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Strategic Objective

SG09.01 Sponsor high quality, consumer friendly, affordable insurance products

Strategic Objective

Increase the percentage of states covered by at least one Multi-State insurance issuer and percentage of states covered by two or more Multi-State insurance issuers.

Increase the number of carriers receiving OPM “Exemplary”

Increase the percentage of states covered by at least one Multi-State insurance issuer and percentage of states covered by two or more Multi-State insurance issuers.

Increase the number of carriers receiving OPM “Exemplary” or “Most Improved” distinction for health care quality or customer service.

Improve overall satisfaction with health plan as reported by health plan enrollees in Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Decrease the number of ineligible dependents on enrollee’s FEHB coverage.

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Lead Office: Healthcare and Insurance

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Overview
Progress Update

Overview

Ensuring Multi-State Plans (MSP) and Federal Employees Health Benefits (FEHB) health plans cover the full range of Essential Health Benefits.
Leveraging our experience in the FEHB and MSP programs to identify and implement best practices across the insurance portfolio.
Providing responsive customer service to insured populations.
Analyzing complaints and appeals to elucidate opportunities to better meet the needs of enrollees.
Updating electronic consumer decision support and health plan selection tools to optimize enrollee choice.
Developing a comprehensive health plan

Progress Update

OPM administers the Federal Employees Health Benefits (FEHB) Program, which includes a comprehensive package of health benefits for more than 8.2 million employees, retirees, tribal employees, and dependents. One of OPM’s aims is to restrain premium increases while offering essential health benefits. OPM engages in annual negotiations with health carriers and has been able to limit average premium increases to less than 6.5 percent for five years. Another aim is to ensure enrollees have sufficient information needed to make a health plan decision. OPM provides plan brochures, web-based decision tools, and customer satisfaction survey results to enrollees prior to the annual Open Season. A third aim is to ensure a variety of plan options are available to enrollees. OPM is adding four new health plans for the 2016 plan year.

OPM also administers the Multi-State Plan Program established under the Affordable Care Act. The Multi-State Plan Program provides Americans more options for affordable coverage through www.healthcare.gov. For the 2015 plan year, OPM contracted with 13 Consumer Operated and Oriented Plans, and also contracted with 38 Blue Cross and Blue Shield plans. Collectively, they offered 179 individual plan options that consumers could purchase from the marketplace as well as 33 options available through the Small Business Health Options Program. OPM has not yet finalized negotiations with Multi-State Plan Program plans for the 2016 plan year.

As of the beginning of 2015, applicable large employers, including the Federal Government, were subject to the Employer Shared Responsibility provisions under sections 6056 and 4980H of the Internal Revenue Code. These employers are required to submit information to the Internal Revenue Service about the health insurance offered to eligible full-time employees. They are also required to furnish this information to their full-time employees. This information is due to the IRS and must be provided to employees in early CY 2016. One of OPM’s roles as administrator of the FEHB Program is to provide guidance to agencies to facilitate their compliance with Internal Revenue Code section 6056. To assist Federal agencies in their administration of these provisions, OPM has provided guidance on its website. During FY 2016, OPM will continue to work with Federal agencies, shared service centers and health insurance carriers to ensure reporting requirements are met by the CY 2016 deadlines.

OPM, in consultation with the Office of Management and Budget, has determined that performance toward this strategy is making noteworthy progress.

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Strategic Goals

Strategic Goal:

SG9 Healthier Americans

Statement:

Increase the percentage of states covered by at least one Multi-State insurance carrier and percentage of states covered by two or more Multi-State insurance issuers. Increase the number of carriers receiving OPM “Exemplary” or “Most Improved” distinction for health care quality or customer service.

Improve overall satisfaction with health plan as reported by health plan enrollees in Consumer Assessment of Healthcare Providers and Systems (CAHPS). Decrease the number of ineligible dependents on enrollee’s FEHB coverage.

Strategic Objectives

SG09.01 Sponsor high quality, consumer friendly, affordable insurance products

Statement:

Increase the percentage of states covered by at least one Multi-State insurance issuer and percentage of states covered by two or more Multi-State insurance issuers.

Increase the number of carriers receiving OPM “Exemplary” or “Most Improved” distinction for health care quality or customer service.

Improve overall satisfaction with health plan as reported by health plan enrollees in Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Decrease the number of ineligible dependents on enrollee’s FEHB coverage.

Description:

Ensuring Multi-State Plans (MSP) and Federal Employees Health Benefits (FEHB) health plans cover the full range of Essential Health Benefits.
Leveraging our experience in the FEHB and MSP programs to identify and implement best practices across the insurance portfolio.
Providing responsive customer service to insured populations.
Analyzing complaints and appeals to elucidate opportunities to better meet the needs of enrollees.
Updating electronic consumer decision support and health plan selection tools to optimize enrollee choice.
Developing a comprehensive health plan assessment methodology that evaluates health care quality, customer service, and financial performance.

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SG09.02 Optimize insurance related business processes

Statement:No Data Available

Description:No Data Available

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FY 16-17 Priority Goal: FEHB Plan Performance

Statement:

Improve health outcomes for the 8.2 million Federal employees, retirees, and their dependents enrolled in health plans participating in the Federal Employees Health Benefits (FEHB) program. In 2016, FEHB plan performance will be assessed based on a common set of measures of clinical quality, customer service and appropriate resource use; this performance assessment will be used in the determination of plan profit margins. While each plan will be assessed based on its performance, overall progress for the FEHB program will be measured by an increase in the number of FEHB plans at or above the 50^th percentile of the relevant national, commercial benchmark year-on-year as measured by FEHB plan scored values on the designated high priority indicators used continuously during the evaluation period. These high priority measures include: risk adjusted all cause readmissions, timeliness of prenatal care and blood pressure control.

Description:

To establish a consistent assessment system that includes objective performance standards, OPM has developed the FEHB Plan Performance Assessment. This assessment incorporates a discrete set of quantifiable measures to examine key aspects of health plan performance and a contract oversight evaluation by the contract officer. The FEHB Plan Performance Assessment will be linked to health plan profit. Quantifiable measures are grouped into three performance areas: Clinical Quality, Customer Services, and Resource Use (collectively termed QCR). The QCR measures consist of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. The National Committee for Quality Assurance (NCQA) oversees the set of HEDIS and CAHPS measures which is used nationwide to measure performance of health plans in various areas. OPM is using NCQA’s national or regional benchmarks in the FEHB Plan Performance Assessment.

To focus attention on priority issues, OPM has developed a hierarchy for the QCR measures. In assigning priority levels to measures, OPM considered whether the measure assessed health outcomes, supported specific OPM policy priorities, and was relevant to FEHB subpopulations with particular health needs. Improvement on these high priority measures will indicate improved quality and carrier focus on critical healthcare areas for the FEHB Program.

This assessment system directly supports Goal 9 of the 2014-2018 OPM Strategic Plan by requiring that FEHB health plans meet rigorous industry standards and higher levels of health plan accountability. These higher standards and increased accountability lead to higher quality health benefits available to federal employees, federal retirees, their families, and newly eligible populations. This new initiative is also closely aligned with the current Administration’s goal of health care system improvement and parallels other federal agency and private payer processes.

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SG09.03 Improve preventive services delivery to employees, retirees, families, tribal employees, and newly insured Americans

Statement:

Increase influenza immunization rates, reported as Flu Shots for Adults in CAHPS Effectiveness of Care Measures.

Improve timeliness of prenatal care as reported by health plans in Healthcare Effectiveness Data and Information Set (HEDIS).

Description:

Increasing influenza immunization rates through optimal use of health insurance benefits, occupational health resources, and employee wellness programs.
Improving access to and timeliness of prenatal care.
Increasing awareness and use of health insurance benefits for tobacco cessation.

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SG09.04 Develop novel partnerships in support of population health

Statement:

Lower Federal employee tobacco use rates as reported in the Federal Employee Benefits Survey

Description:

Prioritizing healthy workforce aims in the Chief Human Capital Officers Council, union negotiations, labor-management forums, and interactions with consumer advocates.
Promoting tobacco free workplaces.
Collaborating with Substance Abuse and Mental Health Services Administration to promote awareness of mental health and Employee Assistance resources available to Federal Employees.
Working with the General Services Administration to create a standard contract clause to promote healthy behaviors among embedded contractors.
Engaging with government agencies and private industry leaders to promote wellness in the work environment through healthy meal and vending choices, safe stairs and walking paths, inclusion of bicycle sharing in transportation subsidies, etc.

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SG09.05 Enhance outreach and health literacy

Statement:No Data Available

Description:

Ensuring Federal agency benefits officers are well informed about insurance programs.
Targeting use of Direct to Enrollee/Direct to Retiree Emails regarding Open Season and key benefits topics.
Communication to employees across all OPM platforms, including USAJOBS, USAStaffing®, Retirement ServicesOnline, EmployeeExpress, and OPM.gov.
Targeting agencies by enrollment to deliver educational seminars on Flexible Spending Accounts and insurance benefits.
Developing outreach strategy and implementing educational sessions to Indian Tribes on FEHBP.

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Agency Priority Goals

FY 14-15: PG3 FEHB Accountability

Statement:

Improve the efficiency of the Federal Employees Health Benefits Program and affordability of coverage offered to employees. By September 30, 2015, Reduce the rate of growth in per capita spending through a range of activities, including improved data analytics, enhanced accountability measures, and programmatic improvements.

Description:

OPM is continuing to focus on ways to optimize pharmacy practices to ensure the safe and clinically effective use of prescription medications while managing drug costs. We continue to monitor carrier performance in several areas of pharmacy benefits management, including overall pharmacy and specialty drug trends as well as generic dispensing rates. We will collect updated data on these measures of pharmacy performance. Most health plans offer programs such as step therapy, medication therapy management programs, and expanded use of prior authorization for selected drugs. Implementing programs of this type and using tiered drug formularies are positively correlated with better performance on overall and specialty drug trends and generic dispensing rates. We will negotiate with FEHB carriers plan to add and expand on these types of drug management programs that control costs and improve quality and patient outcomes.

OPM is implementing an FEHB Health Plan Performance Assessment project to measure and reward all FEHB plan performance (experience-rated and community-rated) through the use of common, objective, and quantifiable performance measures by the 2016 plan year. This will be a new approach to our assessment of the annual performance of health plans contracted under the program. The performance assessment framework will include a discrete set of qualitative and quantifiable performance measures that will be used to assess key aspects of performance. That overall assessment will then be linked to health plan profit factors. There are four primary categories of health plan performance to be assessed: clinical quality, customer service, resource use, and contract oversight.

Industry standards state that, in private employer plans, as much as 10 percent of health claim benefits paid are incurred by family members who are not eligible for coverage. The FEHB Program provides approximately 23 billion dollars in benefits annually for those covered under Self and Family enrollments. This may translate to approximately 23 million dollars for each percent paid in error. Under current FEHB procedures, agencies and the FEHB carriers both have responsibility for family member eligibility determinations. However, there is no evidence that family member eligibility is systematically verified at the time of the initial enrollment, when enrollment is changed during Open Season or upon experiencing a Qualifying Life Event (QLE) (although some agencies do require documentation for QLE changes) or at any time during the employee’s period of coverage. With the advent of electronic enrollment systems, enrollees can make certain FEHB enrollment changes without submitting any proof to their agency benefit officers.

The extent of ineligible family members covered under FEHB Self and Family enrollments is currently unknown. In addition, presently there is no centralized FEHB enrollment system to maintain a database of eligible enrollees and family members. Enrollment systems that currently exist do not require the input of family member dependent information. Thus, there is no centralized database of the FEHB enrollments and consequently, no mechanism to determine who is receiving benefits under any one Self and Family enrollment.

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