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By: FEDweek StaffWhen shopping for health insurance coverage during the annual benefits open season—November 14-December 12 this year—remember that although plan terms vary, sometimes widely, all plans have certain basic terms for hospital, surgical, physician, and emergency care.
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.
However, 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 may be 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.
Once you’re familiar with the basic terms in these areas of plans you’re considering, you can concentrate on more specialized terms that may be of particular interest to you.
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