OPM Seeking More Cost Controls for Federal Employee Health Insurance

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By on January 29, 2018 in Pay & Benefits with 0 Comments

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The Office of Personnel Management (OPM) has issued its annual call letter for benefit and rate proposals for Federal Employees Health Benefits (FEHB) Program. The annual letter outlines policy goals and initiatives for the FEHB Program for 2019. The call letter provides an idea for FEHB participants as to changes that may be implemented in 2019 in this significant federal employee benefit.

Emphasizing Quality and Affordable Health Insurance

The agency notes it is emphasizing quality and affordable health insurance coverage in 2019 for federal employees. The call letter states:

(OPM) has developed an agency strategic objective to improve the quality of healthcare received by enrollees in FEHB plans, increase the affordability of FEHB plans, and enhance the portfolio of available FEHB plans to increase the proportion that offer high quality at an affordable cost. In alignment with this strategy, this year’s Call Letter focuses on topics that we believe will keep the FEHB Program on a path of innovation, quality, and affordability well into the next decade.

To meet this objective, OPM is suggesting that health insurance companies in the FEHB consider items such as “proposing a distinctive new plan option with value, such as:” :

  • Modifying cost sharing for high-value and low-value benefits to help ensure members are getting the most value for their health care dollar;
  • Implementing high-performance tiered provider networks that offer reduced cost sharing for members who choose a provider(s) from such a network;
  • Reducing cost sharing when members take action to manage chronic conditions, or obtain higher-quality or more efficient care through creative provider or vendor partnerships (e.g., patient-centered medical home [PCMH], cancer management);
  • Improving enrollee engagement and decision support through online portals and other key communication methods, and
  • Exploring innovative models that include other cost management techniques, such as new evidence-based utilization management in medical or specialty pharmacy.

Bottle of prescription pills lying on its side with some of the pills scattered around the opening of the bottle

Prescription Drugs and the FEHB

The cost of drugs is a huge part of FEHB expenses. OPM notes that, “[I]n 2016, 26.2 percent of total FEHB expenditures were on prescription medications.” But, while this is a major expense for the FEHB, the call letter states, “Studies have shown that approximately 50 percent of medications for chronic disease are not taken as prescribed.”

Therefore, the agency is asking health companies in the FEHB to find ways to make better use of the drugs that are prescribed, including making sure that people are adhering to how the medicine is supposed to be used to be effective.

OPM is also asking the carriers to “review their contracts and require that members are charged the lesser of the prescription price or applicable copayment amount for prescription medications.” The agency is also urging the companies to use new technology including “electronic prior authorizations” for prescription medicines.

The intended result of this change is to provide quicker turnaround time and to reduce the number of prescription abandonment rates which is apparently a significant problem.

Addressing the Opioid Epidemic

The call letter also emphasizes the opioid epidemic in the U.S. The call letter says that there are a number of items that must be included in the 2019 health plans for the FEHB on this subject. These items include ways to reduce the number of prescriptions for opioids when other alternatives may be available. There is also to be more emphasis on rehabilitation programs for addiction to opioids.

The call letter notes a new system is now in place for tracking opioid use from multiple providers as well as data on prescription and addiction to these medications.

Genetic Testing

As advances in science and medicine are made, health insurance needs to try and keep up with changes. Genetic testing is one area that is becoming more relevant. FEHB participants may start to see significant changes in this area in 2019.

One expense with regard to the FEHB that is now showing up is that “As the number and complexity of these (genetic) tests increase, OPM is receiving more member appeals and disputed claims.”

The area of genetic testing is complex and changing. OPM avoided dictating what the FEHB plans should include and noted some of the problems the agency sees with existing health plans in this area. Instead, OPM wrote:

We strongly encourage FEHB carriers to review their current benefits and propose any needed revisions for 2019. All proposals should include a description of the carrier’s genetic testing strategy, scope of included testing, and any applicable vendor partnerships.

Paying Attention to FEHB Plans

FEHB plans change every year. Many readers will also have changes in their health or personal situation from one year to the next.

The OPM call letter will provide some idea of changes that may be incorporated into FEHB plans in 2019. Readers that take the time to research changes in benefits and premiums may find this is a good use of their time and money instead of just renewing the same plan year after year.

Annual Call Letter from the Office of Personnel Management for Health Insurance Carriers in the FEHB. by FedSmith Inc. on Scribd

© 2019 Ralph R. Smith. All rights reserved. This article may not be reproduced without express written consent from Ralph R. Smith.

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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. Follow Ralph on Twitter: @RalphSmith47

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