12/17/08: Late yesterday, OPM announced the approval of changes to the Blue Cross/Blue Shield Standard Option plan under FEHBP for out-of-network nonemergency surgeries. Under the new agreement, BC/BS’s coverage will be similar to last year’s plan when enrollees use out of network physicians.

Under the new agreement, Blue Cross/Blue Shield Standard Option enrollees will be responsible for 30 percent of the plan's payment allowance for surgeries (including maternity) by out-of-network physicians, plus the difference between the plan's allowance and the amount billed by the surgeon. Last year, enrollees were responsible for 25 percent of the payment allowance plus the “balance billing” difference. Another important change is that Blue Cross/Blue Shield will provide prior approval for all nonemergency, out-of-network surgeries of $5,000 or more, enabling enrollees to know in advance how much BC/BS will pay for the surgery. However, the prior approval process must be initiated by the consumer.

OPM has directed agencies to receive belated enrollments through January, 2009.

As always, NTEU urges federal employees and retirees to closely examine the fine print in their FEHBP plans to see what charges are relevant. OPM and BS/BS did add some transparency to this revised coverage, but enrollees should also pay close attention to the charges by all doctors that are involved in out-of-network surgeries, including hospital staff.