Reg Jones Expert's View

Every year the Office of Personnel Management sends a letter to every health benefit provider in the Federal Employees Health Benefits program. Its purpose is to solicit benefit and rate proposals for the upcoming year. This year it did that on April 20.

In addition to the standard language encouraging carriers to come forward with affordable proposals that are value based and cost neutral, OPM has pointed out certain areas where it expects carriers to toe the line. First is a requirement spelled out in the Mental Health Parity and Addiction Equity Act of 2008, which requires health providers to provide parity between medical and surgical benefits and those required for mental health and substance abuse.

Second is a requirement that carriers follow the guidelines on preventive care for children, which are recommended by the American Academy of Pediatrics, and the guidelines for adults recommended by the United States Preventive Services Task Force (USPSTF).

OPM is also pressing carriers to review their catastrophic limits, to mitigate any gaps they may have in the coverage that they offer. With that in mind, OPM proposes to "clarify the FEHB brochure to make it easier for prospective enrollees to make comparisons regarding the catastrophic coverage offered by FEHB plans. Plans will be required to describe benefits that are not included in catastrophic limits. Also, if an enrollee has a choice of using an in-network benefit or out-of-network benefit, the brochure description should clearly describe the out-of-network benefit and the out of pocket cost associated with this benefit to allow enrollees to make an informed choice of provider."

In addition, OPM is encouraging carriers to explore proven strategies to reduce preventable medical errors. Among its recommendations is that carriers not reimburse providers whose bills are related to such errors, while holding patients harmless. In doing this, OPM would be following Medicare’s lead.

Further, OPM is requesting carriers to "consider coverage for durable medical equipment, including assistive devices for individuals with special needs, such as audible prescription reading devices to prevent the improper use of medications" and to "ensure their benefits include medically necessary laboratory tests, as recommended by the Food and Drug Administration.

Keep tuned to learn what the 2010 FEHB program will look like when all the proposals are in and benefits and rates have been negotiated.