Introduction to the Federal Employees Health Benefits Program. Report Tile UNITED STATES OFFICE OF PERSONNEL MANAGEMENT

Transcription

1 Introduction to the Federal Employees Health Benefits Program Report Tile UNITED STATES OFFICE OF PERSONNEL MANAGEMENT 1

2 Introduction & Program Design Law enacted September 28, 1959 The Federal Employees Health Benefits Act (FEHBA) became effective July 1, health plan choices in the FEHB Program Administered by the Office of Personnel Management (OPM) 2

3 Introduction & Program Design Over 4 million enrollees 2.2 million employees 1.8 million retirees, surviving spouses, other Almost 9 million in total membership $32.5 billion in annual premiums 3

4 FEHB Program Features & Responsibilities 4

5 FEHB Program Features Enrollment opportunities Annual Open Season Qualified Life Events (QLE) Continued Group Coverage 31 day extension of coverage Temporary Continuation of Coverage (TCC) Spouse equity Military service Conversion to non-group (private) coverage 5

6 FEHB Program Features Consumer protections Appeal rights to OPM if member and plan have a dispute over a claim Patients Bill of Rights Privacy protection of medical information 6

7 Approve new plans OPM Responsibilities Administer contracts with carriers Negotiate benefits, rates and FEHB brochure text Audit plans and resolve audit issues Monitor plan performance Publish FEHB regulations, informational material, and forms Prepare Open Season materials 7

8 OPM Responsibilities Maintain OPM and FEHB websites Maintain the FEHB Fund Make final decisions on applicability of the FEHB Law Report to Congress on the operation and administration of FEHB law and plans Provide guidance to agencies and plans Resolve disputed health benefits claims 8

9 Agency Responsibilities Designate a Benefits/Insurance Officer Provide FEHB information and ensure employees make an informed choice Hold health fairs and service days Determine employee s eligibility to enroll and whether family members meet FEHB requirements Review enrollment reconsideration requests 9

10 Agency Responsibilities Ensure election forms are properly completed Process health benefits actions and determine proper effective dates Make belated change determinations Determine capability of self-support of children over age 22 Stock and distribute FEHB forms and literature 10

11 Agency Responsibilities Maintain and certify necessary records Account for and remit premiums Reconcile enrollment records with carriers 11

12 Carrier Responsibilities Determine eligibility to enroll in plan Furnish a plan identification card to each enrollee Process claims and/or provide services to enrollee and covered family members Reconsider disputed claims Reconcile enrollment records with agencies 12

13 Carrier Responsibilities Print and distribute plan brochures Maintain financial and statistical records and report on plan operations Develop and maintain effective communication and control tools 13

14 Enrollment Reconciliation Plans must reconcile with agencies Clearinghouse Enrollment Reconciliation (CLER) can help you reconcile OPM CLER Agency Carrier 14

15 The FEHB Program Contract Cycle The Negotiation Process 15

16 The Negotiation Process Plans review benefits and rates in comparison to FEHB Program competition Plans review the Annual Call Letter and develop a proposal in response Negotiations officially begin when plans submit proposal by May 31 st 16

17 The Annual Call Letter Published each year in early April Provides FEHB Program policy guidance Details specific negotiation objectives for benefit and rate proposals Includes a checklist for additional information that must accompany the benefit proposal 17

18 Technical Guidance and Instructions for Preparing Benefit Proposals Published after the Annual Call Letter (in late April or early May) Provides comprehensive instructions for preparing the plan s proposal Details specific benefits requirements for HMOs Includes Contracting Officials Form and Service Area Expansion Statement Provides the format for submitting benefits and service area changes and clarifications 18

19 Benefit and Rate Proposals Received by OPM no later than May 31 st Must be fully documented and complete Must incorporate all policy guidance from the Annual Call Letter, Technical Guidance, and Rate Instructions Report on all FEHB Program initiatives as outlined in the Annual Call Letter and the checklist OPM will conclude all benefits and rates negotiation by early August 19

20 Proposed Benefit Changes Must incorporate each Annual Call Letter objective Must be cost neutral even when adding OPM required benefits Must contain premium increases Must include state mandated changes Should increase a plan s competitiveness 20

21 Rate Proposals for Community-Rated Plans Must reflect the Community Package we purchase Must include all necessary and supporting documentation of the rates Submit a copy of the group contract the greatest number of non-federal subscribers purchase Must strictly adhere to the instructions for preparing rates as provided by OPM 21

22 Rate Proposals for Experience-Rated Plans Must strictly adhere to the instructions for preparing rates as provided by OPM Submit rate proposal based on projected actual claims experience (dollars for services) for FEHB members 22

23 The FEHB Program Contract Cycle Benefit and Rate Negotiations Closeout 23

24 At the Conclusion of Negotiations Plans must produce a brochure that accurately reflects all negotiated benefit changes and necessary language clarifications The brochure must comply with OPM s format and section 508 requirements for materials for the visually impaired OPM contract specialist will review the text of the brochure and authorize the number of printed brochures chargeable to the FEHB 24 contract

25 At the Conclusion of Negotiations Rates for all plans are published in the OPM Press Release during mid-september Plans print their FEHB brochure and distribute it to current members, Federal agencies as requested, and to prospective members Plans send a specific quantity to OPM s distribution point in Cedar Rapids, Iowa for distribution to Federal annuitants 25

26 At the Conclusion of Negotiations Plans submit zip code information for the search tool on the OPM Open Season web site Plans develop supplemental literature for distribution to Federal enrollees Plans contact Federal agencies to schedule participation in health fairs 26

27 The FEHB Program Contract Cycle Open Season 27

28 What is Open Season? An enrollment opportunity for Federal employees and annuitants to: Choose a health plan and enroll in the FEHB Program for the first time Change from one health insurance plan to another Change the type of enrollment (Self or Family) or plan product (option) 28

29 When is Open Season? Held each year from Monday of the second full work week in November through Monday of the second full work week in December 29

30 Open Season Effective Dates Enrollment changes are effective on the first day of the first full pay period in the new year An employee s effective date depends upon the pay cycle Biweekly (most begin on a Sunday, but U.S. Postal Service begins on a Saturday) Monthly Semi-monthly (every four weeks) An annuitant s effective date is January 1 st 30

31 The FEHB Program Contract Cycle The Contract 31

32 The FEHB Program Contract Standard contracts Experience-rated Community-rated The FEHB brochure is Appendix A (the contractual statement of benefits) Negotiated biweekly net-to-carrier rates are in Appendix B Experience-rated contracts include a contractual expense limitation (for administrative expenses) and service charge in Appendix B 32

33 The FEHB Program Contract FEHB Program contract is negotiated annually and is effective from January 1 to December 31 Virtually automatic renewal Carrier suggestions are solicited for changes to contract and comments on proposed changes by carrier letter 33

34 Contact Information Shirley R. Patterson Chief, Insurance Services Programs 34