FEHB Plan Flexibility
Our comparisons of flexibility capture as best as we can the features of each plan that affect your ability to select the providers of your preference. We would like to display the number of affiliated providers in each local area, but such data are not available for many plans. Of course, staff model HMOs would always show a relatively low number, because they ordinarily limit you to primary care providers on their staff.
In our comparisons, we show first which HMOs allow you to get regular plan benefits from providers located outside the plan's main service area. For example, the Kaiser plans allow you to use Kaiser facilities and providers anywhere they are located. Of course, national plans all cover the entire nation. All plans cover emergencies throughout the world (not shown). Second, we show how plans deal with providers who are not preferred. National plans and some HMOs let you use non-preferred providers with a significantly higher cost sharing. Third, we show which plans provide retirees with Medicare Parts A and B wrap around benefits to make all hospital and doctor care cost-free, in or out of network.
We show which plans allow women to visit a gynecologist without having to be referred by a primary care provider. Almost all HMOs now allow self-referral, at least for an annual exam (those which allow only an examination without referral are marked "Exam"). Unfortunately, some HMOs do not allow self-referral to other specialists, though the number that do so is growing.
Our entry for "open formulary" indicates whether the plan will pay for any name brand drug that your physician prescribes, or just for those that are on the plan's list of approved drugs (commonly called a "formulary"). Most plans will pay for any drug but require higher copays for non-formulary drugs. We indicate these with a "Pay More" entry.
Finally, we indicate whether each company sponsors a Medicare Advantage (MA) plan, so that Medicare participants can elect to stay with their health plan while paying only one premium. However, even though we enter "Yes" you have to check further to see if the Medicare Advantage plan covers the exact area where you live. Not shown, all Medicare Parts A and B enrollees have access to at least some MA plans, and most have access to dozens.