U.S. Family Health Plan (USFHP)

Introduction

The U.S. Family Health Plan (USFHP) is a governmentfunded health insurance program that offers comprehensive, affordable coverage to eligible Federal employees, retirees, and their families living in select regions of the United States. This handbook provides an overview of the most important information you need to make the most of your benefits.

Eligibility

To enroll in USFHP you must meet all of the following criteria:

• Be a Federal civilian employee, retiree, or member of the uniformed services.
• Live in an area where USFHP is available (generally the Pacific Northwest, Southwest, and certain parts of California).
• Have a qualifying family member (spouse, child, or dependent).
• Not be enrolled in another Federal health plan that conflicts with USFHP.

Eligibility is verified during the enrollment process, and you will receive an enrollment confirmation once your application is approved.

Coverage & Benefits

USFHP offers a range of services designed to keep you and your loved ones healthy.

Medical Services

• Doctor visits (primary care, specialists)
• Hospital inpatient and outpatient care
• Emergency department services
• Maternity care and newborn services
• Preventive services (vaccinations, screenings, wellness exams)

Prescription Drugs

A formulary of covered medications is available at participating pharmacies. Tiered copayments apply based on drug class.

Dental & Vision

Optional dental and vision plans can be added for an additional premium. Covered services include routine exams, cleanings, glasses, and contact lenses.

Mental Health & Substance Use

Behavioral health services, including counseling, psychotherapy, and medication management, are covered with the same costshare structure as medical services.

Costs & Payments

Costs are shared between the plan and the member. The main components are:

1. Premiums Fixed monthly amount deducted from payroll.
2. Deductibles Amount you pay for covered services before the plan begins to pay.
3. Copayments Fixed fees for specific services (e.g., $20 for a primarycare visit).
4. Coinsurance Percentage of the allowed amount you pay after meeting your deductible (commonly 20%).
5. OutofPocket Maximum The most you will spend in a plan year; after reaching this limit, the plan pays 100% of allowed charges.

Finding & Using Providers

USFHP works with a network of physicians, hospitals, and pharmacies. To locate a provider:

• Visit the USFHP Provider Directory and search by name, specialty, or ZIP code.
• Call the member services line (see Contact Information) for assistance.
• Confirm that the provider accepts your specific plan tier before your appointment.

For urgent or emergency care, you may go to any hospital emergency department. Nonemergency services should be obtained from an innetwork provider to receive full benefits.

Claims, Billing, and Appeals

Submitting Claims

Most claims are processed automatically when you use an innetwork provider who bills the plan directly. If you receive a bill from an outofnetwork provider, you can submit a claim by:

1. Downloading the claim form from the website.
2. Attaching itemized receipts and the providers NPI number.
3. Mailing or uploading the form through your member portal.

Understanding Explanation of Benefits (EOB)

After a claim is processed, you will receive an EOB that details:

• Service provided
• Amount billed
• Allowed amount
• Member responsibility (deductible, copayment, coinsurance)
• Amount paid by the plan

Appeals Process

If you disagree with a coverage decision:

1. Contact member services within 30 days of the EOB.
2. Submit a written appeal with supporting documentation.
3. The plan must respond within 30 days (15 days for urgent matters).

Member Rights & Responsibilities

• Right to receive prompt, courteous service.
• Right to appeal any denied claim.
• Right to privacy of health information under HIPAA.
• Responsibility to provide accurate personal information.
• Responsibility to keep premiums up to date.
• Responsibility to use innetwork providers whenever feasible.

Contact Information

Member Services Hotline: 1800555USFHP (18005558734)
Hours: MondayFriday, 8am8pm local time
Email: memberservice@usfhp.gov
Website: www.usfhp.gov

For additional resources, visit the Member Resources section of the website, where you can download the full Member Handbook, view plan updates, and access healthmanagement tools.