Change to Health Plan May Surprise Hill Staffers

Posted November 26, 2008 at 3:24pm

Some Capitol Hill staffers and other government workers may have to pay more for surgeries and emergency room visits next year thanks to a few significant changes to a popular federal health insurance plan.

Blue Cross Blue Shield is upping the premium and surgical co-pays in one of its plans — and many staffers apparently don’t know about the change.

Beginning Jan. 1, federal employees under the Blue Cross Blue Shield standard plan will have to pay the entirety of their nonemergency surgical procedures, up to $7,500, if they go to an out-of-network physician.

Among other changes: $350 for some emergency room visits and an increased premium.

Last week, several staffers contacted by Roll Call said they were unaware of the changes, despite the fact that they only have until Dec. 8 to change health plans. A brochure distributed by the Office of Personnel Management outlines the changes on page 10 of a 137-page document — something the average staffer is unlikely to read.

“I don’t really think there’s been any outreach at all,” said one Republican leadership staffer who is covered by Blue Cross but had no idea that the changes were imminent.

OPM officials say the changes actually benefit the 160,000 covered employees in Washington, D.C. The $7,500 co-pay for surgery, they say, will “eliminate the surprise of a larger bill.” In the past, patients going to an out-of-network surgeon paid 25 percent of the plan’s “allowance” and then the difference between the allowance and the bill — a somewhat complicated math problem.

In an e-mail, OPM officials said employees often were surprised when they got the final figure.

“Many members filed disputed claims because the balance owed was a large amount, in most cases larger than the $7,500 co-payment, due to the difference between the allowed amount and the amount billed by the non-participating provider,” the officials said. “In switching to fixed co-payments, we expect members will make informed decisions when selecting providers to ensure that out-of-pocket costs are not burdensome.”

But a group of D.C. doctors, patients and health care providers are outraged at the changes and are hoping to get the word out, with the help of public relations firm Dezenhall Resources.

In a fact sheet that the firm is circulating, it argues that benefits “will be severely curtailed, affecting both emergency and surgical services and placing a significant financial burden on patients.”

The changes essentially turn a preferred provider organization into an health maintenance organization, said Dr. Peter Petrucci, a surgeon at a practice that serves federal employees and a few Hill staffers.

“Really what’s happened is it’s taken away the ability of most patients to have a choice of who they go to,” he said. “It’s really unfair. Not only is it unfair, but it’s not been advertised.”

Petrucci said he found out about the changes from a patient about a week ago. Although Blue Cross estimates that 95 percent of the nation’s doctors are in its plan’s network, Petrucci said many medical providers in the D.C. area aren’t part of a private network.

Critics also point to the new cost of an emergency room visit. According to Blue Cross officials, a patient will be charged a flat fee of $350 if any of the consulting doctors are not in the plan’s network.

Pat Staples, manager of member services at Blue Cross, conceded that patients probably won’t know whether their emergency room doctors are in the plan’s network.

But she also pointed out that for emergency surgical procedures, patients only have to pay the difference between the plan’s allowance and the bill.

Staffers, meanwhile, are still trying to figure out how the changes affect them. Stephanie Lumberg, a spokeswoman for House Majority Leader Steny Hoyer (D-Md.), said the office hadn’t heard of the changes until Tuesday and was looking into the matter.

“We need to look at this with great scrutiny to see what the impact on federal employee is,” she said. “Any effort to diminish benefits will not be well-received.”