothing 20 $15 $7$25$40 Independent Health Assocshy OutshyNetwork $6641$16667 $2000$4000 $5000$10000 40 40 40 Ded40 NA
Ohio AultCare HMOshy InshyNetwork $7458$14958 $2000$4000 $4000$8000 20 20 20 Nothing 202020 AultCare HMOshy OutshyNetwork $7458$14958 $4000$8000 $8000$16000 40 UCR 40 UCR 40 UCR 50 UCR 404040
Pennsylvania
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing $15$25 $5$35$50
HealthAmerica PennsylvaniashyHDHP $5209$10417 $1500$3000 $4000$8000 $15 None Nothing Nothing $5$35$50
UPMC Health Planshy InshyNetwork $10417$20834 $2500$5000 $4000$8000 Nothingafter ded None Nothingafterded Nothing $5$35$70
UPMC Health Planshy OutshyNetwork $10417$20834 $2500$5000 $5500$11000 20afterded 20afterded 20afterded 20 NA
Texas Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
Humana CoverageFirstshy InshyNetwork $8333 $1000$2000 $3000$6000 $25 $300day x 5 $150 Nothing $10$40$60 Humana CoverageFirstshy OutshyNetwork NA $3000$6000 $4000$8000 30 30 30 30 $10+$40+$60+
77
High Deductible and ConsumershyDriven Health Plans See page 68shy69 for an explanation of the columns on these pages
Your Share of Premium
Utah Altius Health Plans shyHDHPshy Wasatch Front
Washington KPS Health Plans shyHDHPshy All of Washington
Wyoming
Altius Health Plans shyHDHPshy Uinta County
Plan Name
800shy377shy4161
800shy552shy7114
800shy377shy4161
Telephone Number
Enrollment Code Monthly Biweekly
9K4
L14
9K4
Self only
9K5
L15
9K5
Self amp family
8704
9545
8704
Self only
18033
20857
18033
Self amp family
4017
4405
4017
Self only
8323
9626
8323
Self amp family
78
Premium Benefit CY Ded Cat Limit Office Inpatient Outpatient Preventive Prescription Contribution Type SelfFamily SelfFamily Visit Hospital Surgery Services Drugs to HSAHRA Levels I II III Plan Name
Utah Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
Washington $10$3550
KPS Health Plansshy InshyNetwork $6250$125 $1500$3000 $5000$10000 20 None 20 Nothingup to $400 $40 max $100 KPS Health Plansshy OutshyNetwork $6250$125 $1500$3000 $5000$10000 40 None 40 Not Covered Not Covered
Wyoming
Altius Health Plans $4583$9166 $1200$2400 $5000$10000 $20 10 10 Nothing $7$25$50
79
This page intentionally left blank
80
Appendix F
FEDVIP Program Features
Waiting Periods
Dental shy limited only to orthodontic services on most plans for all other services you may use your benefits as soon as your coverage becomes effective There are very few preshyexisting condition limitations
Vision shy no waiting period you may use your benefits as soon as your coverage becomes effective There are no preshyexisting condition limitations
A Choice of Coverage
Choose between Self Only Self Plus One or Self and Family
Contributions
There are no Government contributions The enrollee pays 100 of the premium
Salary Deduction
You automatically pay your premium through a payroll deduction using preshytax dollars employees cannot elect to waive this preshytax option and annuitants are not eligible for this option When premium contributions are withheld on a preshytax basis Internal Revenue Service (IRS) guidelines affect your ability to change coverage ie you may cancel or change coverage levels only during a FEDVIP Open Season You may also make changes throughout the plan year if a qualified life event occurs
Annual Enrollment Opportunity Each year you may enroll or change your dental andor vision plan enrollment Open Season runs from the Monday of the second full work week in November through the Monday of the second full work week in December Other events allow for certain types of changes throughout the year
Continued Coverage Eligibility for you or your family member may continue following your retirement or changes in employment status
Claim Dispute Resolution The claim review process will differ among plans Upon written request from the enrollee and as a final option the carrier will submit a dispute for resolution through a binding arbitration process OPM will not review nor resolve disputes regarding FEDVIP Please see your plan brochure for details
81
Appendix G FEDVIP Definitions
Eligible Dependents ndash Your spouse and unmarried dependent children under age 22 Under certain circumstances you may also continue coverage for a disabled child 22 years of age or older who is incapable of selfshysupport PLEASE NOTE The health care law does not change the age or unmarried requirement for dependents under FEDVIP
First Payer ndash Under this rule the FEHB plan is considered the primary payer and pays first while the FEDVIP plan is considered the secondary payer No more than 100 of any claim is paid by both plans
InshyNetwork Services ndash Services provided by members of the planrsquos provider network
Nationwide Plan ndash A plan which provides services throughout the United States and around the world
OutshyofshyNetwork Services ndash Services provided by health care professionals who are not a member of the planrsquos provider network
Plan ndash The insurance company which participates in the FEDVIP program Also called carrier
Precertification ndash Also called predetermination This is the procedure used by dental offices to determine what services a plan will cover and how much will be paid before the service is rendered
Provider ndash A licensed health care professional for example dentists oral surgeons optometrists and ophthalmologists
Provider Network ndash A group of health care providers who have a contract with a specific plan to provide services at an agreed upon cost
Qualifying Life Event (QLE) ndash An event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season There is no QLE under FEDVIP which allows for cancellation except upon deployment to active military duty or transitions to certain agencies
Regional Plan ndash A plan which provides services only in specified geographic regions
Usual Customary and Reasonable ndash A widely used method which may vary from company to company for determining benefit reimbursement levels The initials simply mean
Usual The fee that an individual dentist most frequently charges for a given dental service
Customary A fee determined by the insurance company based on the range of usual fees charged by dentists in the same geographic area
Reasonable A fee which is justifiable considering special circumstances of the particular care rendered
Waiting Period ndash The length of time a person must be covered under the plan before they are eligible for certain benefits For example most plans have a 24 month waiting period for orthodontic benefits This means that you must be covered continuously by the same plan and option for 24 months before your child is eligible for orthodontic coverage
82
Appendix H FEDVIP Qualifying Life Events for Enrollment Changes
A qualifying life event (QLE) is an event that allows you to enroll or if you are already enrolled allows you to change your enrollment outside of an Open Season
The following chart lists the QLEs and the enrollment actions you may take
Qualifying Life Event
From Not Enrolled to Enrolled
Increase Enrollment
Type
Decrease Enrollment
Type
Cancel Change from One Plan to Another
Acquiring an eligible family
member No Yes No No No
Losing a covered family member No No Yes No No
Losing other dentalvision
coverage (eligible or covered person)
Yes Yes No No No
Moving out of regional planrsquos service area
No No No No Yes
Going on active military duty nonshypay status (enrollee
or spouse)
No No No Yes No
Returning to pay status from active military duty
(enrollee or spouse)
Yes No No No No
Annuity compensation
restored Yes Yes Yes No No
Transferring to an eligible position
No No No Yes No
The time frame for requesting a QLE change is from 31 days before to 60 days after the event There are two exceptions
bull There is no time limit for a change based on moving from a regional plans service area and
bull You cannot request a new enrollment based on a QLE before the QLE occurs except for enrollment due to a loss of dental or vision insurance You must make the change no later than 60 days after the event
Generally enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change BENEFEDS will send you confirmation of your new coverage effective date BENEFEDS is a secure enrollment website sponsored by OPM
Cancelling an enrollment
You can cancel your enrollment only during the annual Open Season upon deployment to active military duty or transfers to certain agencies An eligible family members coverage also ends upon the effective date of the cancellation
83
Appendix I
FEDVIP Plan Comparison Charts
This is a brief summary of the features of the dental and vision plans Before making a final decision please read the plan brochures and provider directories thoroughly All plans are not the same All benefits are subject to the definitions limitations copayments annual maximums and exclusions set forth in the individual plan brochures Go to our website at wwwopmgovinsuredentalrates to find the rating region assigned to the area where you live and the related premium cost you will pay for dental coverage Go to wwwopmgovinsurevisionrates to see the premium cost for vision coverage
Reading the Chart
The table on the following pages highlights the selected featuresclasses of dental andor vision services Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Dental Insurance
The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay Service Class refers to the level of benefits for each plan The Service Classes are listed below Calendar year maximum refers to the annual amount of benefits that you can receive per person
Please Note Most plans require that you are continuously enrolled in the same dental plan andor option for the full waiting period before accessing orthodontia services There are no other waiting periods for services
Dental plans provide a comprehensive range of services including but not limited to the following
bull Class A (Basic) services which include oral examinations prophylaxis diagnostic evaluations sealants and xshyrays
bull Class B (Intermediate) services which include restorative procedures such as fillings prefabricated stainless steel crowns periodontal scaling tooth extractions and denture adjustments
bull Class C (Major) services which include endodontic services such as root canals periodontal services such as gingivectomy major restorative services such as crowns oral surgery bridges and prosthodontic services such as complete dentures
bull Class D (Orthodontic) services with up to a 24shymonth waiting period for children up to age 19
Please review the dental plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
Vision Insurance
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) Other benefits such as discounts on lasik surgery may also be available
Please review the vision plansrsquo benefits material for detailed information on the benefits covered costshysharing requirements and provider directories
84
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Dental Plans Open to All
Plan Name
Telephone amp
Website
You pay Calendar Year Maximum
Class A
Class B
Class C
Class D
Deductible
Aetna High (InshyNetwork Benefits)
1shy877shy459shy6604 wwwaetnafedscom
0 40 60 70 $0 $3000 per year per person shy inshynetwork $2000 per year per person shy outshyofshynetwork $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
Aetna High (OutshyofshyNetwork Benefits)
0 40 60 70 $0
GEHA Standard (InshyNetwork Benefits)
1shy877shy434shy2336 wwwgehadentalcom
0 45 65 50 $0 $5000 per year per person (high option) or $1200 per year per person (standard option) per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
GEHA Standard (OutshyofshyNetwork Benefits)
0 45 65 50 $0
GEHA High (InshyNetwork Benefits)
0 20 50 50 $0
GEHA High (OutshyofshyNetwork Benefits)
0 20 50 50 $0
MetLife Standard (InshyNetwork Benefits)
1shy888shy865shy6854 wwwfederaldentalmetlifecom
0 45 65 50 $0 $1200 standard option inshynetwork annual nonshyorthodontic maximum per person $1500 standard option inshynetwork lifetime max per person for orthodontics $600 standard option outshynetwork annual nonshyorthodontic maximum
MetLife Standard (OutshyofshyNetwork Benefits)
40 60 80 50 $100person per person $1000 standard option outshyofshynetwork lifetime max per person for orthodontics $10000 high option inshynetwork annual nonshyorthodontic maximum
MetLife High (InshyNetwork Benefits)
0 30 50 50 $0 per person $3500 high option inshynetwork lifetime max per person for orthodontics $10000 high option outshyofshynetwork annual nonshyorthodontic maximum per person
MetLife High (OutshyofshyNetwork Benefits)
10 40 60 50 $50person $3500 high option outshyofshynetwork lifetime max per person for orthodontics There is no calendar year deductible for Class D services 24shymonth waiting period for orthodontia services
United Concordia High (InshyNetwork Benefits)
1shy877shy438shy8224 (Open Season) 1shy877shy394shy8224 (General)
wwwuccifedvipcom
0 20 50 50 $0 $3500 per year per person $1500 lifetime max per person (orthodontic services only) 24shymonth waiting period for orthodontia services
United Concordia High (OutshyofshyNetwork Benefits)
20 (0 for Dental Accident Services)
40 60 50 $0
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
85
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Regional Dental Plans Only Open to Persons Living in Specific Geographic Areas
You pay Calendar Year Maximum
Plan Name
Telephone amp
Website
Class A
Class B
Class C
Class D Deductible
Humana High 1shy877shy692shy2468 0 Flat Flat Flat $0 $10000 per year per person (Open to residents of wwwfedshumanacom Rate Rate Rate Unlimited lifetime orthodontic coverage the Southeastern Outshyofshynetwork benefits NOT provided Midwestern and Approx Approx Approx No waiting period for orthodontic services MidshyAtlantic states) 25 35 50
GHI High 212shy501shy4444 0 0 0 0 $0 $2500 per year per person (Inshynetwork benefits) wwwghicom $2000 lifetime max per person
(orthodontic services only) (Open to NY and Northern Outshyofshynetwork benefits available ndash NJ residents and parts of paid at the same inshynetwork rate CT and PA) 12shymonth waiting period for
orthodontia services GHI High 0 0 0 0 $50 self$150 self amp (Outshyofshynetwork benefits) familyself plus one
Class B and Class C
TripleshyS Salud High (Open to Puerto Rico
787shy774shy6060 787shy749shy4777
0 30 60 30
50 $0 No maximum $1500 lifetime max per person
residents) 1shy800shy981shy3241 TTY 787shy792shy1370 TTY 1shy866shy215shy1999
(orthodontic services only) Outshyofshynetwork benefits NOT provided 24shymonth waiting period for
wwwsssprcom orthodontia services
Please Note OutshyofshyNetwork Benefits ndash members are responsible for paying the difference between the planrsquos payment and the nonshynetwork providerrsquos billed charges
86
Appendix I Federal Employees Dental and Vision Insurance Program (FEDVIP)
Nationwide and International Vision Plans Open to All The table below highlights the selected features of available vision plans Always consult plan brochures before making a decision The chart does not show all of your possible outshyofshypocket costs
Vision plans provide comprehensive eye examinations and coverage for lenses frames and contact lenses (in lieu of eye glasses) There are no deductibles or waiting periods Other benefits such as discounts on lasik surgery may also be available
Plan Name Frames Lenses Exams Coshy
payments Covered Lens
Options Additional Features
FEP BlueVision Standard
FEP BlueVision High
UnitedHealthcare Vision Plan Standard
UnitedHealthcare Vision Plan High
VSP (Vision Service Plan) Standard
VSP (Vision Service Plan) High
Every 24 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
Every 12 months
$0
$0
$10 exam $25 material
$10 exam $10 material
$10 exam $20 material
$10 (including exam and glasses)
Single Lined Bifocal Lined Trifocal Lenticular UV Coating Scratchshyresistant coating
Single Lined Bifocal Lined Trifocal Lenticular Standard Progressives UV Coating Scratchshyresistant coating Transitionsreg
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Tinted Lenses UV Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating
Single Lined Bifocal Lined Trifocal Lenticular Polycarbonate Scratchshyresistant Coating Antishyreflective Coating Lenses that transition to light UV Coating Select tints
Breakage warranty Laser vision correction discount low vision coverage $130 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits NOT provided Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Breakage warranty Laser vision correction discount low vision coverage $150 plus 20 of remaining cost frame allowance Additional lens options covered with a coshypay Outshyofshynetwork benefits available at a lower rate Flat rate reimbursement in limited access areas and internationally FSAFEDS paperless reimbursement available
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Low vision prosthetic eye vision therapy Laser vision correction discount $130 frame allowance Additional lens option discounts Outshyofshynetwork benefits availablendash paid at a lower rate Flat rate reimbursement for international outshyofshynetwork and limited access services
Laser vision correction discount $120 frame allowance Additional lenses options covered at a discount Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
Laser vision correction discount $150 frame allowance Outshyofshynetwork benefits available ndash paid at a lower rate Additional lens option and contact lens exam discounts Additional prescription glasses and sunglasses discounts FSAFEDS paperless reimbursement available
87
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
AK entire state 5 5 5 5 5 5 NA NA NA
AL 356shy358 1 1 1 1 1 1 1 NA NA AL rest of state 2 1 1 1 1 1 1 NA NA
AR entire state 2 1 1 1 1 1 5 NA NA
AZ entire state 3 3 3 1 1 1 2 NA NA
CA 900shy918 922shy935 3 4 4 5 5 3 4 NA NA CA 919shy921 3 4 4 4 4 4 4 NA NA CA 939shy941 943shy954 4 5 5 5 5 5 4 NA NA CA 942 956shy958 4 4 4 4 4 4 4 NA NA CA rest of state 4 4 4 5 5 4 4 NA NA
CO entire state 3 4 4 4 4 3 4 NA NA
CT 060shy063 5 4 4 5 5 5 NA NA NA CT 064shy069 3 5 5 5 5 5 NA 1 NA
DC entire state 2 4 4 4 4 4 2 NA NA
DE entire state 2 3 3 3 3 2 NA NA NA
FL 327shy328 337 2 2 2 1 1 1 2 NA NA FL 330shy334 2 4 4 3 3 3 2 NA NA FL rest of state 3 2 2 1 1 1 2 NA NA
GA 300shy303 311 3 3 3 2 2 1 3 NA NA GA rest of state 4 2 2 1 1 1 5 NA NA
GU entire state 5 1 1 5 5 5 NA NA NA
HI entire state 4 3 3 4 4 5 NA NA NA
IA entire state 3 1 1 1 1 2 NA NA NA
ID entire state 4 2 2 1 1 2 NA NA NA
IL 600shy608 2 3 3 4 4 3 1 NA NA IL 620shy622 2 2 2 1 1 1 1 NA NA IL rest of state 3 1 1 1 1 1 1 NA NA
IN 460shy462 2 2 2 1 1 1 1 NA NA IN 463shy464 2 3 3 4 4 3 1 NA NA IN rest of state 3 1 1 1 1 2 1 NA NA
KS 660shy662 1 2 2 1 1 2 1 NA NA KS rest of state 3 1 1 1 1 2 1 NA NA
KY 410 2 2 2 1 1 1 1 NA NA KY rest of state 1 1 1 1 1 1 1 NA NA
88
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas
State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS Salud
LA entire state 2 2 2 1 1 1 5 NA NA
MA entire state 5 4 4 5 5 5 NA NA NA
MD 206shy218 2 4 4 4 4 4 2 NA NA MD 219 2 3 3 3 3 2 NA NA NA MD rest of state 2 2 2 2 2 4 NA NA NA
ME entire state 5 3 3 2 2 3 NA NA NA
MI 480shy485 3 3 3 3 3 2 NA NA NA MI rest of state 3 2 2 2 2 3 NA NA NA
MN 550shy555 2 3 3 4 4 3 NA NA NA MN rest of state 3 2 2 2 2 2 NA NA NA
MO 630shy633 2 2 2 1 1 1 1 NA NA MO 640shy641 1 2 2 1 1 2 1 NA NA MO rest of state 3 1 1 1 1 1 1 NA NA
MS entire state 2 1 1 1 1 1 5 NA NA
MT entire state 4 2 2 1 1 1 NA NA NA
NC entire state 4 2 2 1 1 1 5 NA NA
ND entire state 3 1 1 1 1 2 NA NA NA
NE entire state 1 1 1 1 1 2 NA NA NA
NH entire state 5 4 4 5 5 5 NA NA NA
NJ 080shy084 2 3 3 3 3 2 NA NA NA NJ rest of state 3 5 5 5 5 5 NA 1 NA
NM entire state 3 3 3 1 1 1 NA NA NA
NV 897 4 4 4 4 4 4 NA NA NA NV rest of state 2 3 3 2 2 2 NA NA NA
NY 004 005 3 5 5 5 5 5 NA 1 NA NY 100shy119 124shy126 3 5 5 5 5 5 NA 1 NA NY rest of state 4 2 2 2 2 3 NA 1 NA
OH 430shy432 2 2 2 1 1 2 3 NA NA OH 440shy443 2 2 2 1 1 3 1 NA NA OH 450shy452 2 2 2 1 1 1 1 NA NA
OH 453shy455 2 2 2 1 1 2 1 NA NA
OH rest of state 3 1 1 1 1 1 1 NA NA
OK entire state 2 2 2 1 1 1 3 NA NA
OR 970shy973 4 3 3 4 4 5 NA NA NA OR rest of state 5 3 3 3 3 4 NA NA NA
89
Appendix J Federal Employees Dental and Vision Insurance Program (FEDVIP)
Dental Rating Regional Chart
Rating Areas State StateZIP (first 3) Aetna GEHA Std GEHA High MetLife Std MetLife High United Concordia Humana GHI TripleshyS
Salud
PA 150shy154 156 160 1 1 1 1 1 1 NA NA NA PA 183 3 5 5 5 5 5 NA 1 NA PA 189shy194 2 3 3 3 3 2 NA NA NA PA rest of state 3 1 1 1 1 1 NA NA NA
PR entire state 3 1 1 1 1 1 NA NA 1
RI entire state 5 4 4 5 5 5 NA NA NA
SC entire state 4 2 2 1 1 1 5 NA NA
SD entire state 3 1 1 1 1 2 NA NA NA
TN entire state 1 2 2 1 1 1 1 NA NA
TX 750shy753 760shy762 2 3 3 1 1 1 3 NA NA TX 770shy775 2 3 3 1 1 1 3 NA NA TX rest of state 2 2 2 1 1 1 3 NA NA
UT entire state 2 1 1 1 1 2 1 NA NA
VA 201 220shy226 2 4 4 4 4 4 2 NA NA VA 230shy232 238 3 2 2 1 1 2 5 NA NA VA rest of state 3 2 2 1 1 1 4 NA NA
VI entire state overseas 1 1 5 5 5 NA NA NA
VT entire state 5 2 2 2 2 3 NA NA NA
WA 980shy985 5 5 5 5 5 5 NA NA NA WA 986 4 3 3 4 4 5 NA NA NA WA rest of state 5 4 4 4 4 4 NA NA NA
WI 530shy534 3 2 2 2 2 3 NA NA NA WI 540 2 3 3 4 4 3 NA NA NA WI rest of state 3 2 2 2 2 2 NA NA NA
WV entire state 4 2 2 1 1 1 3 NA NA WY entire state 4 1 1 1 1 2 NA NA NA
90
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Nationwide Dental Rates Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Biweekly Premium Monthly Premium
Plan Name Option Rating Region Self Only Self
Plus One Self amp Family Self Only Self
Plus One Self amp Family
Aetna PPO High 1 $1256 $2511 $3767 $2721 $5441 $8162 (In and OutshyofshyNetwork benefits) 2 $1382 $2764 $4146 $2994 $5989 $8983
3 $1471 $2941 $4411 $3187 $6372 $9557 4 $1622 $3243 $4865 $3514 $7027 $10541 5 $1760 $3521 $5281 $3813 $7629 $11442
GEHA PPO Standard 1 $908 $1816 $2726 $1967 $3935 $5906 (In and OutshyofshyNetwork benefits) 2 $997 $1994 $2991 $2160 $4320 $6481
3 $1132 $2262 $3393 $2453 $4901 $7352 4 $1221 $2441 $3662 $2646 $5289 $7934 5 $1355 $2710 $4064 $2936 $5872 $8805
GEHA PPO High 1 $1489 $2977 $4469 $3226 $6450 $9683 (In and OutshyofshyNetwork benefits) 2 $1637 $3274 $4914 $3547 $7094 $10647
3 $1857 $3715 $5573 $4024 $8049 $12075 4 $2005 $4010 $6017 $4344 $8688 $13037 5 $2225 $4453 $6681 $4821 $9648 $14476
MetLife PPO Standard 1 $853 $1708 $2563 $1848 $3701 $5553 (In and OutshyofshyNetwork benefits) 2 $923 $1845 $2770 $2000 $3998 $6002
3 $1022 $2042 $3064 $2214 $4424 $6639 4 $1135 $2270 $3404 $2459 $4918 $7375 5 $1246 $2492 $3739 $2700 $5399 $8101
MetLife PPO High 1 $1567 $3133 $4696 $3395 $6788 $10175 (In and OutshyofshyNetwork benefits) 2 $1752 $3507 $5259 $3796 $7599 $11395
3 $1910 $3815 $5725 $4138 $8266 $12404 4 $2066 $4129 $6194 $4476 $8946 $13420 5 $2313 $4625 $6937 $5012 $10021 $15030
United Concordia PPO High 1 $1418 $2833 $4251 $3072 $6138 $9211 (In and OutshyofshyNetwork benefits) 2 $1627 $3250 $4877 $3525 $7042 $10567
3 $1767 $3529 $5295 $3829 $7646 $11473 4 $1906 $3806 $5713 $4130 $8246 $12378 5 $2054 $4107 $6160 $4450 $8899 $13347
9911
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts Regional Dental Rates
Please note Rating areas for each carrier are not the same for all plans Please refer to Appendix K to determine your specific region
Plan Name Option Rating Region
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Humana High 1 $965 $1928 $2893 $2091 $4177 $6268 (InshyNetwork Benefits only 2 $1038 $2075 $3113 $2249 $4496 $6745
except for emergency services) 3 $1045 $2089 $3134 $2264 $4526 $6790 4 $1426 $2852 $4278 $3090 $6179 $9269 5 $1433 $2865 $4298 $3105 $6208 $9312
GHI PPO High (Inshyand OutshyofshyNetwork Benefits)
1 $1618 $3234 $4852 $3506 $7007 $10513
TripleshyS Salud PPO High (InshyNetwork Benefits only
except for services rendered by orthodontists)
1 $435 $869 $1141 $943 $1883 $2472
International Dental Rates Please note International premium rates are not regionally based
Plan Name
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
Aetna
GEHA Standard
GEHA High
MetLife Standard
MetLife High
United Concordia
$1882
$908
$1489
$1246
$2313
$2054
$3762
$1816
$2977
$2492
$4625
$4107
$5644
$2726
$4469
$3739
$6937
$6160
$4078
$1967
$3226
$2700
$5012
$4450
$8151
$3935
$6450
$5399
$10021
$8899
$12229
$5906
$9683
$8101
$15030
$13347
92
Appendix K Federal Employees Dental and Vision Insurance Program (FEDVIP)
Premium Rate Charts
Nationwide Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
International Vision Rates
Plan Name Telephone amp Website
Plan Option
Biweekly Premium Monthly Premium
Self Only Self Plus One
Self amp Family Self Only Self Plus One
Self amp Family
FEP BlueVision
UnitedHealthcare Vision Plan
VSP (Vision Service Plan)
1shy888shy550shy2583 wwwfepblueorg
1shy866shy249shy1999 TTY 800shy524shy3157
wwwmyuhcvisioncomfedvip
1shy800shy807shy0764 wwwchoosevspcom
Standard High
Standard High
Standard High
$377 $475
$300 $423
$413 $617
$752 $949
$585 $824
$825 $1233
$1129 $1425
$871 $1228
$1238 $1850
$817 $1029
$650 $916
$895 $1337
$1629 $2056
$1269 $1786
$1788 $2672
$2446 $3088
$1887 $2660
$2682 $4008
93
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
bull If you are eligible for health coverage from your employer but are unable to afford the premiums some States have premium assistance programs that can help pay for coverage These States use funds from their Medicaid or CHIP programs to help people who are eligible for employershysponsored health coverage but need assistance in paying their health premiums
bull If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below you can contact your State Medicaid or CHIP office to find out if premium assistance is available
bull If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs you can contact your State Medicaid or CHIP office or dial 1shy877shyKIDS NOW or wwwinsurekidsnowgov to find out how to apply If you qualify you can ask the State if it has a program that might help you pay the premiums for an employershysponsored plan
bull Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP your employerrsquos health plan is required to permit you and your dependents to enroll in the plan ndash as long as you and your dependents are eligible but not already enrolled in the employerrsquos plan This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance
If you live in one of the following States you may be eligible for assistance paying your employer health plan premiums The following list of States is current as of January 31 2011 You should contact your State for further information on eligibility ndash
ALABAMA ndash Medicaid IOWA ndash Medicaid Website httpwwwmedicaidalabamagov Website wwwdhsstateiaushipp Phone 1shy800shy362shy1504 Phone 1shy888shy346shy9562
ALASKA ndash Medicaid KANSAS ndash Medicaid Website httphealthhssstateakusdpaprogramsmedicaid Website httpswwwkhpaksgov Phone (Outside of Anchorage) 1shy888shy318shy8890 Phone 1shy800shy792shy4884 Phone (Anchorage) 907shy269shy6529
ARIZONA ndash CHIP KENTUCKY ndash Medicaid Website httpwwwazahcccsgovapplicantsdefaultaspx Website httpchfskygovdmsdefaulthtm Phone (Outside of Maricopa County) 1shy877shy764shy5437 Phone 1shy800shy635shy2570 Phone (Maricopa County) 602shy417shy5437
ARKANSAS ndash CHIP LOUISIANA ndash Medicaid Website httpwwwarkidsfirstcom Website httpwwwlahippdhhlouisianagov Phone 1shy888shy474shy8275 Phone 1shy888shy342shy6207
CALIFORNIA ndash Medicaid MAINE ndash Medicaid Website httpwwwdhcscagovservicesPagesTPLRD_CAU_contaspx Website httpwwwmainegovdhhsOIASpublicshyassistanceindexhtml Phone 1shy866shy298shy8443 Phone 1shy800shy321shy5557
COLORADO ndash Medicaid and CHIP MASSACHUSETTS ndash Medicaid and CHIP Medicaid Website httpwwwcoloradogov Medicaid amp CHIP Website httpwwwmassgovMassHealth Medicaid Phone 1shy800shy866shy3513 Medicaid amp CHIP Phone 1shy800shy462shy1120 CHIP Website http wwwCHPplusorg CHIP Phone 303shy866shy3243
FLORIDA ndash Medicaid MINNESOTA ndash Medicaid Website httpwwwfdhcstateflusMedicaidindexshtml Website httpwwwdhsstatemnus (Health Care then Medical Assistance) Phone 1shy877shy357shy3268 Phone (Outside of Twin Cities area) 800shy657shy3739
Phone (Twin Cities area) 651shy431shy2670
GEORGIA ndash Medicaid MISSOURI ndash Medicaid Website httpdchgeorgiagov (Programs then Medicaid) Website httpwwwdssmogovmhdindexhtm Phone 1shy800shy869shy1150 Phone 573shy751shy6944
IDAHO ndash Medicaid and CHIP MONTANA ndash Medicaid Medicaid Website wwwaccesstohealthinsuranceidahogov Website httpmedicaidproviderhhsmtgovclientpagesclientindexshtml Medicaid Phone 1shy800shy926shy2588 Telephone 1shy800shy694shy3084 CHIP Website wwwmedicaididahogov CHIP Phone 1shy800shy926shy2588
INDIANA ndash Medicaid NEBRASKA ndash Medicaid Website httpwwwingovfssa Website httpwwwdhhsnegovmedmedindexhtm Phone 1shy800shy889shy9948 Phone 1shy877shy255shy3092
94
Medicaid and the Childrenrsquos Health Insurance Program (CHIP) Offer Free or LowshyCost Health Coverage to Children and Families
NEVADA ndash Medicaid and CHIP Medicaid Website httpdwssnvgov Medicaid Phone 1shy800shy992shy0900 CHIP Website httpwwwnevadacheckupnvorg CHIP Phone 1shy877shy543shy7669
SOUTH CAROLINA ndash Medicaid Website httpwwwscdhhsgov Phone 1shy888shy549shy0820
NEW HAMPSHIRE ndash Medicaid Website httpwwwdhhsnhgovombpindexhtm Phone 603shy271shy4238
TEXAS ndash Medicaid Website httpswwwgethipptexascom Phone 1shy800shy440shy0493
NEW JERSEY ndash Medicaid and CHIP Medicaid Website httpwwwstatenjushumanservicesdmahsclientsmedicaid Medicaid Phone 1shy800shy356shy1561 CHIP Website httpwwwnjfamilycareorgindexhtml CHIP Phone 1shy800shy701shy0710
UTAH ndash Medicaid Website httphealthutahgovupp Phone 1shy866shy435shy7414
NEW MEXICO ndash Medicaid and CHIP Medicaid Website httpwwwhsdstatenmusmadindexhtml Medicaid Phone 1shy888shy997shy2583 CHIP Website httpwwwhsdstatenmusmadindexhtml (Insure New Mexico) CHIP Phone 1shy888shy997shy2583
VERMONTndash Medicaid Website httpwwwgreenmountaincareorg Telephone 1shy800shy250shy8427
NEW YORK ndash Medicaid Website httpwwwnyhealthgovhealth_caremedicaid Phone 1shy800shy541shy2831
NORTH CAROLINA ndash Medicaid Website httpwwwncgov Phone 919shy855shy4100
VIRGINIA ndash Medicaid and CHIP Medicaid Website httpwwwdmasvirginiagovrcpshyHIPPhtm Medicaid Phone 1shy800shy432shy5924 CHIP Website httpwwwfamisorg CHIP Phone 1shy866shy873shy2647
NORTH DAKOTA ndash Medicaid Website httpwwwndgovdhsservicesmedicalservmedicaid Phone 1shy800shy755shy2604
WASHINGTON ndash Medicaid Website httphrsadshswagovpremiumpymtApplyshtm Phone 1shy800shy562shy3022 ext 15473
OKLAHOMA ndash Medicaid Website httpwwwinsureoklahomaorg Phone 1shy888shy365shy3742
WEST VIRGINIA ndash Medicaid Website httpwwwwvrecoverycomhipphtm Phone 304shy342shy1604
OREGON ndash Medicaid and CHIP Medicaid amp CHIP Website httpwwworegonhealthykidsgov Medicaid amp CHIP Phone 1shy877shy314shy5678
WISCONSIN ndash Medicaid Website httpwwwbadgercareplusorgpubspshy10095htm Phone 1shy800shy362shy3002
PENNSYLVANIA ndash Medicaid Website httpwwwdpwstatepauspartnersprovidersmedicalassistancedoingbusiness003670053htm Phone 1shy800shy644shy7730
RHODE ISLAND ndash Medicaid WYOMING ndash Medicaid Website wwwdhsrigov Website httpwwwhealthwyogovhealthcarefinindexhtml Phone 401shy462shy5300 Telephone 307shy777shy7531
To see if any more States have added a premium assistance program since January 31 2011 or for more information on special enrollment rights you can contact either
US Department of Labor US Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare amp Medicaid Services wwwdolgovebsa wwwcmshhsgov 1shy866shy444shyEBSA (3272) 1shy877shy267shy2323 Ext 61565
OMB Control Number 1210shy0137 (expires 09302013)
95
Summary Information
New Hires Can Enroll
Federal Benefits Open Season
How to Enroll OPMrsquos Program Website
FEHB Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Varies by agency automated enrollment or via SF 2809
wwwopmgovinsurehealth
FEDVIP Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwBENEFEDScom or call 1shy877shy888shy3337
wwwopmgovinsuredental wwwopmgovinsurevision
FSAFEDS Within 60 days from new hire date
Annual ndash November 14 to December 12 2011
Go to wwwFSAFEDScom or call 1shy877shy372shy3337
wwwopmgovinsureflexible
FEGLI Within 60 days from new hire date for optional insurance automatically enrolled in Basic insurance until you take action to cancel
No annual Open Season
Varies by agency automated enrollment or via SF 2817 for new hires
Others provide medical information on SF 2822
wwwopmgovinsurelife
FLTCIP Apply (not necessarily enroll) within 60 days from new hire date with abbreviated underwriting
No annual Open Season
Go to wwwLTCFEDScom or call 1shy800shy582shy3337 wwwopmgovinsureltc
96