Late Friday afternoon, shortly after the FEHBlog hit post on Friday’s message, HHS issued its proposed ACA benefit and payment parameter notice for 2017 which clocks in at 381 pages.  This rule principally provides guidance to qualified health plans in the exchanges but some of the guidance  extends to plans outside the exchanges including FEHB plans.  Here are links to the HHS fact sheet ,  Professor Tim Jost’s initial column on the annual rulemaking, and even a Washington Post article.

With respect to provisions that do apply to the FEHBP, the notice proposes  (p. 215)that the “2017 maximum annual limitation on cost sharing would be $7,150 for self-only coverage and $14,300 for other than self-only coverage.”  For 2016, “The maximum out-of-pocket limit for self-only coverage is $6,850 (up from $6,600 in 2015). For coverage other than self-only (such as family coverage), the maximum out-of-pocket limit is $13,700 (up from $13,200 in 2015).”  The maximum applies to deductibles, copayments and coinsurance but not premiums or out of network provider charges.

The notice (p. 275-76) also proposes to end the transitional reinsurance program after 2016 as it must.  The transitional reinsurance program requires most FEHB plans to contribute to a fund to help finance the QHPs in the exchanges.

This Week in Congress reviews the current week’s activities on Capitol Hill here. The House and Senate are leaving town for Thanksgiving and will return on November 30. At that point, there will be eleven calendar days for Congress to extend or finalize the continuing resolution that currently is funding the federal government.

Federal News Radio explains  with the help of Walt Francis why Open Season doesn’t have to be overwhelming.  Open Season continues until Monday December 14. Here is a link to the online chat that Federal News Radio held with Mr. Francis earlier this week.

Drug Channels reviews the steps that prescription benefit manager is taking to weed out of their retail networks pharmacies that have unholy links with drug manufacturers or act as mail order pharmacies, similar to Philidor.

The Wall Street Journal reports that the Centers for Medicare and Medicaid Services is considering imposing a penalty on doctors who order PSA tests which screen men for prostate cancer. “Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.”  This is another government initiative for value based medicine. According to the article many doctors aren’t amused by the initiative.

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”

Govexec.com suggests the best ways that federal and postal employees and retirees can obtain assistance with their Federal Benefits Open Season decisionmaking.

Avalere Health has concluded not surprisingly that health insurance premium changes reflects consumer spending on healthcare.

The prescription benefit manager (“PBM”) trade association informs us on the battles between PBMs and independent pharmacies that are being waged on Capitol Hill.

According to Medpage Today, the Centers for Medicare and Medicaid Services is pushing ahead with its initiative to create a new quality based payment model for joint replacement surgeries performed on Medicare beneficiaries.  “Known as the Comprehensive Care for Joint Replacement (CCJR) rule, the new regulation requires bundled payments for joint replacements to the lower extremities over a 90-day “episode of care” in 67 metropolitan areas.” The mandatory pilot takes effect April 1, 2016.

Finally Modern Healthcare reports that “Hospital and physician groups are cautioning the CMS that it needs better [quality] measures before it ties physician pay to quality and outcomes.” The FEHBlog expects that payers appreciate the providers’ concern.

OPM today posted its FY 2015 financial statements which discuss the FEHBP at several points — in particular Strategic Goal 9 beginning on page 23. On page 123, you will find a general OPM response to the Inspector General’s management challenges and recommendations which the FEHBlog discussed last week.

Professor Tim Jost in his Health Affairs explains that

The final rules make no major changes in the interim rules. Indeed, they make virtually no changes in the interim rules as interpreted by current guidance.
What the final rules do in many instances, however, is to incorporate existing [FAQ] guidance into final rule form. As guidance is not as legally authoritative as are regulations, this clarifies the legal status of existing interpretations of the rules. The finalization of these rules also makes it more difficult for a future administration to change them as the Obama administration nears its final year.
The final rule will go into effect on January 1, 2017, at which time the interim rules will no longer remain in effect.

The FEHBlog disagrees with Mr. Jost that the finalization of the rules makes it more difficult for a future administration to change them as interim rules are final rule. It is stunning to the FEHBlog that the ACA regulators did not open a new comment period given the lapse of time since the first round of comments.  But that’s the ACA for you.

We are entering the second week of the Federal Benefits Open Season. A reader submitted a FEHBlog comment  late last week asking about a particular plan’s prescription drug coverage. Because the FEHBlog represents FEHB plans, he will not post comments about plans, either positive or negative.  However, if readers want to email the FEHBlog with questions, he will try to help out.

Also this week, the federal agencies are issuing their financial statements for the fiscal year  that ended September 30, 2015.  Here is a Federal News Radio article on the Postal Service’s financial report which indicates that the Postal Service is banking, in part, on Sen. Carper’s postal service health program measure.  That measure would fully integrate Postal Service annuitant coverage with Medicare while preserving the existing risk pool structure — employees and annuitants in the same risk pool per plan option.

Finally, the FEHBlog’s attention was drawn to the Boston Globe article on health insurer efforts to tackle our country’s opioid abuse crisis with supported for those afflicted by it.

The growing costs — in the billions of dollars nationally — have spurred insurers to tackle the opioid problem through a variety of new measures, including imposing restrictions on prescriptions for painkillers like Vicodin and OxyContin, because addiction often starts with such drugs, lifting restrictions for addiction treatment, and deploying case managers and coaches to guide patients through treatment.
Blue Cross Blue Shield of Massachusetts, which first put limits on opioid prescriptions three years ago, is now contacting its members who are in detox programs to help coordinate their care and prevent relapses. Boston Medical Center HealthNet Plan, a subsidiary of Boston Medical Center, has assigned staff to call and visit members with addiction to help them find and stick with treatments.
Neighborhood Health Plan, the insurance arm of Partners HealthCare, where nearly 9 percent of members were diagnosed with substance abuse in the last year, recently partnered with Massachusetts General Hospital to hire a recovery coach to help members stay sober.

Well done.

Around this time of the year, OPM issues its annual Performance and Accountability Report. The report includes, among other items, the agency’s financials statements and the Inspector General’s management recommendations.  This year the Inspector General released those recommendations separately. Several pages of recommendations beginning on page 3 concern the FEHB Program. 

Because the FEHBlog is the blog of record for the FEHB Program, here is a link to OPM’s Open Season announcement issued yesterday.  Emphasis is placed on the federal employees flexible spending account programs.

Today, the Centers for Medicare and Medicaid Services finally announced 2016 Medicare Parts A and B cost sharing amounts.  Complete tables of premiums, deductibles and other cost sharing amounts may be found at the link. Thank heavens.

The Hill provides a progress report on Congressional efforts to kill the 40% excise tax on high cost employer sponsored coverage.

The Robert Wood Johnson Foundation and the University of Wisconsin released their 2015 U.S. county health rankings, right here.  Modern Healthcare reports

The analysis ranks the health of each state’s county against the healthiest county in the state and provides strategies for improvement. It doesn’t compare counties from different states.  “Americans love rankings,” said Bridget Catlin, who directs the program at the Population Health Institute in Madison. “But we wanted to identify opportunities toward providing everybody a fair chance to be their healthiest and how many deaths could be avoided if every county could be as healthy as the healthiest.”

The Federal Benefits Open Season begins tomorrow and will end on December 14.  Self plus one enrollment will be available in the FEHB Program this Open Season. The Washington Post warns that some plans charge an enrollee premium for self plus one coverage that is more than the enrollee premium for self and family coverage.

In all FEHBP plans, the total self plus one premium (government plus enrollee contribution) is less than the total self plus family premium. Nevertheless because the government contribution for self plus one coverage is less than the government contribution for self and family coverage, the enrollee contribution for self plus one can exceed the enrollee contribution for self and family if the total premiums for the two enrollment types are close to one another in amount. The Washington Post article explains the reason for such an outcome (it’s the FEHB Program’s demographics at work)

For example, assume the following facts — the total premium for self and family is $100 and the government contribution is $75; the total premium for self plus one is $90 and the government contribution is $60. In that event the enrollee contribution for self plus one would be $30 and the enrollee contribution for self and family would be $25.  You can elect self and family if there are two people in your family group.  Look before you leap.

As the FEHBlog noted on Friday, Congress is out of town this coming week.  The Hill reports that the Democratic leadership in Congress is actively pushing for repeal of the 40% excise tax on high cost employer sponsored health coverage.

Opponents of the 40 percent excise tax on high-cost health plans believe 2015 is their last, best chance to get the provision repealed before presidential politics grind the legislative process to a halt.
With just two months left in the year, sources say the most ideal option for Democrats is attaching repeal to the package known as “tax extenders.” The cost of the extenders bill is typically not offset, making it an attractive vehicle for ending one of ObamaCare’s biggest revenue generators.
Reid and Pelosi have not settled on a plan and are leaving their options open, the aide said, adding that the work on ending the tax could carry over into next year.
“It is clearly a commitment for the Democratic leadership,” AFL-CIO lobbyist Tom Leibfried said in an interview in his downtown office Friday. “We think there’s a real chance to get this done, as big a lift as this is.”

Hope springs eternal.

Last week, Truven Analytics issued its annual list of top performing cardiovascular hospitals in the U.S. as reported in Cardiovascular Business.  Modern Healthcare adds that

Leaders at Truven’s top cardiovascular hospitals say standardizing care enables them to be more cost-effective. “By adhering to guidelines, you should see better quality,” said Dr. Mohamed Hamdan, chief of cardiovascular medicine at the University of Wisconsin. “I don’t think that ordering more tests results in better quality. But ordering the right test is better and less costly.” 

Here’s a link to The Week in Congress’s report on what happened up on the Hill this past week. The Hill reports on the ongoing battle over the excise tax on high cost employer sponsored coverage. Congress is adjourned until November 16.

Next Monday is the beginning of the Federal Benefits Open Season. OPM has updated its FEHB website with 2016 plan information. The FEHBlog noticed that OPM is offering a link to plan benefit summaries for 2016 which also can be helpful.

The Washington Post reports that OPM has hired Clifton Triplett to serve  as the senior cyber and information technology adviser to the acting OPM Director Beth Cobert. Mr. Triplett says “his mission is twofold: To create a ‘new culture of security’ at the OPM and upgrade some of the oldest information technology systems in government — quickly.”  Best wishes.

Earlier this week CMS released an interactive map “which shows geographic comparisons at the state, county, and ZIP code levels of de-identified Medicare Part D opioid prescription claims – prescriptions written and then submitted to be filled – within the United States” in 2013. This new mapping tool allows the user to see both the number and percentage of opioid claims at the local level and better understand how this critical issue impacts communities nationwide.” There is widespread use of opioids across the court with the heaviest utilization in Alabama, Nevada, and Oklahoma.