This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan’s operations and/or care management meet nationally recognized standards. Geisinger Health Plan holds the following accreditations: Accredited with the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following websites: National Committee for Quality Assurance (www.ncqa.org). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your healthcare services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
General features of our Options
Geisinger Health Plan’s Standard Option and Basic Option are Solutions HMO plans. You select a Primary Care Provider who will coordinate all of your care. Members may self-refer for covered services to a participating provider without the need of a referral from the member’s Primary Care Provider. Services include inpatient hospitalization, outpatient surgery, diagnostic testing, rehabilitation therapy, and other services as prescribed by your Primary Care Provider.
The Standard Option and Basic Option affords you protection from catastrophic illness because there is a limit to your out-of-pocket costs for covered care. After you have met the annual out-of-pocket maximum, the coinsurance will be eliminated for the balance of the benefit year for most covered procedures. Please note that you must still make copayments for covered office visits and prescription drugs.
For the Standard Option, you must satisfy a calendar year deductible of $750 per Self Only, $1500 per Self Plus One or $1,500 per Self and Family . After you have satisfied the annual deductible, you will then be required to pay 20% coinsurance for covered surgical procedures and inpatient hospitalization up to the coinsurance out-of-pocket maximum of $4,250 under Self Only, $8500 under Self Plus One or $8,500 under Self and Family. The annual deductible is in addition to the out-of-pocket maximum.
For the Basic Option, you must satisfy a calendar year deductible of $1,500 per Self Only, $1500 per Self Plus One or $3,000 per Self and Family. After you have satisfied the annual deductible, you will then be required to pay 30% coinsurance for covered surgical procedures and inpatient hospitalization up to the coinsurance out-of-pocket maximum of $7,000 under Self Only, $14,000 under Self Plus One or $14,000 under Self and Family. The annual deductible is in addition to the out-of-pocket maximum.
Preventive care services
Preventive care services are generally covered with no cost sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.
Annual deductible
The annual deductible must be met before Plan benefits are paid for care other than preventive care services.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Your rights and responsibilites
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- More than 20 years' experience
- A not-for-profit HMO
- Compliant with federal and state licensing requirements
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, at www.TheHealthPlan.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
If you want more information about us, call 844-863-6850, or write to Geisinger Health Plan, Customer Services, 100 North Academy Avenue, Danville, PA 17822-3229. You may also contact us by fax at 570-271-5871 or visit our website at www.TheHealthPlan.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.TheHealthPlan.com to obtain a copy of our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice.
Our service area includes the following Pennsylvania counties: Adams, Bedford, Berks, Blair, Bradford, Cambria, Cameron, Carbon, Centre, Clearfield, Clinton, Columbia, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Jefferson, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York and portions of Elk as denoted by the zip codes below:
Elk: 15821, 15822, 15823, 15827, 15831, 15841, 15846, and 15868.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.