This Plan is a health maintenance organization (HMO) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Sentara Health Plans holds the following accreditation: National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation, please visit the following website: www.ncqa.org.
We require you to see specific providers, hospitals, and other providers that contract with us. These Plan providers coordinate your health care 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. We offer a High Option HMO plan.
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 and coinsurance 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 High Option
We have Open Access benefits
Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.
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 and non-covered services and supplies). Except for emergencies outside the service area, we will not pay for care or services from non-Plan providers unless it has been authorized by us. You are responsible for making sure that a provider is a Plan provider. If you use a non-Plan provider without our prior authorization, you may be responsible for charges.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments or annual limits when received from a network provider.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including copayments, cannot exceed $5,500 for Self Only enrollment, and $11,000 for a Self Plus One or Self and Family.
Health education resources and accounts management tools
We have online, interactive health and benefits information tools to help you make more informed health decisions (see page 106).
Your rights and responsibilities
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/healthcare-insurance/) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Sentara Health Plans is a not-for-profit health maintenance organization fully licensed under the laws of the Commonwealth of Virginia to arrange for the provision of health care services to its members.
- Sentara Health Plans is one of the first HMOs in the Hampton Roads area of Virginia operating since 1984.
- Sentara Health Plans pays providers on a fee for service basis according to a fee schedule. You may find some additional information about the Plan’s providers in this brochure in Section 3, "Where You Get Covered Care". If you would like information about the Plan’s provider network, including participating hospitals, physician education, and board certification, and whether or not providers are accepting new patients, you may check your provider directory, or the Plan’s website at www.sentarahealthplans.com/federal or call Member Services at 757-552-7550 or 800-206-1060.
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.sentarahealthplans.com/federal. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 757-552-7550 or 800-206-1060, or write to Sentara Health Plans, PO Box 66189
Virginia Beach, VA 23466. You may also visit our website at www.sentarahealthplans.com/federal.
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.sentarahealthplans.com/federal to obtain our Notice of Privacy Practices. You can also contact us to request that we mail a copy of the Notice.
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.
Service Area
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area in the State of Virginia:
Cities of:
Aldie, Alexandria, Annadale, Arlington, Ashburn, Bealeton, Bentonville, Berryville, Bluemont, Boyce, Bristow, Broad Run, Brooke, Burke, Calverton, Casanova, Catharpin, Catlett, Centreville, Chantilly, Clifton, Delaplane, Dulles, Dumfries, Dunn Loring, Fairfax, Fairfax Station, Falls Church, Fort Belvoir, Fredericksburg, Front Royal, Ft. Myer, Gainesville, Garrisonville, Goldvein, Great Falls, Greenway, Hamilton, Hartwood, Haymarket, Herndon, Hume, Leesburg, Lincoln, Linden, Lorton, Lovettsville, Manassas, Markham, Marshall, McLean, Merrifield, Middleburg, Middletown, Midland, Millwood, Mount Vernon, Newington, Nokesville, Oakton, Occoquan, Orlean, Paeonian Springs, Paris, Partlow, Philmont, Purcellville, Quantico, Rectortown, Remington, Reston, Round Hill, Ruby, Somerville, Spotsylvania, Springfield, Stafford, Sterling, Sumerduck, The Plains, Thornburg, Triangle, Upperville, Vienna, Warrenton, Waterford, West McLean, White Post and Woodbridge.
Counties of:
Alexandria, Arlington, Clarke, Fairfax, Fauquier, Loudoun, Manassas City, Manassas Park City, Prince William, Spotsylvania, Stafford, and Warren.
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.