Moving Closer to Self-Plus-One Option Under FEHB

In December 2013, a budget deal reached in Congress allowed the Office of Personnel Management (OPM) to create a “self-plus-one option” in the Federal Employees Health Benefits Program. OPM is moving forward to implement the new system as outlined in the “FEHB Program Carrier Letter” dated March 13, 2015.

Lower Rates Likely for Self-Plus-One Option Under FEHB

The major change in the federal employee health insurance program for 2016 will be the addition of self-plus-one to the current two options of self-only and self-and-family.

While the new insurance rates for 2016 will not be known for some time, under the “self-plus-one option”, a couple using the FEHB system is likely to have lower rates than the family rates under this program.

“We expect proposals for Self Plus One rates to be lower than Self and Family rates. In no event can Self Plus One rates be higher than Self and Family rates,” OPM advised the health insurance companies in its call letter.

It is also likely that some federal employees with children are likely to face an increase in the cost of their health insurance. In a proposed rule issued in December 2014, OPM noted that those who use the self plus one option are likely to have lower premiums, and the premiums are likely to increase for those with the family plans.

No doubt, that is exactly what those who are looking forward to the new plan hope to see as a couple using the Federal Employee Health Benefits Plan (FEHB) will probably pay less than the family rate for their health insurance. For a number of years, readers have commented that the existing system of requiring a couple to purchase a health benefits plan at the same rate as an entire family is not reasonable.

OPM has noted in previous guidance that the second person in a self-plus-one enrollment would have to be someone who would be eligible as a family member under current policy. In plain English, this means, for example, that while same-sex spouses are eligible for enrollment in the FEHB, as noted in the call letter,  “domestic partners” will not be eligible. While that may change in the future, it will apparently require Congressional authorization for this change and that has not been forthcoming.

Medicare and the FEHB

OPM notes in its call letter that new “Medicare-eligible Federal retirees are enrolling in Medicare Part B in declining rates. In the past 15 years, the participation rate in Part B for newly eligible annuitants has declined by twenty percent among fee for service plans and by ten percent for HMOs.”

OPM is asking insurance companies to “propose benefit changes that allow members to maximize their benefits under FEHB and Medicare, such as reduced cost sharing under hospital, medical or pharmacy benefits for members with part B.

Other Changes Likely in 2016 FEHB Plans

There will be other changes in the 2016 FEHB insurance plans as well. As noted in the OPM call letter, “benefits that vary between enrollment type, such as catastrophic maximum, deductibles and wellness incentives should be for dollar amounts that are less than or equal to corresponding benefits in Self and Family enrollment.”

Other benefits under the federal program, such as the amount of copays and coinsurance amounts, are probably going to be the same regardless of whether a participant is using the self-plus-one option or the family plan.

Other changes for 2016 that may impact readers include:

Transgender Services—For 2016, health plans under FEHB may pay for proposed services for members with gender sysphoria as they do for all other medical conditions. Surgical services offered must include “details of preauthorization or case management requirements….”

In-Network Benefits—OPM is encouraging all plans to work with institutional providers to address the fact that FEHB members receive bills from non-network providers who render services in network hospitals. The bills from non-network providers can cost more and OPM would like to have in-network options provided “whenever practicable” with notice provided before non-network services are provided.

2016 FEHB Call Letter

© 2016 Ralph R. Smith. All rights reserved. This article may not be reproduced without express written consent from Ralph R. Smith.


About the Author

Ralph Smith has several decades of experience working with federal human resources issues. He has written extensively on a full range of human resources topics in books and newsletters and is a co-founder of two companies and several newsletters on federal human resources.