Changes in Health Coverage FAQs
U.S. Office of Personnel Management Members of Congress and Designated Staff How will Members of Congress and designated congressional staff obtain health coverage in 2014? House of Representatives and Senate offices will provide health coverage to Members of Congress and designated staff through the Marketplace. OPM has determined the most appropriate Marketplace is the Small Business Health Options Program (SHOP). SHOPs were established to administer group health benefits to employees of small businesses. Given the location of Congress in Washington D.C., OPM has determined that the DC SHOP, known as the DC Health Link Small Business Market administered by the DC Health Benefit Exchange Authority, is the appropriate SHOP from which Members of Congress and designated congressional staff will purchase health insurance in order to receive a Government contribution. From which “Metal Level” on the DC SHOP will Members of Congress and designated congressional staff choose their plans? Members of Congress and designated staff will choose from plans on the Gold Metal Level of the DC SHOP, which currently includes 112 choices. While all plans have the same “essential health benefits” (EHB), plans vary in copays, coinsurance, deductibles, and benefits beyond the EHB. Plans include fee-for-service, HMOs, Point of Service, and HSA-compatible plans. http://www.opm.gov/healthcare-insurance/changes-in-health-coverage/changes-in-health-coverage-faqs/#SHOPHealthCoverage
Comment:
By Don McCanne, M.D. Supposedly requiring Members of Congress and their staffs to participate in the insurance exchanges established by the Affordable Care Act was to make their coverage comparable to what the rest of us would have (an oversimplification since most of us will not be enrolled in the exchanges). Yet the benchmark plans setting the subsidies in the exchanges are silver tier plans with an actuarial value of 70 percent, and the plans which qualify for Federal Employees Health Benefits (FEHB) premiums for Members of Congress are limited to the gold tier plans with an actuarial value of 80 percent. This is much more significant than it appears to be. The gold plans for the Members of Congress pay about 80 percent of their health care costs, and about three-fourths of their premiums are paid by the taxpayers. This is comparable to the more traditional employer-sponsored plans that most of us considered to be good insurance coverage. In essence, as members of Congress and their staffs move into the exchanges, they are being assured that they will have coverage very close to that which they now have in the FEHB program. The standard silver tier for individuals selecting their plans though the exchanges will leave the patient responsible for paying 30 percent of costs out-of-pocket, though lower income individuals will qualify for subsidies that are considered to be inadequate. Also the narrow networks of the exchange plans risk exposing patients to 100 percent of sometimes unavoidable out-of-network costs, with no cap on spending. Further, because of their lower premiums, many will choose the bronze plans at 60 percent actuarial value, risking greater financial hardship should significant health care be required. This is a huge difference since the 80 percent actuarial value plans for Congress are considered to be standard insurance, whereas the 60 to 70 percent actuarial value plans for the general public are considered to be underinsurance – plans that do not provide adequate financial security in the face of medical need. We didn’t get this right. A gold standard for Congress and a lesser standard for the people? Let’s “Occupy Congress” by replacing those in Congress who don’t seem to get it with legislators who will bring us what we need – a single payer, improved Medicare that covers everyone.
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