OPM Sets Date for Self Plus One Health Coverage

Federal employees cannot enroll in self-plus-one health coverage until 2016, the Office of Personnel Management has announced.

The coverage option -- which will enable federal employees with a spouse and no dependents a new choice when enrolling in the Federal Employees Health Benefits Program -- was included in the 2013 budget deal. FEHBP currently offers just self-only and family coverage.

Federal workers can sign up for self-plus-one coverage during the 2015 open season, which begins Nov. 9 of that year. The new enrollment type will kick in Jan. 1, 2016. The delayed rollout is necessary to allow agencies and payroll offices to revamp their enrollment processes and systems to ensure they are compatible with the new option, OPM said in a letter to all agencies.

Federal employees and their advocates long have complained about the lack of a self-plus-one option in FEHBP. Employees with spouses and no dependents have balked at having to pay more for a family plan when they don’t have any children. But it’s not clear a self-plus-one option would be any cheaper for enrollees since that demographic -- employees with a spouse and no dependents -- tends to be older and more expensive to insure than a young couple with children, according to OPM’s analysis.

President Obama included a provision to offer self-plus-one in FEHBP in his fiscal 2014 budget proposal.

In a separate letter -- one sent annually to health insurance providers to kick off negotiations for plans and rates -- OPM called on health care companies wishing to establish plans in FEHBP to focus on “optimizing the delivery of prescription drug benefits,” bringing offerings in line with the Affordable Care Act and improving mental health coverage.

OPM also focused on prescription drug costs in its 2013 call letter, when it noted pharmacy claims accounted for about 30 percent of FEHBP premiums. Last year OPM asked carriers to increase the use of generic drugs, limit the use of expensive specialty drugs and find alternative options for illnesses besides prescription drugs. OPM said it will collect data to track progress in these areas.

The agency encouraged providers to “more closely manage” their lists of covered drugs. Medicines that are less effective than other options, less safe or provide little incremental clinical value at a much higher cost should not be covered, OPM said.

Providers should increase the use of “high value medication distribution channels,” including mail-order programs. OPM also supported more selective pharmacy networks and carriers encouraging enrollees to use Medicare Part B for prescription costs when possible.

To comply with the Affordable Care Act, plans within FEHBP must set 2015 out-of-pocket maximums of $6,600 for self-only plans and $13,200 for self and family. The maximum applies to all in-network deductibles, copayments and co-insurance for essential health benefits. Carriers should also provide coverage for habilitation -- when individuals need to acquire skills for the first time after receiving medical treatment -- OPM advised.

The Health and Human Services Department and other federal agencies in 2013 released final rules for the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equality Act, which requires health care carriers to provide equal mental health and medical or surgical benefits. OPM said all FEHBP providers must comply with these rules.

OPM also told carriers to continue with ongoing goals of enhancing wellness programs and advancing quality of care. Providers must submit all benefit and rate proposals to the agency by May 31.  

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