Insurer renegotiates out-of-network surgery benefits

Blue Cross Blue Shield has reached an agreement with the Office of Personnel Management to change out-of-network benefits for nonemergency surgeries under its Standard Option plan, the carrier announced this week.

The new arrangement will require enrollees to pay 30 percent of the plan allowance for an out-of-network procedure, plus any difference between the allowance and the billed amount, the carrier stated in a letter to members.

The deal came in response to concerns over a change in coverage in the Blue Cross Blue Shield Standard Option -- the most popular federal employee plan -- that would have required enrollees to pay a deductible of up to $7,500 for each procedure or surgery performed by a nonparticipating physician. Previously, enrollees paid 25 percent of the plan allowance for an out-of-network procedure, plus any difference between the allowance and the billed amount.

The issue was the subject of a Dec. 3 hearing before the House Oversight and Government Reform Federal Workforce subcommittee, during which lawmakers urged OPM to renegotiate the Blue Cross benefit and extend open season to federal employees who were unaware of the plan change. On Dec. 5, OPM asked the 269 carriers in the Federal Employees Health Benefits Program to propose changes to their out-of-network benefits by Dec. 8. The agency also extended the FEHBP enrollment period until the end of January 2009.

"Changing the benefit structure to impose a $7,500 limit was an effort to control the unexpected expenses," Blue Cross said. "However, this benefit structure did not provide for the payment of benefits for surgeries costing less than the $7,500 limit and was not consistent with the way we provide other types of care you may receive from out-of-network providers."

To help federal employees avoid unexpectedly large charges, the carrier will add a special telephone service for situations where the surgeon's bill will be $5,000 or more. The new service will allow enrollees to call Blue Cross for help estimating out-of-pocket costs ahead of time, the letter stated.