Multi State Plan Program

A Multi-State Plan insurer must offer a benefits package that is uniform within each State and includes “essential health benefits” in the following categories:

1.Ambulatory patient services
2.Emergency services
3.Hospitalization
4.Maternity and newborn care
5.Mental health and substance use disorder services, including behavioral health treatment
6.Prescription drugs
7.Rehabilitative and habilitative services and devices
8.Laboratory services
9.Preventive and wellness services and chronic disease management
10.Pediatric services, including oral and vision care

A Multi-State Plan insurer must also offer any additional benefits required under its State’s laws.

In order to be approved to offer one or more Multi-State Plan options, an insurer, among other things, must—

• meet requirements for qualified health plans under the Affordable Care Act;
• offer a package of “essential health benefits”; and
• determine premiums using the rating rules under the Affordable Care Act except that if the state has more protective age rating requirements, defer to the state age rating rules.

Some Multi-State Plan options offer in-network care outside of your service area, but not all.  If you live in one State and work, go to college, or spend a lot of time in another State, carefully check the provider directories of the plans you’re considering buying.  See if their networks have doctors, hospitals, and other healthcare providers in the places you’ll be.  Also, check out the plan’s payment policies for out-of-network care.

External review is the process by which OPM, or an Independent Review Organization if the case requires medical judgment, reviews a health insurance plan’s decision to deny a benefit or payment for a service for an enrollee in an MSP option. Except in certain circumstances, you must first file an internal appeal with the health plan to reconsider its decision. If the plan continues to deny the benefit or payment, you have the right to request an external review.  Please visit the Multi-State Plan Program External Review website for more information.

The Multi-State Plan Program External Review Process is unique because OPM administers the process directly. OPM will review whether your insurance company’s denial was justified by examining the terms of coverage and the specific circumstances surrounding the denial. If medical expertise is needed for review of a denial, an Independent Review Organization (IRO) will provide a decision. In most cases, OPM or an IRO will reach a decision within 30 days. If you are denied emergency services or if your doctor has determined that the denial of care would seriously jeopardize your life or jeopardize your ability to regain maximum function, you may be able to request expedited External Review without first exhausting your insurance company's appeal process. In that case, OPM or the IRO generally will make a decision within 72 hours.