FEHB Plan Quality

For traditional fee-for-service insurance plans, service quality was up until recently not a major issue. The main service concerns were how easily you could get help from plan representatives regarding coverage questions and how fairly and promptly claims were paid.

However, even fee-for-service plans now have some involvement in the quality of your health care. All of these plans require you to get authorization before hospitalization or surgery. And almost all have assembled networks of preferred providers and have prescription drug formularies. Because you save money by using providers from these networks and preferred drugs in these formularies, the availability and quality of preferred providers and the lists of preferred drugs are important.

Meanwhile, many prepaid (HMO) plans are available and now substantial numbers of Federal employees have selected these plans. Your choice of HMO can have a big effect on the quality of medical care and service you receive. Not only does an HMO offer you a selected list of providers to choose among; your HMO may be set up so that your primary care doctor is a "gatekeeper" who decides whether to authorize you to get specialist, hospital, and other types of services. In addition, an HMO may be able to manage care so that members get better service than they would get in a less structured system. For example, some HMOs have succeeded in reducing asthma problems by having doctors, nurses, pharmacists, and other HMO staff work together to train patients and families in self-medication and other self-care techniques.