Open Season, Part Deux

When the most popular plan in the federal health program makes a change in its out-of-network benefit, workers, retirees and politicians covered by said plan demand a change. And they got it. The flap about the very popular Blue Cross standard plan prompted complaints from policy-holders and that produced a media blitz that in turn produced last minute congressional hearings.

The result: Although the health insurance open season ended on Dec. 8 federal agencies have been told to accept “belated” enrollments through January 30. English translation: You have until then (not Dec. 8) to pick your plan.

So, what happened? Explaining the problem, the correction and the solution is only slightly less complex than the formula for changing sand to gold. So here is the explanation from BC-BS about its new standard option benefit:

As a result of our collaborative efforts with OPM and in response to their request that all Federal Employees Health Benefits Program plans re-evaluate out-of-network surgical service payments, we have improved the process and FEP’s Standard Option members now will have a benefit consistent with other out-of-network services in 2009…We thank Rep. Danny Davis (D-Ill.) for his attention to this matter and his support of our efforts to reach a workable resolution. We also want to thank our members for their patience as we worked with OPM to find a solution.

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Under the new benefit, FEP will pay 70 percent of the amount specified by the plan allowance for planned surgeries performed by non-participating providers and members will be responsible for 30 percent of that allowance. This 30 percent of the allowable expense is their financial responsibility along with the FEP Standard Option’s annual deductible. These costs will be limited by FEP’s annual catastrophic maximum of $7,000. This benefit does not apply to emergency surgery or surgery for accidental injuries within 72 hours of such an occurrence.

In addition to their 30 percent responsibility, members using a non-participating surgeon will, as they have in all previous years, be responsible for making up the difference between FEP’s plan allowance and the billed amount or the “balance bill.” To provide Standard Option members with information to help them avoid unexpectedly high balance billing, FEP is initiating a pre-approval process for higher-cost out-of-network surgeries – meaning out-of-network surgeries with a billed charge of $5,000 or more.

Generally, the cost of care is less if a Blue Cross and Blue Shield preferred or a participating provider is used but when a surgery is planned using a non-participating provider, Standard Option members may call the customer service number located on the back of their I.D. cards before the surgery to request prior approval. This process will give members using non-participating providers specific benefit information to help them estimate their out-of-pocket costs. Using this information, members can make a more informed decision about the provider or surgeon they select for their care with a more thorough understanding about their medical bills.

More detailed information will be mailed to members and made available on the FEP website during the week of December 15th.

Bottom line: No matter how much you like your doctor, be sure he or she is part of your particular health plans’ PPO network or be prepared to pay more.

Nearly Useless Factoid

Want to save some money this holiday season? According to Amusingfacts.com in England during Queen Victoria’s time, oranges were given as Christmas presents. The perfect gift for the entire family!

To reach me: mcausey@federalnewsradio.com

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