Blue Cross Plan Means High Costs for Some; Senator Calls for Changes

By STEPHEN LOSEY
The Federal Times
December 4, 2008 

December 04, 2008 Lawmakers on Tuesday accused Blue Cross Blue Shield of burying "in the fine print" a change in health insurance coverage that could leave some patients paying a hefty surgery co-payment beginning in January. Sen. Benjamin Cardin, D-Md., called on the Office of Personnel Management to reverse the changes. Patients under the Blue Cross Standard option who go to an out-of-network surgeon next year will have to pay a $7,500 co-pay. Patients will have to repay the entire co-pay each time they have additional surgeries from out-of-network doctors. Blue Cross' Standard plan is the most popular plan in the Federal Employees Health Benefits Program, covering more than 4 million people, which is about half of enrollees. 
 

Patients also will have to pay an $800 co-pay for anesthesia provided by an out-of-network anesthesiologist and a $350 co-pay for emergency room care administered by an out-of-network physician. Out-of-network surgeries for medical emergencies and accidental injuries are billed differently. For emergency surgery, the patient pays 30 percent of the plan allowance and up to $5,000 of the difference between the plan allowance and the total bill. For accidental injury surgery, the patient pays up to $5,000 of the difference between the plan allowance and the billed charges. Federal employees have until Dec. 8 to choose their health plans for 2009.

Lawmakers and some industry observers said OPM did not do enough to inform participants of the changes. OPM officials did not mention the changed coverage for out-of-network surgeries at a Sept. 25 news conference on the new federal health care plans prior to the open season. The change was listed among 43 total changes in Blue Cross' 136-page brochure. "You don't bury this cost increase in the fine print," Del. Eleanor Holmes Norton, D-D.C., said at a Dec. 3 hearing of the House Oversight and Government Reform subcommittee on the federal work force, Postal Service and the District of Columbia. Walt Francis, a consultant who writes the annual Checkbook health care guide for federal employees, agreed. "It's a ‘gotcha,' " he said. Cardin on Wednesday called on OPM to reverse the changes. "Because health plan choices automatically renew from year to year, a major change in out-of-pocket costs for patients facing surgery would be a catastrophic surprise for individuals dealing with a major health issue," Cardin said. "This is unacceptable and jeopardizes access to care."

Previously, patients covered by Blue Cross Blue Shield paid 25 percent of the plan allowance - which varied depending on the procedure and the health care provider - plus the entire difference between the plan allowance and the total billed amount. That meant there was no cap on what patients might have to pay on some out-of-network health care procedures. As a result, the $7,500 cap is an improvement for patients, said Nancy Kichak, associate director of OPM's Strategic Human Resources Policy Division. Kichak gave the example of one patient who had out-of-network back surgery in 2007 and had to pay nearly $58,000. Blue Cross paid $5,700 of the plan allowance for that patient's surgery, Kichak said. "That's the real ‘gotcha,' " Kichak said. "The set co-payment of $7,500 enables members to know, should they choose a nonparticipating provider, that they will be responsible for paying only up to that amount." Kichak told lawmakers that less than 3 percent of surgeries performed under Blue Cross Blue Shield are out-of-network and the changes will cut costs for many participants using out-of-network surgeons. Although Kichak defended the change in the Blue Cross plan, she said OPM should have done a better job informing participants that it was coming. "I think we should work on the language,"