Health benefits see little change in open season

The Federal Employees Health Benefits (FEHB) program began its open season last week during which federal employees retirees and survivors can switch their health benefit plans. Very little has changed in terms of the benefits being offered by individual plans. That is because the Office of Personnel Management in its effort to keep costs down has told plans to keep benefits static. Still federal employees should take advantage of the open season which runs through Dec. 9 to carefully weigh the different plans.

Open season gives participants who currently have family coverage an opportunity to elect self-only coverage. Participants whose spouses also work for the federal government those with no children or those who have chosen a plan that offers a better deal for two self-only enrollments than for one-family enrollment should consider this option.

Participants should watch for a few minor changes in benefits. Overall average premiums will rise by 2.4 percent for 1997. That is somewhat less than the overall rate of inflation so that is not bad.

On the other hand this low increase rate is not consistent throughout all plans. The largest health benefit plan Blue Cross/Blue Shield actually offers a reduction in premiums while most other health benefit plans have increased their premiums - some of them substantially.

These increases can be partially attributed to "adverse selection." This is the technical term used by insurance professionals to describe the phenomenon whereby heavy users of health benefits flock to plans that offer superior benefits causing those plans to incur significant costs and raise their premiums.

In another new development OPM for the first time conducted a customer satisfaction survey of health plan users during the past year. The results contained in the 1997 FEHB guide rate customer satisfaction for access to care coverage doctors available within a preferred provider network customer service especially providing status information to claimants claims processing and other categories.

I think this is very useful information that participants should use when they determine which health benefit plan to choose.

The information is presented in a format that allows participants to compare plans. The survey ranked the Government Employees Hospital Association (GEHA) plan as best among those open to all federal employees. The Foreign Service and SAMBA plans also received the "top rated" designation but these plans are open only to certain employees.

The survey also includes separate customer-satisfaction ratings for the five largest fee-for-service prescription drug program plans. The scores vary considerably. For example the Mail Handlers plan had a score of only 54 out of 100 for its prescription drug benefits while the National Association of Letter Carriers had a score of 93. The guide also provides information on health maintenance organizations (HMOs) based on an evaluation by the National Committee for Quality Assurance (NCQA) a nationally recognized leader in evaluating managed-care plans such as HMOs.

NCQA evaluates how well a health plan manages its delivery system but it only reviews plans at the request of the benefits provider. Because an NCQA review could result in a denial of accreditation my guess is that plans that are not accredited may have some problems the providers would rather not expose to an outside organization. Plans can receive one-year accreditation and provisional accreditation from NCQA. Both categories are progressively poorer than full accreditation.

All fee-for-service plans have preferred provider organization (PPO) networks. If you use health care providers that are in the PPO network you pay less than if you use nonparticipating providers. Clearly the plans would prefer you use health care providers that are in their PPO network because these providers have agreed to charge less for their services.

Another change in health care coverage involves point of service (POS) a new term that has cropped up in FEHB literature. POS refers to a managed care plan that like an HMO allows members to choose service from a selected network of providers. But unlike an HMO a POS plan also gives customers the option of obtaining service from other providers at an extra charge.

The only plan offering a POS program on a nationwide basis is the Postmasters plan. If you use the plan's network of providers your out-of-pocket expenses are minimal - just about what they would be if you were in an HMO. But if you use out-of-network providers you are subject to substantial out-of-pocket costs in the form of deductibles co-insurance charges and co-payments.

You should look at the last few pages of your current plan's brochure - as well as those from any other plans that you may be interested in - to see what changes have occurred. If you are satisfied with your plan and the premiums are not rising too much this year you are probably better off staying put.

If you are unhappy with your plan review the other plans and see how they compare. It is possible that none of the plans are going to offer more than your present plan.

The only other variable in this equation is to make sure your doctors continue to work within your PPO in 1997. Doctors drop in and out of PPO organizations so this is something worth checking out. If your family doctor is leaving the PPO of your fee-for-service plan you will have to pay a larger co-insurance charge if you want to continue to use this doctor.

If your doctor is joining another plan's PPO check out that plan to see whether it meets your needs.

Bureaucratus is a retired federal employee who is a regular contributor to Federal Computer Week.