Health-care offerings to be available in multiple states through the Affordable Care Act’s insurance exchange system would parallel those of the Federal Employees Health Benefits Program in many ways, although the two programs would not affect each other directly, under rules to be proposed on Wednesday.
The rules from the Office of Personnel Management would set standards for multi-state plans on the exchanges, which are to be available starting in calendar year 2014.
The law requires that at least two multi-state plans be offered and that they be available in at least 31 states at the outset. The initial enrollment opportunity is to start next October.
OPM was given responsibility for the multi-state plans because of its experience in running the FEHBP, for which nearly all federal employees and retirees are eligible. As with the FEHBP, insurance companies wishing to participate will apply to OPM, and if they meet certain standards, they would negotiate with OPM over the precise terms of coverage and premiums.
The rules aim to maintain a level playing field with other health-care plans to be offered through the exchanges, officials said. A multi-state insurance issuer could follow standards set by each pertinent state or could instead base an offering on one of the three largest nationwide FEHBP plans — two of Blue Cross-Blue Shield and one of the Government Employees Health Association — although they still would have to adhere to certain state requirements.
The rules require that a multi-state plan’s enrollee pool, whose claims rates will determine premiums, must be kept separate from the FEHBP population.
The Affordable Care Act allows FEHBP-eligible persons to get their health-insurance coverage through the exchanges instead. However, there would be a strong disincentive against doing so, since they would lose the employer contribution toward premiums, officials said. The government pays about 70 percent of the total premium cost for either self-only or self-and-family coverage under FEHBP.
The law meanwhile requires members of Congress and their personal staff, both in Washington and in their home states, to leave the FEHBP and get their health insurance through the exchanges when they become available. The rules do not address the status of the employer contribution for them.
The proposed rules, which will be open for public comment until Jan. 4, also cover technical issues such as contracting procedures, performance monitoring, quality assurance, fraud and abuse prevention, and how enrollees could challenge claims decisions.