Second Chances

The Office of Personnel Management has given federal employees more than seven additional weeks to evaluate and enroll in a health plan for the 2009 season. With recent changes to the Blue Cross Blue Shield Standard Option's out-of-network surgical benefits, it might be wise to take the extra time to assess those changes as well as other health plan alternatives.

In a letter to members, Blue Cross announced it would forgo a significant benefit change that would have required Standard Option enrollees to pay a deductible of up to $7,500 for each procedure or surgery performed by a nonparticipating physician.

Instead, employees will pay 30 percent of the plan allowance for an out-of-network procedure, plus any difference between the allowance and the amount billed. For example, if a nonparticipating surgeon charged $5,000 for an operation and the Blue Cross allowance for the surgery was $4,000, an enrollee would pay $1,200 (30 percent) plus $1,000 for the difference between the allowance and the billed amount -- a total of $2,200. Under the change Blue Cross scrapped, an enrollee would have paid the full amount -- $5,000 - in the above example.

Previously, enrollees paid 25 percent of the plan allowance for an out-of-network procedure, plus any difference between the allowance and the amount billed.

Blue Cross also is adding a special telephone service for situations where a surgeon's bill will be $5,000 or more. Beginning in 2009, Standard Option enrollees can call the number on the back of their ID card to obtain the information necessary to estimate the out-of-pocket cost for out-of-network surgery. Prior to the approval process, employees must ask the nonparticipating surgeon about the cost and inform Blue Cross, the carrier said.

Typically, the cost of care will be less if a Blue Cross preferred or participating provider is used, but Standard Option members will be able to compare the costs through the preapproval service, according to Blue Cross.

For retirees who have Medicare Part B as their primary payer, the company will provide benefits in the same manner as 2008. "When Medicare Part B is your primary payer, federal regulation limits the amounts physicians can bill you, and we waive some of your costs under the Service Benefit Plan," the letter to members stated. "As a result, your cost-sharing responsibility is limited."

On Dec. 5, OPM asked the 269 carriers in the Federal Employee Health Benefits Program to propose changes to their out-of-network surgical benefits by Dec. 8, a move that was fueled by Blue Cross' changes to its out-of-network surgical benefit. The agency said on Tuesday that Blue Cross was the only carrier to propose a change.

Walton Francis, author of Consumer's Checkbook Guide to Health Plans for Federal Employees and Annuitants, said on Tuesday that the benefit change is generally a better value for employees than the $7,500 co-payment would have been. The prior approval service will enable employees to make a better decision, he added.

Still, Francis said, employees should consider a variety of factors when determining which plan is the best fit for them, including family size, age, pay system, full- or part-time status, geographic area, retirement status, Medicare status and overall risk of high medical costs. Some of the lower cost plans, including the Blue Cross Basic Option, are prime alternatives, he said.

"This is a time for people who were otherwise couch potatoes to take a few minutes to think through and ask, 'Am I in the right place?' " Francis said. "The controversy of the out-of-network surgical benefit is behind us."

Standard Option's change in out-of-network benefits should prompt federal employees to examine their health plan options more carefully throughout the extended 2009 enrollment period, and in the future, he added.

"This is an example that it really pays to pay attention," Francis said. "People who didn't pay attention just got saved by those who did. Normally, you don't get saved by someone; normally you find out the hard way."

Employees have until the end of January to change their health plans, and they can do so even if they modified them during the regular open season, which ran Nov. 12 through Dec. 10. They can use the belated enrollment period to sign up for any of the plans participating in open season, including FEHBP as well as the dental and vision and flexible spending account programs.

Click here for OPM's answers to frequently asked questions about the FEHBP belated enrollment period.

Insurance Policy

OPM announced in a Nov. 24 letter to federal agencies that certain civilian and Defense Department employees are now eligible to elect Federal Employees Group Life Insurance coverage outside of the program's open season and without experiencing a qualifying life event or providing medical information.

The FEGLI open season does not have a regularly scheduled date and usually is held infrequently. The most recent open seasons for the life insurance program were in 1999 and 2004, according to OPM.

The new election opportunity applies to civilian employees eligible for FEGLI who are deployed in support of a contingency operation. It also applies to Defense Department civilians eligible for FEGLI who are designated as "emergency essential," meaning they could be subject to deployment.

Under the law, affected civilian employees who previously waived some or all FEGLI coverage may elect either basic or the standard and/or additional coverage options outside of open season. The new law does not provide for retroactive coverage or authorize an opportunity to elect family coverage outside of open season.

Elections must be made within 60 days after the date of notification of deployment in support of a contingency operation or the designation as an emergency-essential employee, OPM said.