Choosing the right health insurance plan can be a daunting task, especially when you’re faced with numerous options and complex details. For federal employees, the Office of Personnel Management (OPM) offers a range of health insurance plans under the Federal Employees Health Benefits (FEHB) Program. Understanding and comparing these plans is crucial to making an informed decision that suits your individual health needs and financial situation. This guide will help you navigate the process of OPM health insurance comparison, ensuring you select the best plan for you and your family.
The information provided here is designed to help you compare different aspects of various FEHB plans. However, it is important to remember that this comparison is not an official statement of benefits. Always refer to the individual FEHB plan brochures for the complete and official details before making your final enrollment decision. These brochures are the definitive source for understanding the benefits, costs, and specific coverage details of each plan.
Understanding Your OPM Health Insurance Options
The FEHB program provides a wide array of health insurance choices, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Fee-for-Service (FFS) plans, and High Deductible Health Plans (HDHPs). Each type of plan has its own structure, network of providers, and cost-sharing arrangements.
To effectively compare OPM health insurance plans, consider these key factors:
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Premiums: This is the regular payment you make to maintain your health insurance coverage. Premiums vary significantly between plans and enrollment types (Self, Self Plus One, and Self & Family). It’s important to note that in some instances, the premium for “Self Plus One” enrollment might be higher than “Self and Family.” Always check the official OPM website (www.opm.gov/fehbpremiums) for the most accurate and up-to-date premium information.
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Deductibles: This is the amount you pay out-of-pocket for covered healthcare services before your plan starts to pay. Some plans have no deductible, while HDHPs typically have higher deductibles but often come with Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs) to help offset these costs.
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Coinsurance and Copayments: Coinsurance is a percentage of the cost of a covered healthcare service that you pay, while a copayment is a fixed amount you pay for a specific service, like a doctor’s visit or prescription.
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Out-of-Pocket Maximum: This is the maximum amount you will have to pay in cost-sharing (deductibles, coinsurance, and copayments) for covered in-network services within a plan year. Once you reach this limit, your plan pays 100% of covered in-network services for the rest of the year.
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Network Coverage: Plans have different networks of doctors, hospitals, and other healthcare providers. In-network providers typically cost less, while out-of-network care can be more expensive, or in some cases, not covered at all.
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Prescription Drug Coverage: Each plan has a formulary, which is a list of covered prescription drugs. Costs for prescriptions vary by plan and drug tier. Pay attention to mail service pharmacy options and any restrictions on specialty pharmacies.
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Additional Benefits: Some plans offer extra benefits like dental and vision care, wellness programs, or alternative care options. Consider these benefits based on your personal needs.
Using the Plan Selection Comparison Tool
The table below provides a comparison of several FEHB plans, focusing on High Deductible Health Plans (HDHPs) as an example. HDHPs are known for their lower premiums and the option to use a Health Savings Account (HSA), which offers tax advantages for healthcare expenses.
This comparison tool highlights key aspects such as costs, network details, and quality ratings to help you make a side-by-side assessment.
| Plans | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) | Blue Cross and Blue Shield Service Benefit Plan (Basic) | GEHA Benefit Plan (HDHP) | MHBP Consumer Option (HDHP) |
|---|---|---|---|---|
| Plan Links | ||||
| General Information – State | Alabama | Alabama | Alabama | Alabama |
| General Information – Enrollment Code – Self | 224 | 111 | 341 | 481 |
| General Information – Enrollment Code – Self & Family | 225 | 112 | 342 | 482 |
| General Information – Enrollment Code – Self Plus One | 226 | 113 | 343 | 483 |
| General Information – Carrier Code | 22 | 11 | 34 | 48 |
| General Information – Telephone Number | 877-459-6604 | 1-800-411-2583 | 800-821-6136 | 800-694-9901 |
| Biweekly Premium | $135.20 | $113.16 | $76.27 | $84.20 |
| Biweekly Premium | $287.01 | $274.14 | $163.99 | $186.33 |
| Biweekly Premium | $241.49 | $303.61 | $201.52 | $195.65 |
Costs & Network Comparison
| Plans – Networks | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) – In-Network 1 | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) – Out-of-Network | Blue Cross and Blue Shield Service Benefit Plan (Basic) – In-Network 1 | Blue Cross and Blue Shield Service Benefit Plan (Basic) – In-Network 2 | Blue Cross and Blue Shield Service Benefit Plan (Basic) – Out-of-Network | GEHA Benefit Plan (HDHP) – In-Network 1 | GEHA Benefit Plan (HDHP) – Out-of-Network | MHBP Consumer Option (HDHP) – In-Network 1 | MHBP Consumer Option (HDHP) – Out-of-Network |
|---|---|---|---|---|---|---|---|---|---|
| Annual Deductible | $1,800.00 | $2,600.00 | None | None | None | $1,650.00 | $3,300.00 | $2,000.00 | $2,000.00 |
| Annual Deductible | $3,600.00 | $5,200.00 | None | None | None | $3,300.00 | $6,600.00 | $4,000.00 | $4,000.00 |
| Annual Deductible | $3,600.00 | $5,200.00 | None | None | None | $3,300.00 | $6,600.00 | $4,000.00 | $4,000.00 |
| Type of Account | HSA/HRA | HSA/HRA | None | None | None | HSA/HRA | HSA/HRA | HSA/HRA | HSA/HRA |
| Medical Account Contribution | $800.00 | $800.00 | N/A | N/A | N/A | $1,000.00 | $1,000.00 | $1,200.00 | $1,200.00 |
| Medical Account Contribution | $1,600.00 | $1,600.00 | N/A | N/A | N/A | $2,000.00 | $2,000.00 | $2,400.00 | $2,400.00 |
| Medical Account Contribution | $1,600.00 | $1,600.00 | N/A | N/A | N/A | $2,000.00 | $2,000.00 | $2,400.00 | $2,400.00 |
| Net Deductible | $1,000.00 | $1,800.00 | None | None | None | $650.00 | $2,300.00 | $800.00 | $800.00 |
| Net Deductible | $2,000.00 | $3,600.00 | None | None | None | $1,300.00 | $4,600.00 | $1,600.00 | $1,600.00 |
| Net Deductible | $2,000.00 | $3,600.00 | None | None | None | $1,300.00 | $4,600.00 | $1,600.00 | $1,600.00 |
| Annual Out-of-Pocket Maximum | $6,900.00 | $9,000.00 | $7,500.00 | None | None | $6,000.00 | $8,500.00 | $6,000.00 | $7,500.00 |
| Annual Out-of-Pocket Maximum | $13,800.00 | $18,000.00 | $15,000.00 | None | None | $12,000.00 | $17,000.00 | $12,000.00 | $15,000.00 |
| Annual Out-of-Pocket Maximum | $13,800.00 | $18,000.00 | $15,000.00 | None | None | $12,000.00 | $17,000.00 | $12,000.00 | $15,000.00 |
| Member Cost with Medicare A & B Primary – Deductible Waiver with Parts A & B | $1800 | $2600 | N/A | N/A | N/A | $1650 $3300 | $3300 $6600 | Deductible Waived | Deductible Waived |
| Member Cost with Medicare A & B Primary – Out-of-Pocket Maximum with Parts A & B | $6900 | $9000 | $7500 $15000 | N/A | N/A | $6000 $12000 | $8500 $17000 | $6000 $12000 | $7500 $15000 |
| Member Cost with Medicare A & B Primary – Primary Care Physician Office Visit with Medicare A & B Primary | 15% Coinsurance | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Copayment Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Specialty Office Physician Visit with Parts A & B | 15% Coinsurance | 40% Coinsurance + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Copayment Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Inpatient Hospital Services with Parts A & B | 15% Coinsurance | 40% Coinsurance + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% Coinsurance | 35% Coinsurance + Difference Between Plan Allowance and Billed Amount | Coinsurance Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Outpatient Hospital Services with Parts A & B | 15% Coinsurance | 40% Coinsurance + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% Coinsurance | 35% Coinsurance + Difference Between Plan Allowance and Billed Amount | Coinsurance Waived | Coinsurance Waived |
| Member Cost with Medicare A & B Primary – Part B Premium Reimbursement with Parts A & B | No | No | $800 Max | N/A | N/A | $1000 Max | N/A | No | No |
| Member Cost with Medicare Advantage (Part C) Primary – Deductible Waiver with Part C | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Member Cost with Medicare Advantage (Part C) Primary – Out-of-Pocket Maximum with Part C | N/A | N/A | $7500 $15000 | N/A | N/A | N/A | N/A | $6000 | $7500 |
| Member Cost with Medicare Advantage (Part C) Primary – Primary Care Physician Office Visit with Medicare Advantage (Part C) Primary | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Specialty Physician Office Visit with Part C | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Inpatient Hospital Services with Part C | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $75 Per Day Up To $750 Per Admission | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Outpatient Hospital Services with Part C | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | N/A | N/A | $75 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Member Cost with Medicare Advantage (Part C) Primary – Part B Premium Reimbursement with Part C | N/A | N/A | No | N/A | N/A | N/A | N/A | No | No |
| Member Cost with Medicare Part D EGWP – Prescription Drug Deductible | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Member Cost with Medicare Part D EGWP – Out-of-Pocket Maximum | N/A | N/A | $2000 | N/A | N/A | N/A | N/A | $2000 | $2000 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 0 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | Member Pays Nothing | Member Pays Nothing |
| Member Cost with Medicare Part D EGWP – EGWP Tier 1 | N/A | N/A | $10 | N/A | Member Pays All Charges | N/A | N/A | $8 | $8 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 2 | N/A | N/A | $45 Copayment | N/A | Member Pays All Charges | N/A | N/A | $45 | $45 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 3 | N/A | N/A | 50% | N/A | Member Pays All Charges | N/A | N/A | $70 | $70 |
| Member Cost with Medicare Part D EGWP – EGWP Tier 4 | N/A | N/A | $75 Copayment | N/A | Member Pays All Charges | N/A | N/A | 25% | 25% |
| Member Cost with Medicare Part D EGWP – EGWP Tier 5 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| Member Cost with Medicare Part D EGWP – EGWP Tier 6 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 30% $275 Max | Member Pays All Charges |
| Primary/Specialty Care – Preventive Care | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | Member Pays Nothing | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges |
| Primary/Specialty Care – Primary Care Office Visit | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Primary/Specialty Care – Specialist Office Visit | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Primary/Specialty Care – Plan Requires Referral to See Certain Specialists | No | No | No | N/A | N/A | No | No | No | No |
| Emergency & Urgent Care – Emergency Care | 15% | 15% | $0 Copayment + $350 | N/A | $0 + $350 | 5% | 5% | $50 Copayment | $50 Copayment + Difference Between Plan Allowance and Billed Amount |
| Emergency & Urgent Care – Urgent Care | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $50 Copayment | N/A | $50 Or Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $50 Copayment | $50 Copayment + Difference Between Plan Allowance and Billed Amount |
| Emergency & Urgent Care – Out-of-Pocket Waived | No | No | Yes | N/A | N/A | No | No | Yes | Yes |
| Surgery & Hospital Charges – Doctor Costs Inpatient Surgery | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $200 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Hospital Inpatient Cost Per Admission | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $350 Per Day Up To $1750 Per Admission | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Per Day $750 Max | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Room & Board Charges | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Other Inpatient Costs | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Doctor Costs Outpatient Surgery | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment Or $200 | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $150 | 40% + Difference Between Plan Allowance and Billed Amount |
| Surgery & Hospital Charges – Other Outpatient Costs | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $250 Per Day Or $350 Per Day | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Lab, X-Ray & Other Diagnostic Tests – Simple Diagnostic Tests/Procedures | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 15% Or $40 Copayment Or $100 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Lab, X-Ray & Other Diagnostic Tests – Complex Diagnostic Tests/Procedures | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $40 Or $100 | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Lab, X-Ray & Other Diagnostic Tests – Enhanced Lab Network | 15% | 40% + Difference Between Plan Allowance and Billed Amount | N/A | N/A | N/A | N/A | N/A | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Prescription Drugs – Mail Service Pharmacy Benefit | Yes | No | No | N/A | N/A | Yes | N/A | Yes | No |
| Prescription Drugs – Mail Order Pharmacy Restriction | Yes | N/A | N/A | N/A | N/A | Yes | N/A | Yes | N/A |
| Prescription Drugs – Specialty Pharmacy Restriction | Yes | N/A | Yes | N/A | N/A | Yes | N/A | Yes | N/A |
| Prescription Drugs – Hormone Therapy | Covered | Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Prescription Drugs – Tier 0 Prescription | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount | N/A | N/A | N/A | Member Pays Nothing | $0 + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges |
| Prescription Drugs – Tier 1 Prescriptions | $10 Copayment | 40% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | N/A | Member Pays All Charges | 25% | 25% + Difference Between Plan Allowance and Billed Amount | $10 | Member Pays All Charges |
| Prescription Drugs – Tier 2 Prescriptions | 50% $200 Max | 40% + Difference Between Plan Allowance and Billed Amount | $75 Copayment | N/A | Member Pays All Charges | 25% | 25% + Difference Between Plan Allowance and Billed Amount | 30% $200 Max | Member Pays All Charges |
| Prescription Drugs – Tier 3 Prescriptions | 50% $300 Max | 40% + Difference Between Plan Allowance and Billed Amount | 60% | N/A | Member Pays All Charges | 40% | 40% + Difference Between Plan Allowance and Billed Amount | 50% $200 Max | Member Pays All Charges |
| Prescription Drugs – Tier 4 Prescriptions | 50% $350 Max | 40% + Difference Between Plan Allowance and Billed Amount | $120 Copayment | N/A | Member Pays All Charges | 25% | N/A | 30% $225 Max | Member Pays All Charges |
| Prescription Drugs – Tier 5 Prescriptions | 50% $700 Max | 40% + Difference Between Plan Allowance and Billed Amount | $200 Copayment | N/A | Member Pays All Charges | 40% | N/A | 30% $225 Max | Member Pays All Charges |
| Prescription Drugs – Tier 6 Prescriptions | N/A | 40% + Difference Between Plan Allowance and Billed Amount | N/A | N/A | N/A | N/A | N/A | 30% $275 Max | Member Pays All Charges |
| Treatment, Devices, and Services – Applied Behavioral Analysis (ABA) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Chiropractic | Member Pays All Charges | Member Pays All Charges | $35 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Occupational Therapy | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Physical Therapy | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Speech Therapy | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | N/A | N/A | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Professional Services (Mental Health and Substance Use Disorder) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Inpatient Hospital (Mental Health and Substance Use Disorder Services) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $350 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Copayment $750 Max | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Outpatient Hospital (Mental Health and Substance Use Disorder Services) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Infertility Services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Fertility Preservation Procedures (e.g., iatrogenic infertility) (Infertility Services) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Artificial Insemination Services (e.g. ICI, IVI, IUI) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | Member Pays All Charges 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Assisted Reproductive Technology (ART) (e.g., IVF, GIFT, ZIFT) (Infertility Services) | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges |
| Treatment, Devices, and Services – Surgical Procedures | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Reconstructive Surgery | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Gender Affirming Surgery | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $150 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Hearing Services | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment Or $50 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Hearing Aids (External) | Not Covered | Not Covered | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered |
| Treatment, Devices, and Services – Maternity Care | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges | Member Pays All Charges | 0% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Maternity Care – Hospital Stay | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $350 Copayment | Member Pays All Charges | Member Pays All Charges | 0% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Hospice Care | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | Member Pays All Charges | Member Pays Nothing | 5% $30000 Max | 35% + Difference Between Plan Allowance and Billed Amount $30000 Max | $5 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Home Health Services (Skilled Nursing Care) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | Member Pays All Charges | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $15 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Durable Medical Equipment | 15% | 40% + Difference Between Plan Allowance and Billed Amount | 30% | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Outpatient Rehabilitation (Skilled Nursing Care Facility) | 15% | 40% + Difference Between Plan Allowance and Billed Amount | $35 Copayment | Member Pays All Charges | Member Pays All Charges | 5% | 35% + Difference Between Plan Allowance and Billed Amount | $75 Copayment | 40% + Difference Between Plan Allowance and Billed Amount |
| Treatment, Devices, and Services – Diabetes Education | Member Pays Nothing | Member Pays All Charges | $35 Copayment Or $50 Copayment | Member Pays All Charges | Member Pays All Charges | Member Pays Nothing | Member Pays Nothing | Member Pays Nothing | Member Pays All Charges |
| Treatment, Devices, and Services – Nutritional Counseling | Member Pays Nothing | Member Pays All Charges | Member Pays Nothing | Member Pays All Charges | Member Pays All Charges | 0% | 35% + Difference Between Plan Allowance and Billed Amount | Member Pays Nothing | 40% + Difference Between Plan Allowance and Billed Amount |
| Dental – Routine Dental Exams and Cleaning for Adults | Yes | No | Yes | N/A | N/A | Yes | Yes | No | No |
| Dental – Routine Dental Exams and Cleaning for Children | Yes | No | Yes | N/A | N/A | Yes | Yes | No | No |
| Dental – Minor Restorative for Adults | No | No | No | N/A | N/A | Yes | Yes | No | No |
| Dental – Minor Restorative for Children | No | No | No | N/A | N/A | Yes | Yes | No | No |
| Dental – Major Restorative for Adults | No | No | No | N/A | N/A | No | No | No | No |
| Dental – Major Restorative for Children | No | No | No | N/A | N/A | No | No | No | No |
| Dental – Orthodontic | No | No | No | N/A | N/A | No | No | No | No |
| Vision – Routine Eye Exams | Yes | Yes | No | N/A | N/A | Yes | Yes | No | No |
| Vision – Eye Exams for Medical Condition or Non-Surgical Treatment | Yes | Yes | Yes | N/A | N/A | Yes | Yes | Yes | Yes |
| Vision – Eyeglass Frames & Lenses | Yes | Yes | No | N/A | N/A | Yes | Yes | Yes | Yes |
| Vision – Contacts | Yes | Yes | No | N/A | N/A | Yes | Yes | Yes | Yes |
| Alternative Care – Alternative Care | Yes | Yes | Yes | N/A | N/A | Yes | Yes | Yes | Yes |
| Alternative Care – Chronic Disease Management: Asthma | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Alternative Care – Chronic Disease Management: Heart Disease | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Alternative Care – Chronic Disease Management: Hypertension | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
| Alternative Care – Chronic Disease Management: Obesity | Covered | Not Covered | Covered | Not Covered | Not Covered | Covered | Covered | Covered | Covered |
Key: Outstanding Excellent Good Fair Poor NA (NA is displayed if a plan did not report or is unable to report a result in this coverage area.)
Quality and Customer Service Ratings
Beyond costs and coverage, it’s vital to consider the quality of care and customer service provided by each plan. OPM provides quality ratings based on various health outcomes and customer satisfaction metrics. These ratings can give you insights into how well each plan performs in areas like preventive care, chronic disease management, and member experience.
| Plans | Aetna HealthFund HDHP and Aetna Direct Plan (HDHP) | Blue Cross and Blue Shield Service Benefit Plan (Basic) | GEHA Benefit Plan (HDHP) | MHBP Consumer Option (HDHP) |
|---|---|---|---|---|
| Quality – Controlling High Blood Pressure | ||||
| Quality – Hemoglobin A1c Control for Patients with Diabetes | ||||
| Quality – Timeliness of Prenatal Care | ||||
| Quality – Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis Ages 18 to 64 | ||||
| Quality – Asthma Medication Ratio | ||||
| Quality – Breast Cancer Screening | ||||
| Quality – Follow Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence 30 day | ||||
| Quality – Follow Up After Emergency Department Visit for Mental Illness 30 day | ||||
| Quality – Childhood Immunization Status—Combination 10 | ||||
| Quality – Use of Imaging Studies for Low Back Pain | ||||
| CustomerService – Overall Plan Satisfaction | ||||
| CustomerService – Claims Processing | NA | NA | NA | |
| CustomerService – Getting Needed Care | ||||
| CustomerService – Coordination of Care | NA |
Understanding the Quality Ratings:
- Outstanding: Indicates the highest level of performance in the given quality measure.
- Excellent: Represents a very high level of performance, exceeding expectations.
- Good: Shows solid performance, meeting the standard for quality care.
- Fair: Suggests average performance, with room for improvement in the quality measure.
- Poor: Indicates performance below the expected standard, requiring significant improvement.
- NA (Not Available): Represents that the plan did not report data for this particular quality or customer service measure.
These ratings, visualized with icons, offer a quick way to assess the strengths and weaknesses of each plan in critical areas of healthcare delivery and member satisfaction. For example, a plan with an “Excellent” rating for “Hemoglobin A1c Control for Patients with Diabetes” demonstrates strong performance in managing diabetes care. Similarly, a plan rated “Outstanding” for “Overall Plan Satisfaction” suggests a positive member experience.
Making Your Decision
Comparing OPM health insurance plans effectively involves a holistic approach. Don’t just focus on premiums. Consider your healthcare needs, risk tolerance, and preferred way of accessing care.
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Assess Your Healthcare Needs: Do you have chronic conditions? Do you anticipate needing frequent medical care? Are prescription drugs a significant expense for you? Your individual health situation will influence which plan features are most important.
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Compare Costs Beyond Premiums: Look at deductibles, coinsurance, copays, and the out-of-pocket maximum. HDHPs might have lower premiums, but higher out-of-pocket costs if you need significant care. Conversely, plans with higher premiums may offer lower cost-sharing when you receive services.
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Evaluate Network Adequacy: Check if your preferred doctors and hospitals are in-network for the plans you are considering. Network coverage is especially important if you have established relationships with specific providers or live in an area with limited provider choices.
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Review Quality and Customer Service Ratings: Use the OPM quality ratings to understand how plans perform in delivering effective care. Customer service ratings can give you insights into member satisfaction and the ease of interacting with the plan.
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Consider HSAs and HRAs: If you are considering an HDHP, understand the benefits of Health Savings Accounts (HSAs) and Health Reimbursement Arrangements (HRAs). These accounts can help you save money on healthcare expenses and offer tax advantages.
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Always Refer to the Plan Brochure: This comparison tool provides a starting point, but the official FEHB plan brochure is your definitive guide. Download and carefully review the brochures for your top plan choices before making your final decision.
By thoroughly comparing OPM health insurance plans using these factors and the provided tools, you can confidently choose a plan that provides the right coverage, quality, and value for your needs as a federal employee. Take the time to research and understand your options – your health and financial well-being depend on it.
