An FEHB plan’s failure to provide benefits required under basic program guidelines could become the basis for challenging a claim denial.
FEHB plans cover basic hospital, surgical, physician, and emergency care. OPM may prescribe reasonable minimum standards for health benefit plans. FEHB follows the guidelines on preventive care for children recommended by the American Academy of Pediatrics. FEHB guidelines on preventive care for adults are based on accepted medical practice.
Plans are required to cover certain special benefits 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; child immunizations; 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 networks in fee-for-service plans and hospital pre-admission certification.
Deductibles, copayments, and coinsurance amounts vary across plans. Many plans offer two or more options with different premiums and levels of coverage. Even within individual plans, enrollees are offered a lower deductible and coinsurance amount if they choose to use services, such as a physician or hospital provider, in the plan’s network.
ask.FEDweek.com: FEHB – Federal Employee Health Benefits