OPM sets certain minimum coverage requirements in the FEHB program that insurance carriers must make available equally to active and retired employees, in contrast to the practice of many private sector companies that provide less generous benefits—or none—to their retirees.
Although there is no core or standard benefit package required for FEHB, the statute requires that all plans cover basic hospital, surgical, physician, and emergency care. OPM requires certain minimum standards for health benefit plans including prescription drugs (which may have separate deductibles and coinsurance); mental health care with parity of coverage for mental health and general medical care coverage; preventive care; and limits on an enrollee’s total out-of-pocket costs for a year, called the catastrophic limit.
Generally, once an enrollee’s covered out-of-pocket expenditures reach the catastrophic limit, the plan pays 100 percent of covered medical expenses for the remainder of the year. Plans must also include certain cost-containment provisions, such as offering preferred provider organization (PPO) networks in fee-for-service plans and hospital pre-admission certification.