Frequently Asked FEHB Program Questions

  • What if I expect to have a baby? What plan offers the best maternity benefits? Most plans offer low or no cost maternity coverage. Check brochures for this, and check network lists online to make sure you will have a good selection of obstetricians. Or select an obstetrician and then use her experience to steer you towards a few plans from which to choose.
  • What if I am going to have a major operation? Pay attention to catastrophic limits. If you know for sure that you are going to face bills of $25,000 or more, then pick a plan with a tight limit on your costs. In comparing catastrophic expense limits, use Guide figures. Our estimates include the "for sure" premium expense and adjust for inconsistencies among stated catastrophic limits, such as failing to include deductibles in the stated limit. If you are not sure what plans will work best in your case, check brochures and consult your surgeon to discuss which plans work best. Be sure your surgeon is in your plan network or will give you a network rate.
  • My two doctors aren't preferred providers for any plan. What should I do? Set up an FSA account for about half the amount you expect to spend on those doctors. Then pick one of the top ranked plans that includes a fee-for-service benefit, use that benefit for whatever it will pay (which will probably be about half), and use the FSA to cover the rest. Or change doctors.
  • I need over 30 psychiatric visits. What plan is best? The mental health parity requirement—which theoretically allows unlimited visits at a low cost—might arguably make all plans meet your needs. But plans require using preferred providers to get network rates. First, talk to your provider and see if he or she is "preferred" under any plan. If so, this plan is likely to be your best choice. Alternatively, most plans will pay sixty or seventy percent of the "plan allowance" for out of network visits. Since that is well below what most providers charge, you will likely pay half or more of the cost of each visit. Try making an arithmetic calculation. Estimate the number of visits you are likely to make and how much each of several plans will pay for these visits. Then add the annual premium cost to the amount that you will pay the doctor under each of those plans. If one of them stands out, you have an answer. If they are all about the same, choose on some other basis (like our overall ratings). Finally, you are a perfect candidate for a Flexible Spending Account, and your FSA tax savings will reduce your cost by about a third.
  • I really like the service from plan X. But it is rated halfway down your cost table. Would I be a sucker to stay with it? No. Differences of several hundred dollars in estimated costs can move a plan up or down the table a long way. Our methods of estimating average costs are only approximations. Differences of $100 or less are not significant, and a national plan even halfway down the table is a perfectly acceptable deal. Furthermore, staying with the same plan will eliminate the hassle of changing doctors and of dealing with a plan bureaucracy that may not be as customer friendly as the one you have now.
  • You rated the plan I am in highly last year, but this year it has moved way down. Why did this happen, and should I switch? Premium differences are the biggest factor in our cost rankings, and premiums can swing widely from year to year. That is probably why your plan moved so far—but check the brochure's change page for a benefit cutback that could have affected our ratings. Or other plans could have improved their benefits. One of the big change factors, for example, is the catastrophic limit promised to you by the plan: these often move up or down by thousands of dollars and are big factors in our ratings. You can stick with your plan if it has not become unreasonably costly and has given you good service. But consider the possible savings from the plans we rank higher.
  • I don't have much money and can't afford an expensive premium. Is it safe to join one of the plans with a low premium? All plans are reputable, and all will pay the benefits they promise. Every plan, not just the ones with the lowest premiums, has gaps or loopholes of one kind or another. But the lower-premium national plans generally expose you to higher copayments and deductibles, so they may not save you as much money as you think. Look at our Guide and several brochures carefully, and then decide. A lower premium does not mean a worse plan, or a higher premium a better plan. Our estimates of average costs are a far better guide to likely costs than premiums alone.
  • I'm not very healthy and could easily have expenses of many thousands of dollars next year. So, I don't think that your rankings based on average costs are what I should use. What should I do? A good method is to skip the average column and look at the column for high expenses of $30,000. Within that column, choose among several plans that our comparisons indicate are relatively low-cost. Another approach is to compare catastrophic limits. But keep in mind that our "average" columns include some very expensive years. Most people, in most years, will be out-of-pocket far less.
  • I can't decide whether I should get Medicare Part B and join a plan that guarantees I won't pay anything at all for medical bills, or plan to drop Medicare Part B and save about $1,300 a year in premium cost. If your doctors are mostly preferred providers, consider dropping Part B. You won't save the entire amount of the Part B premium, but you will save most of it in most years. The main argument for keeping Part B on top of FEHB coverage is that you have complete flexibility to use any doctor who accepts new Medicare patients, even if he/she is not preferred, and in the many plans with wraparound benefits you will pay nothing for hospital or doctor costs. But these savings and this flexibility costs you close to or even more than a thousand dollars a year in most plans. Check out the plans we rate as costing you almost nothing, or even saving you money, when you are covered by Part B. Whatever you do, do not drop out of the FEHB program. If you decide to keep Part B, move to a low premium plan that waives cost sharing for those with Medicare Parts A and B, such as Aetna Direct, Blue Cross Basic, MHBP High Deductible, or in the Washington DC area CareFirst High Deductible. Some plans not only provide a Medicare wraparound, but also pay part of the Part B premium.
  • My spouse has excellent family coverage from his or her employer and pays no premium. Is there any reason why I should not drop out of the Federal program? If you are within five years of retirement, do not even consider dropping out. That private plan will go away sooner or later, and you and your spouse will be stuck. You are not allowed to remain in the FEHB program after retirement without five years of continuous prior enrollment immediately preceding retirement (there are some narrow exceptions, such as layoffs).
  • I read that High Deductible plans are bad buys for older and less healthy individuals. Nonsense. These plans are among the best deals in the program. Considering their tax advantages and savings accounts, they rival or beat many other plans. If you know for sure that your routine physician and drug expenses, priced at retail, will be three or four thousand dollars next year, you will probably do better in an HMO or national plan with low copayments. But high expense, in and of itself, is not an argument against High Deductible plans. They have some of the best catastrophic limit guarantees.
  • Some expensive plans have much better-quality scores than some less expensive plans. How much weight should I put on quality? The quality scores are driven by survey results from enrollees in each plan. Our ratings also show some of the factors those enrollees most like or dislike. Only you can judge how important these are to you. It may help to consider two things: most enrollees in just about all plans rate the plans quite favorably; and ultimately it is the doctors you choose, not the plan, that drives the quality of medical care you get.
  • I have an expensive condition that I am not sure is covered by several plans that you rank high. What should I do? The first step is to get those plan brochures and compare them side-by-side. OPM's policy for standard brochure formats is one of the best things about the FEHB program. If you read and compare the specific language you may find the answer. If you do not, call at least one plan, and preferably several plans, and call again to protect yourself against mistakes that plan representatives sometimes make. If you are still not sure, consult providers who deal with your condition, or other patients with your condition, or both. Sometimes there is no way around doing your homework.
  • Skip all the details. What is the best plan? There is no one best plan. Every plan is best for at least some people. Our rankings give you a good starting point, but only a starting point. If you don't want to be bothered with details, then check out only one or two plans carefully. But whatever else you do, read the "how we change" pages of the brochure, along with the "summary of benefits" near the end of the brochure, before you stay in the plan you are in or sign up for a new plan.