Access to Physicians Under FEHBP Plans in Selected Montana Counties Source: Senate Finance Committee staff analysis of Medicare physician participation data, www.fepblue.org, www.geha.com, and www.firsthealth.com. Answer: Since the fee-for-service_plans introduced preferred provider networks into the Federal Employees Health Benefits (FEHB) Program in the 1980s, we have always made clear in our informational materials that the preferred provider benefit is an enhancement over the standard non-network benefit offered by the plans. In a typical network arrangement, the provider agrees to accept a rate of payment lower than billed charges in exchange for advantages such as more potential patients, expedited reimbursement, and other services offered by the plan. Often plans monitor the services provided in-network to ensure that their providers are well informed about current practice patterns and new developments in health care delivery. The plan, in turn, can pass on the benefits it derives from provider participation in the network to members in the form of lower out-of-pocket costs when they use a preferred provider. Those lower costs are offered as an incentive to members to choose in-network services when they are available. We have never guaranteed in-network coverage except in the Blue Cross Blue Shield (BCBS) Basic Option. Since Basic is an Option in a nationwide plan and it provides no coverage for outof-network services, we negotiated special provisions to ensure that coverage would be available everywhere in the country. While the other nationwide plans, such as GEHA and Mail Handlers, make a concerted effort to keep expanding their networks, they do not guarantee in-network coverage everywhere in the country. However, GEHA and Mail Handlers members have access to all of the providers available in the community. But for those providers that have not agreed to accept a discounted payment rate, the member does not get the advantage of reduced out-ofpocket costs. Information on provider availability is available during the annual open season, and members make their plan election based on that information as well as other factors that help them determine which plans best suits their needs and the needs of their family. Question 2: During your testimony to the Finance Committee, I asked you whether enrollees in FEHBP have access to specialists located in rural areas. You responded: I think that we can demonstrate that there are not only primary care physicians but specialists available. Although there are certain differences among the plans and as I suggested earlier, Blues basic is probably the best, simply because of the structure of that plan it was necessary for them to make special arrangements to have access absolutely everywhere our other fee-forservice plans may not have broad access, but they have reasonably good access, I must say. Later, you added: In urban areas, where there are more providers available, some may not be in the network. But typically in areas where there are fewer providers available, virtually every provider is in the network, because that's the only way you can arrange in-network service in every geographic area. However, a recent analysis by Senate Finance Committee minority staff found that even the Blue Cross Blue Shield Standard Option does not include many spe cialists in its network, and as a result, many rural Montanans must travel significant distances to receive care from an in-network specialist or else face higher deductibles or cost-sharing amounts. Montana Access to Selected Specialists Under Medicare and FEHBP Blue Cross Plan Source: Senate Finance Committee staff analysis of Medicare physician participation data, www.fepblue.org, and www.bluecrossmontana.com. Based upon this analysis, do you still believe that Blue Cross enrollees have reasonable access to in- network health care providers in rural Montana? Answer: For the record, the BCBS rural access standard for key specialties, including cardiology, gastroenterology, general surgery, ophthalmology, orthopedic surgery, otolaryngology, and urology, is that 90 percent of members will have access within 75 miles of their home. In rural areas, there may be isolated instances where highly specialized_care is not available at the Preferred benefit level within a 75 mile travel distance. In most instances this is due to the fact that there is no provider in the area. The Montana BCBS plan requires that all of its providers be credentialed. The credentialing process protects consumers because it ensures that the providers who treat them meet generally accepted quality standards. Some providers decide that they do not want to complete the paperwork required. A few do not meet the credentialing requirement. Some of those who refuse to be crentialed, although they may not be Preferred, are Participating with BCBSMT. Many OB-GYN providers and Orthopedic Surgeons in the Bozeman area fall into that category. Participating providers, because they have a contractual relationship with the Montana Plan, cannot balance bill members for charges in excess of the Plan allowance under the BCBS Standard Option. In the specific instance you cite of a urologist practicing in Glasgow but not participating in the BCBS network, I have verified that the sole practitioner in that specialty has now retired. However, in all instances, primary care providers are available and routinely provide similar service to BCBS members. In addition, there are network specialists that visit rural hospitals to see patients on a weekly or monthly basis although they do not have offices in the area. While they do evalua tions, minor testing, surgeries and follow-up care, major diagnostic testing and/or surgery typically is done at an urban or suburban hospital. Finally, Basic Option members may use their "exception" process negotiated by OPM and noted in the BSBS plan brochure. The brochure directs members in special provider access situations to contact their Local Plan for more information. The "exception" process allows for case by case exceptions if a Preferred Provider is not available. However, since the providers whose services may be covered on an exception basis are not network providers, they are not listed in the plan directories. Members who contact the Local Plan prior to receiving services will be granted an exception if no Preferred Provider is available within the distances specified in the access standards. If a member receives services without contacting the Local Plan, the claim may be denied initially, but will be paid if reconsideration is requested in accordance with the provisions of the contract. Question 3: During your testimony to the Finance Committee, you discussed access to services from remote rural hospitals with Senator Breaux: BREAUX: You pick the most rural county in America, you probably have a Fish and Wildlife Service employee or a USDA employee or a postal worker that has the FEHBP health care plan. How does that person get insurance coverage when there is no competition. how does FEHBP guarantee that that person gets health care at an affordable price? BLOCK: Well there are a couple of ways. For one thing, as I mentioned earlier, under the Blue Cross-Blue Shield basic option, that plan, because it's a nation-wide in-network-only plan, has guaranteed access. Absolutely everywhere in the country has access to an in-network benefit. BREAUX: OK, suppose that hospital is the only hospital in the county? BLOCK: Then that plan has made special arrangements to include that hospital in its network.. BREAUX: But you have at least one national plan that would make sure that that hospital, that doctor, if they're the only ones in that county, are included in the plan that's offered by the FEHB provider? BLOCK: That's correct. Research by the Senate Finance Committee minority staff indicates that in Montana at least three rural hospitals are not included in the Blue Cross-Blue Shield network: Fallon Medical Complex in Baker, Big Sandy Medical Center in Big Sandy, and Dahl Memorial Hospital in Ekalaka. All of these hospitals participate under Medicare. But federal employees in these communities who are seeking in-network hospital care must drive thirty to sixty miles to obtain it sometimes across state lines. Based on this research, do you still believe that every facility that is the only hospital in a rural county is included in the Blue Cross-Blue Shield network? Answer: All BCBS members have access to the 3 rural hospitals cited in emergency situations. However, 2 of the 3 are not full service hospitals and could not provide the full range of services. Nevertheless, the Montana BCBS plan has asked all of those hospitals to accept a 10 percent discount if they participate in the network. These facilities have made the business decision to not accept the discount or participate in the network. BCBS of Montana will continue to seek their participation in the network. Question 4: Relatively few FEHBP enrollees switch plans each year, even in light of rapid increases in premiums. Some argue tat the fact that OPM does not require standardized benefits and cost-sharing makes it very difficult for enrollees to adequately evaluate their plan options. As a result, few enrollees switch plans during the open enrollment period. Would enrollees have an easier time selecting a health plan, if all of the benefit packages were standardized? Answer: OPM and the FEHB participating health plans provide extensive informational materials during the annual open season. In addition to printed information, the OPM web site offers retirees as well as employees data in user friendly format including decision support tools to facilitate plan comparison. Standardized benefits would dilute the strength of the FEHB Program which is consumer choice. Members would no longer be able to select the plan that best meets their needs if all plans were, in fact, identical. We believe that relatively few enrollees switch plans each year because the vast majority is very satisfied with the plan they are in. There is a one percent decrease in premiums due to enrollees switching plans, presumably because they have determined that the benefits by those plans meet their needs. Question 5: Please provide a breakdown of the number of FEHBP plan options and the percent of eligible FEHBP members enrolled in each plan for all 50 states. Answer: Code Plan FOR ALABAMA (AL) (April 11, 2003) 10S BLUE CROSS AND BLUE SHIELD SERVICE BENEFIT PLANS 78.96% 45H MAIL HANDLERS BENEFIT PLAN 9.32% 7887 102 31H GEHA BENEFIT PLAN 2.04% 1728 45S MAIL HANDLERS BENEFIT PLAN 1.93% 1630 41 THE OATH (HEALTH PARTNERS OF ALABAMA) 1.84% 1561 131 1.53% 1298 32 NALC HEALTH BENEFIT PLAN 1.39% 1172 18 38 NATIONAL RURAL LETTER CARRIERS ASSOCIATION 1.08% 916 20 AMERICAN POSTAL WORKERS UNION HEALTH PLAN 31S GEHA BENEFIT PLAN 0.22% 183 44 SAMBA HEALTH BENEFIT PLAN 0.13% 106 36S POSTMASTERS BENEFIT PLAN 0.11% 95 2 40 AMERICAN FOREIGN SERVICE PROTECTIVE ASSOCIATION 0.07% 62 42 ASSOCIATION BENEFIT PLAN 0.06% 47 1R ALLIANCE HEALTH BENEFIT PLAN (WAS CODE YQ/YK/YA) 0.05% 45 Total 84615 1,687 6,289 9,619 20,859 24,461 21,700 30 299 232 109 60 35,767 48,848 |