Federal Employees Health Benefits Program: FEHB Plan Performance Assessment System, 74054-74056 [2014-29224]
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Federal Register / Vol. 79, No. 240 / Monday, December 15, 2014 / Proposed Rules
• Is certified as not having a
significant economic impact on a
substantial number of small entities
under the Regulatory Flexibility Act (5
U.S.C. 601 et seq.);
• Does not contain any unfunded
mandate or significantly or uniquely
affect small governments, as described
in the Unfunded Mandates Reform Act
of 1995 (Public Law 104–4);
• Does not have Federalism
implications as specified in Executive
Order 13132 (64 FR 43255, August 10,
1999);
• Is not an economically significant
regulatory action based on health or
safety risks subject to Executive Order
13045 (62 FR 19885, April 23, 1997);
• Is not a significant regulatory action
subject to Executive Order 13211 (66 FR
28355, May 22, 2001);
• Is not subject to requirements of
section 12(d) of the National
Technology Transfer and Advancement
Act of 1995 (15 U.S.C. 272 note) because
application of those requirements would
be inconsistent with the Clean Air Act;
and
• Does not provide EPA with the
discretionary authority to address, as
appropriate, disproportionate human
health or environmental effects, using
practicable and legally permissible
methods, under Executive Order 12898
(59 FR 7629, February 16, 1994).
In addition, this rule does not have
tribal implications as specified by
Executive Order 13175 (65 FR 67249,
November 9, 2000), because the SIP is
not approved to apply in Indian country
located in the state, and EPA notes that
it will not impose substantial direct
costs on tribal governments or preempt
tribal law.
List of Subjects in 40 CFR Part 52
Environmental protection, Air
pollution control, Incorporation by
reference, Intergovernmental relations,
Lead, Ozone, Particulate matter,
Reporting and recordkeeping
requirements.
tkelley on DSK3SPTVN1PROD with PROPOSALS
Authority: 42 U.S.C. 7401 et seq.
Dated: December 2, 2014.
Judith A. Enck,
Regional Administrator, Region 2.
[FR Doc. 2014–29332 Filed 12–12–14; 8:45 am]
BILLING CODE 6560–50–P
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Jkt 235001
OFFICE OF PERSONNEL
MANAGEMENT
48 CFR Parts 1609, 1615, 1632, and
1652
RIN 3206–AN13
Federal Employees Health Benefits
Program: FEHB Plan Performance
Assessment System
Office of Personnel
Management.
ACTION: Notice of proposed rulemaking.
AGENCY:
The United States Office of
Personnel Management (OPM) is issuing
a proposed rule to amend the system for
assessing the annual performance of
health plans contracted under the
Federal Employees Health Benefits
(FEHB) Program. The purpose of this
rule is to measure and assess all FEHB
plan performance (experience-rated and
community-rated) through the use of a
common, objective, and quantifiable
performance assessment for the 2016
plan year.
DATES: OPM must receive comments on
or before January 14, 2015.
ADDRESSES: Send written comments to
Wenqiong Fu, Policy Analyst, Planning
and Policy Analysis, U.S. Office of
Personnel Management, Room 4312,
1900 E Street NW., Washington, DC; or
FAX to (202) 606–6010 Attn: Wenqiong
Fu. You may also submit comments
using the Federal eRulemaking Portal:
https://www.regulations.gov. Follow the
instructions for submitting comments.
FOR FURTHER INFORMATION CONTACT:
Wenqiong Fu, Policy Analyst at (202)
606–0004.
SUPPLEMENTARY INFORMATION:
SUMMARY:
FEHB Background
The Federal Employees Health
Benefits (FEHB) Program was
established in 1960 and provides health
insurance to over eight million Federal
employees, annuitants, and their family
members. Chapter 89 of Title 5 United
States Code, which authorizes the FEHB
Program, allows OPM to contract with
health insurance carriers to provide
coverage under certain types of plans.
FEHB contracts are either communityrated or experience-rated. In
community-rated contracts, the overall
premium is based on the carrier’s
standard rating methodology, taking
into account factors in the larger
geographic area or ‘‘community.’’ In
experience-rated contracts, the FEHB
carrier considers actual ‘‘experience’’ or
medical costs of the group of covered
lives. The two types of contracts are
regulated under different sections of the
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Fmt 4702
Sfmt 4702
FEHB Acquisition Regulation
(FEHBAR). Premiums are determined
according to distinct processes and plan
performance is rewarded differently.
Current Performance Assessment
System
Under current regulations,
performance is assessed for experiencerated plans based on profit analysis
factors that are weighted to create a
service charge that OPM pays to
carriers. For community-rated plans,
performance is assessed according to
specific elements that can result in a
percentage of premium withheld from
payment to the carrier. Both of these
performance frameworks are under the
umbrella of the Federal Acquisition
Regulation, which governs contracting
government-wide.
In determining the level of the service
charge (profit/risk margin) for
experience-rated plans, Contracting
Officers consider six categories of
factors: Contractor performance,
contract cost, federal socioeconomic
programs, cost control, independent
development, and capital investments.
OPM Contracting Officers conduct the
service charge analysis and rely heavily
on the contractor performance factor.
Contractor performance is weighted the
highest, comprises a significant portion
of the total service charge, and involves
the largest amount of data.
Community-rated plans have two
performance elements that may lead to
a percentage of premium being
withheld: Customer service and critical
contract compliance requirements.
Proposed FEHB Plan Assessment
System
To establish a consistent assessment
system, create a more objective
performance standard, and provide
more transparency for enrollees, OPM is
developing a framework that will utilize
a discrete set of quantifiable measures
examining key aspects of contract
performance and specific criteria for
performance factors which will then be
linked to health plan premium
disbursements.
This regulation proposes to replace
the current methods of plan assessment
with a new framework, in which both
experience-rated and community-rated
plans utilize the same measurement
criteria. For experience-rated plans, the
performance-based service charge will
be administered similarly to the current
service charge process. For communityrated plans, the performance adjustment
will be administered similarly to the
current process using an adjustment to
net-to-carrier premium payments made
during the first quarter of the following
E:\FR\FM\15DEP1.SGM
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tkelley on DSK3SPTVN1PROD with PROPOSALS
Federal Register / Vol. 79, No. 240 / Monday, December 15, 2014 / Proposed Rules
contract period. OPM proposes the new
assessment system will impact service
charge and performance adjustment
premium disbursements made in 2017.
This proposed regulation includes
four measurement categories for both
experience-rated and community-rated
plans aimed at improving standards of
accountability and transparency. The
following categories, defined in 48 CFR
1615.404–70, will be applied to both
experience-rated and community-rated
plans: (1) Clinical Quality, (2) Customer
Service, (3) Resource Use, and (4)
Contract Oversight.
The new performance assessment
structure is incorporated in 48 CFR,
Subpart 1615.4, Contract pricing, which
describes the profit factors and rewards
for FEHB plans. Contract requirements
will be amended to indicate required
performance measures, and the scoring
of measures within the assessment
system will be based on plan
performance relative to FEHB or
national benchmarks, or with respect to
the Contract Oversight category, the
Contracting Officer’s judgment. Each
year, identified measures will be
communicated to FEHB carriers through
advance guidance and then
incorporated as a part of the contract.
Three of the performance areas,
Clinical Quality, Customer Service, and
Resource Use, will contain one or more
domains that reflect priorities within
each area, and each domain will be
comprised of one or more performance
areas. The fourth category, Contract
Oversight, will be based upon the
Contracting Officer’s evaluation of
contractor performance such as audit
findings, fraud/waste/abuse,
responsiveness to OPM, benefits/
network management, contract
compliance, technology management,
data security, and Federal socioeconomic programs.
OPM expects to update the measures
over time, and therefore the regulation
lists representative examples of the
domains and measures within each
category. OPM will issue and
periodically update technical guidance
describing the measures and methods/
formulae for performance scoring. FEHB
carriers will receive technical guidance
updating measures, methods and
scoring in advance of their use in the
plan assessment process.
Plan performance on Clinical Quality,
Customer Service, and Resource Use
will be evaluated against national or
FEHB benchmarks. OPM’s goal is to
build on current performance
assessment practices so that we can
formally link annual evaluations of
FEHB plans with profit factors. The
proposed measures will rely upon the
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74055
evaluation of data from sources familiar
to FEHB carriers such as:
HEDIS—Healthcare Effectiveness Data
and Information Set is a group of
clinical measures developed by the
National Committee for Quality
Assurance (NCQA). HEDIS measures are
widely used in U.S. health plan
performance systems and have been
collected by FEHB for more than ten
years.
CAHPS—Consumer Assessment of
Healthcare Providers and Systems is a
survey of health plan enrollees
developed by the Agency for Healthcare
Research and Quality (AHRQ). FEHB
plans have participated in CAHPS and
reported results to OPM since 2000.
Plan administrative data—OPM
collects data from health plans for
contract oversight purposes. These may
include data on financial management;
claims payment timeliness; claims
records and utilization data; enrollment
reconciliation; surveillance for fraud,
waste, and abuse; health information
technology implementation; data
security; and network adequacy.
This regulatory change is intended to
promote a comprehensive approach to
health plan management by measuring
key performance components.
introduction of new measures that are
deemed relevant to plan performance.
Measurement
The new performance assessment
system will begin in 2016. OPM will
announce the applicable categories,
domains, measures and weights in
FEHB Carrier guidance at a later time,
well in advance of implementation so
that FEHB carriers have the opportunity
to provide feedback through established
OPM channels. Prior to each contract
year, OPM will identify the most recent
available benchmarks for each measure
which will be used in applying the new
weighted guidelines to determine that
year’s service charge or performance
adjustment for FEHB contracts.
Following rate negotiations, for both
experience-rated plans and communityrated plans, OPM Contracting Officers
will inform FEHB plans of the
performance scoring results used in
determining each plan’s service charge
or performance adjustment.
U.S. Office of Personnel Management.
Katherine Archuleta,
Director.
Assessing Progress
Specific domains, measures and
weights will be provided in future
technical guidance. While there will be
continuity over time in many of the
domains and measures, the plan
assessment system must be dynamic to
account for: (1) Changes in clinical
guidelines and professional standards of
care, (2) removal of measures where
overall plan performance is at a
consistently high level, and (3) the
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Fmt 4702
Sfmt 4702
Regulatory Flexibility Act
I certify that this regulation will not
have a significant economic impact on
a substantial number of small entities
because the regulation affects only
health insurance carriers under the
Federal Employees Health Benefits
Program.
Executive Orders 13563 and 12866,
Regulatory Review
This rule has been reviewed by the
Office of Management and Budget in
accordance with Executive Orders
13563 and 12866.
Federalism
We have examined this rule in
accordance with Executive Order 13132,
Federalism, and have determined that
this rule will not have any negative
impact on the rights, roles and
responsibilities of State, local, or tribal
governments.
List of Subjects in 48 CFR Parts 1615
and 1609
Government employees, Government
procurement, Health insurance.
For the reasons set forth in the
preamble, OPM amends chapter 16 of
title 48 CFR (FEHBAR) as follows:
PART 1609—CONTRACTOR
QUALIFICATIONS
1. The authority citation for part 1609
continues to read as follows:
■
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c);
48 CFR 1.301.
Subpart 1609.71—[Removed]
■
2. Remove subpart 1609.71.
PART 1615—CONTRACTING BY
NEGOTIATION
3. The authority citation for part 1615
continues to read as follows:
■
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c);
48 CFR 1.301.
4. In section 1615.404–4, paragraph
(a) is revised to read as follows:
■
1615.404–4
Profit.
(a) When the pricing of FEHB Program
contracts is determined by cost analysis
(experience-rated) or by a combination
of cost and price analysis (communityrated), OPM will determine a
performance based percentage of the
price using a weighted guidelines
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Federal Register / Vol. 79, No. 240 / Monday, December 15, 2014 / Proposed Rules
structured approach based on the profit
analysis factors described in 1615.404–
70. For experience-rated plans, OPM
will use the performance based
percentage so determined to develop the
profit or fee prenegotiation objective,
which will be the total profit (service
charge) negotiated for the contract. For
community-rated plans, OPM will use
the performance based percentage so
determined to develop an adjustment to
net-to-carrier premiums, (performance
adjustment) to be made during the first
quarter of the following contract period.
*
*
*
*
*
■ 5. Section 1615.404–70 is revised as
follows:
tkelley on DSK3SPTVN1PROD with PROPOSALS
1615.404–70
Profit analysis factors.
(a) OPM Contracting Officers will
apply a weighted guidelines method in
developing the performance based
percentage for FEHB Program contracts.
For experience-rated plans, the
performance based percentage will be
applied to projected incurred claims
and allowable administrative expenses.
For community-rated plans, the
performance based percentage will be
applied to subscription income and will
be used to calculate a performance
adjustment to net-to-carrier premiums,
as described at 48 CFR 1632.170(a)(2), to
be made during the first quarter of the
following contract period. In the context
of the factors outlined in FAR 15.404–
4(d), OPM will assess performance of
FEHB carriers according to four factors.
(1) Clinical quality. OPM will
consider elements within such domains
as preventive care, chronic disease
management, medication use, and
behavioral health. This factor
incorporates elements from the FAR
factor ‘‘contractor effort.’’
(2) Customer service. OPM will
consider elements within such domains
as communication, access, claims, and
member experience/engagement. This
factor incorporates elements of the FAR
factor ‘‘contractor effort.’’
(3) Resource use. OPM will consider
elements within such domains as
utilization management, administrative,
and cost trends. This factor incorporates
elements of the FAR factors ‘‘contractor
effort,’’ ‘‘contract cost risk,’’ and ‘‘cost
control and other past
accomplishments.’’
(4) Contract oversight. OPM will
consider an assessment of contract
performance in specific areas such as
audit findings, fraud/waste/abuse, and
responsiveness to OPM, benefits/
network management, contract
compliance, technology management,
data security, and Federal socioeconomic programs. This factor could
incorporate any of the FAR profit
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19:17 Dec 12, 2014
Jkt 235001
analysis factors listed at 15.404–
4(d)(1)(i)–(vi).
(b) The sum of the maximum scores
for the profit analysis factors will be 1
percent.
PART 1632—CONTRACT FINANCING
6. The authority citation for part 1632
continues to read as follows:
■
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c);
48 CFR 1.301.
7. In section 1632.170, paragraph
(a)(2) is revised to read as follows:
■
1632.170
carriers.
Recurring premium payments to
(a) * * *
(2) The difference between one
percent and the performance based
percentage of the contract price
described at 1615.404–4 will be
multiplied by the carrier’s subscription
income for the year of performance and
the resulting amount (performance
adjustment) will be withheld from the
net-to-carrier premium disbursement
during the first quarter of the following
contract period unless an alternative
payment arrangement is made with the
carrier’s Contracting Officer.
Amounts withheld from a community
rated plan’s premium disbursement will
be deposited into the plan’s
Contingency Reserve.
*
*
*
*
*
PART 1652—CONTRACT CLAUSES
8. The authority citation for part 1652
continues to read as follows:
■
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c);
48 CFR 1.301.
9. In section 1652.232–70, revise the
introductory text and paragraph (a) and
remove paragraph (f).
The revisions read as follows:
■
1652.232–70
contracts.
Payments—Community-rated
As prescribed in 1632.171, the
following clause shall be inserted in all
community-rated FEHBP contracts:
Payments
(a) OPM will pay to the Carrier, in full
settlement of its obligations under this
contract, subject to adjustment for error or
fraud, the subscription charges received for
the plan by the Employees Health Benefits
Fund (hereinafter called the Fund) less the
amounts set aside by OPM for the
Contingency Reserve and for the
administrative expenses of OPM, amounts for
obligations due pursuant to paragraph (b) of
this clause and the performance adjustment
described at 1615.404–4, plus any payments
made by OPM from the Contingency Reserve.
*
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*
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*
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*
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10. In section 1652.232–71, revise the
introductory text and paragraph (a) and
remove paragraph (f).
The revisions read as follows:
■
1652.232–71
contracts.
Payments—experience-rated
As prescribed in 1632.172, the
following clause shall be inserted in all
experience-rated FEHBP contracts:
(a) OPM will pay to the Carrier, in full
settlement of its obligations under this
contract, subject to adjustment for error or
fraud, the subscription charges received for
the plan by the Employees Health Benefits
Fund (hereinafter called the Fund) less the
amounts set aside by OPM for the
Contingency Reserve and for the
administrative expenses of OPM, amounts for
obligations due pursuant to paragraph (b) of
this clause, and the performance-based
service charge described at 1615.404–4, plus
any payments made by OPM from the
Contingency Reserve.
*
*
*
*
*
[FR Doc. 2014–29224 Filed 12–12–14; 8:45 am]
BILLING CODE 6325–63–P
DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric
Administration
50 CFR Part 648
RIN 0648–BE50
Magnuson-Stevens Fishery
Conservation and Management Act
Provisions; Fisheries of the
Northeastern United States; Northeast
Region Standardized Bycatch
Reporting Methodology Omnibus
Amendment
National Marine Fisheries
Service (NMFS), National Oceanic and
Atmospheric Administration (NOAA),
Commerce.
ACTION: Notice of availability of
proposed fishery management plan
amendment; request for comments.
AGENCY:
NMFS announces that the
Mid-Atlantic and New England Fishery
Management Councils have submitted
an Omnibus Amendment to the Fishery
Management Plans of the Northeastern
U.S. to establish a Standardized Bycatch
Reporting Methodology, incorporating a
draft Environmental Assessment and
preliminary Regulatory Impact Review,
for review and approval by the Secretary
of Commerce, and is requesting
comments from the public. The
Standardized Bycatch Reporting
Methodology Omnibus Amendment
would establish a standardized bycatch
reporting methodology for all 13 Fishery
Management Plans in the region, as
SUMMARY:
E:\FR\FM\15DEP1.SGM
15DEP1
]]>Agencies
[Federal Register Volume 79, Number 240 (Monday, December 15, 2014)]
[Proposed Rules]
[Pages 74054-74056]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-29224]
=======================================================================
-----------------------------------------------------------------------
OFFICE OF PERSONNEL MANAGEMENT
48 CFR Parts 1609, 1615, 1632, and 1652
RIN 3206-AN13
Federal Employees Health Benefits Program: FEHB Plan Performance
Assessment System
AGENCY: Office of Personnel Management.
ACTION: Notice of proposed rulemaking.
-----------------------------------------------------------------------
SUMMARY: The United States Office of Personnel Management (OPM) is
issuing a proposed rule to amend the system for assessing the annual
performance of health plans contracted under the Federal Employees
Health Benefits (FEHB) Program. The purpose of this rule is to measure
and assess all FEHB plan performance (experience-rated and community-
rated) through the use of a common, objective, and quantifiable
performance assessment for the 2016 plan year.
DATES: OPM must receive comments on or before January 14, 2015.
ADDRESSES: Send written comments to Wenqiong Fu, Policy Analyst,
Planning and Policy Analysis, U.S. Office of Personnel Management, Room
4312, 1900 E Street NW., Washington, DC; or FAX to (202) 606-6010 Attn:
Wenqiong Fu. You may also submit comments using the Federal eRulemaking
Portal: https://www.regulations.gov. Follow the instructions for
submitting comments.
FOR FURTHER INFORMATION CONTACT: Wenqiong Fu, Policy Analyst at (202)
606-0004.
SUPPLEMENTARY INFORMATION:
FEHB Background
The Federal Employees Health Benefits (FEHB) Program was
established in 1960 and provides health insurance to over eight million
Federal employees, annuitants, and their family members. Chapter 89 of
Title 5 United States Code, which authorizes the FEHB Program, allows
OPM to contract with health insurance carriers to provide coverage
under certain types of plans.
FEHB contracts are either community-rated or experience-rated. In
community-rated contracts, the overall premium is based on the
carrier's standard rating methodology, taking into account factors in
the larger geographic area or ``community.'' In experience-rated
contracts, the FEHB carrier considers actual ``experience'' or medical
costs of the group of covered lives. The two types of contracts are
regulated under different sections of the FEHB Acquisition Regulation
(FEHBAR). Premiums are determined according to distinct processes and
plan performance is rewarded differently.
Current Performance Assessment System
Under current regulations, performance is assessed for experience-
rated plans based on profit analysis factors that are weighted to
create a service charge that OPM pays to carriers. For community-rated
plans, performance is assessed according to specific elements that can
result in a percentage of premium withheld from payment to the carrier.
Both of these performance frameworks are under the umbrella of the
Federal Acquisition Regulation, which governs contracting government-
wide.
In determining the level of the service charge (profit/risk margin)
for experience-rated plans, Contracting Officers consider six
categories of factors: Contractor performance, contract cost, federal
socioeconomic programs, cost control, independent development, and
capital investments. OPM Contracting Officers conduct the service
charge analysis and rely heavily on the contractor performance factor.
Contractor performance is weighted the highest, comprises a significant
portion of the total service charge, and involves the largest amount of
data.
Community-rated plans have two performance elements that may lead
to a percentage of premium being withheld: Customer service and
critical contract compliance requirements.
Proposed FEHB Plan Assessment System
To establish a consistent assessment system, create a more
objective performance standard, and provide more transparency for
enrollees, OPM is developing a framework that will utilize a discrete
set of quantifiable measures examining key aspects of contract
performance and specific criteria for performance factors which will
then be linked to health plan premium disbursements.
This regulation proposes to replace the current methods of plan
assessment with a new framework, in which both experience-rated and
community-rated plans utilize the same measurement criteria. For
experience-rated plans, the performance-based service charge will be
administered similarly to the current service charge process. For
community-rated plans, the performance adjustment will be administered
similarly to the current process using an adjustment to net-to-carrier
premium payments made during the first quarter of the following
[[Page 74055]]
contract period. OPM proposes the new assessment system will impact
service charge and performance adjustment premium disbursements made in
2017.
This proposed regulation includes four measurement categories for
both experience-rated and community-rated plans aimed at improving
standards of accountability and transparency. The following categories,
defined in 48 CFR 1615.404-70, will be applied to both experience-rated
and community-rated plans: (1) Clinical Quality, (2) Customer Service,
(3) Resource Use, and (4) Contract Oversight.
The new performance assessment structure is incorporated in 48 CFR,
Subpart 1615.4, Contract pricing, which describes the profit factors
and rewards for FEHB plans. Contract requirements will be amended to
indicate required performance measures, and the scoring of measures
within the assessment system will be based on plan performance relative
to FEHB or national benchmarks, or with respect to the Contract
Oversight category, the Contracting Officer's judgment. Each year,
identified measures will be communicated to FEHB carriers through
advance guidance and then incorporated as a part of the contract.
Three of the performance areas, Clinical Quality, Customer Service,
and Resource Use, will contain one or more domains that reflect
priorities within each area, and each domain will be comprised of one
or more performance areas. The fourth category, Contract Oversight,
will be based upon the Contracting Officer's evaluation of contractor
performance such as audit findings, fraud/waste/abuse, responsiveness
to OPM, benefits/network management, contract compliance, technology
management, data security, and Federal socio-economic programs.
OPM expects to update the measures over time, and therefore the
regulation lists representative examples of the domains and measures
within each category. OPM will issue and periodically update technical
guidance describing the measures and methods/formulae for performance
scoring. FEHB carriers will receive technical guidance updating
measures, methods and scoring in advance of their use in the plan
assessment process.
Plan performance on Clinical Quality, Customer Service, and
Resource Use will be evaluated against national or FEHB benchmarks.
OPM's goal is to build on current performance assessment practices so
that we can formally link annual evaluations of FEHB plans with profit
factors. The proposed measures will rely upon the evaluation of data
from sources familiar to FEHB carriers such as:
HEDIS--Healthcare Effectiveness Data and Information Set is a group
of clinical measures developed by the National Committee for Quality
Assurance (NCQA). HEDIS measures are widely used in U.S. health plan
performance systems and have been collected by FEHB for more than ten
years.
CAHPS--Consumer Assessment of Healthcare Providers and Systems is a
survey of health plan enrollees developed by the Agency for Healthcare
Research and Quality (AHRQ). FEHB plans have participated in CAHPS and
reported results to OPM since 2000.
Plan administrative data--OPM collects data from health plans for
contract oversight purposes. These may include data on financial
management; claims payment timeliness; claims records and utilization
data; enrollment reconciliation; surveillance for fraud, waste, and
abuse; health information technology implementation; data security; and
network adequacy.
This regulatory change is intended to promote a comprehensive
approach to health plan management by measuring key performance
components.
Measurement
The new performance assessment system will begin in 2016. OPM will
announce the applicable categories, domains, measures and weights in
FEHB Carrier guidance at a later time, well in advance of
implementation so that FEHB carriers have the opportunity to provide
feedback through established OPM channels. Prior to each contract year,
OPM will identify the most recent available benchmarks for each measure
which will be used in applying the new weighted guidelines to determine
that year's service charge or performance adjustment for FEHB
contracts. Following rate negotiations, for both experience-rated plans
and community-rated plans, OPM Contracting Officers will inform FEHB
plans of the performance scoring results used in determining each
plan's service charge or performance adjustment.
Assessing Progress
Specific domains, measures and weights will be provided in future
technical guidance. While there will be continuity over time in many of
the domains and measures, the plan assessment system must be dynamic to
account for: (1) Changes in clinical guidelines and professional
standards of care, (2) removal of measures where overall plan
performance is at a consistently high level, and (3) the introduction
of new measures that are deemed relevant to plan performance.
Regulatory Flexibility Act
I certify that this regulation will not have a significant economic
impact on a substantial number of small entities because the regulation
affects only health insurance carriers under the Federal Employees
Health Benefits Program.
Executive Orders 13563 and 12866, Regulatory Review
This rule has been reviewed by the Office of Management and Budget
in accordance with Executive Orders 13563 and 12866.
Federalism
We have examined this rule in accordance with Executive Order
13132, Federalism, and have determined that this rule will not have any
negative impact on the rights, roles and responsibilities of State,
local, or tribal governments.
List of Subjects in 48 CFR Parts 1615 and 1609
Government employees, Government procurement, Health insurance.
U.S. Office of Personnel Management.
Katherine Archuleta,
Director.
For the reasons set forth in the preamble, OPM amends chapter 16 of
title 48 CFR (FEHBAR) as follows:
PART 1609--CONTRACTOR QUALIFICATIONS
0
1. The authority citation for part 1609 continues to read as follows:
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c); 48 CFR 1.301.
Subpart 1609.71--[Removed]
0
2. Remove subpart 1609.71.
PART 1615--CONTRACTING BY NEGOTIATION
0
3. The authority citation for part 1615 continues to read as follows:
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c); 48 CFR 1.301.
0
4. In section 1615.404-4, paragraph (a) is revised to read as follows:
1615.404-4 Profit.
(a) When the pricing of FEHB Program contracts is determined by
cost analysis (experience-rated) or by a combination of cost and price
analysis (community-rated), OPM will determine a performance based
percentage of the price using a weighted guidelines
[[Page 74056]]
structured approach based on the profit analysis factors described in
1615.404-70. For experience-rated plans, OPM will use the performance
based percentage so determined to develop the profit or fee
prenegotiation objective, which will be the total profit (service
charge) negotiated for the contract. For community-rated plans, OPM
will use the performance based percentage so determined to develop an
adjustment to net-to-carrier premiums, (performance adjustment) to be
made during the first quarter of the following contract period.
* * * * *
0
5. Section 1615.404-70 is revised as follows:
1615.404-70 Profit analysis factors.
(a) OPM Contracting Officers will apply a weighted guidelines
method in developing the performance based percentage for FEHB Program
contracts. For experience-rated plans, the performance based percentage
will be applied to projected incurred claims and allowable
administrative expenses. For community-rated plans, the performance
based percentage will be applied to subscription income and will be
used to calculate a performance adjustment to net-to-carrier premiums,
as described at 48 CFR 1632.170(a)(2), to be made during the first
quarter of the following contract period. In the context of the factors
outlined in FAR 15.404-4(d), OPM will assess performance of FEHB
carriers according to four factors.
(1) Clinical quality. OPM will consider elements within such
domains as preventive care, chronic disease management, medication use,
and behavioral health. This factor incorporates elements from the FAR
factor ``contractor effort.''
(2) Customer service. OPM will consider elements within such
domains as communication, access, claims, and member experience/
engagement. This factor incorporates elements of the FAR factor
``contractor effort.''
(3) Resource use. OPM will consider elements within such domains as
utilization management, administrative, and cost trends. This factor
incorporates elements of the FAR factors ``contractor effort,''
``contract cost risk,'' and ``cost control and other past
accomplishments.''
(4) Contract oversight. OPM will consider an assessment of contract
performance in specific areas such as audit findings, fraud/waste/
abuse, and responsiveness to OPM, benefits/network management, contract
compliance, technology management, data security, and Federal socio-
economic programs. This factor could incorporate any of the FAR profit
analysis factors listed at 15.404-4(d)(1)(i)-(vi).
(b) The sum of the maximum scores for the profit analysis factors
will be 1 percent.
PART 1632--CONTRACT FINANCING
0
6. The authority citation for part 1632 continues to read as follows:
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c); 48 CFR 1.301.
0
7. In section 1632.170, paragraph (a)(2) is revised to read as follows:
1632.170 Recurring premium payments to carriers.
(a) * * *
(2) The difference between one percent and the performance based
percentage of the contract price described at 1615.404-4 will be
multiplied by the carrier's subscription income for the year of
performance and the resulting amount (performance adjustment) will be
withheld from the net-to-carrier premium disbursement during the first
quarter of the following contract period unless an alternative payment
arrangement is made with the carrier's Contracting Officer.
Amounts withheld from a community rated plan's premium disbursement
will be deposited into the plan's Contingency Reserve.
* * * * *
PART 1652--CONTRACT CLAUSES
0
8. The authority citation for part 1652 continues to read as follows:
Authority: 5 U.S.C. 8913; 40 U.S.C. 486(c); 48 CFR 1.301.
0
9. In section 1652.232-70, revise the introductory text and paragraph
(a) and remove paragraph (f).
The revisions read as follows:
1652.232-70 Payments--Community-rated contracts.
As prescribed in 1632.171, the following clause shall be inserted
in all community-rated FEHBP contracts:
Payments
(a) OPM will pay to the Carrier, in full settlement of its
obligations under this contract, subject to adjustment for error or
fraud, the subscription charges received for the plan by the
Employees Health Benefits Fund (hereinafter called the Fund) less
the amounts set aside by OPM for the Contingency Reserve and for the
administrative expenses of OPM, amounts for obligations due pursuant
to paragraph (b) of this clause and the performance adjustment
described at 1615.404-4, plus any payments made by OPM from the
Contingency Reserve.
* * * * *
0
10. In section 1652.232-71, revise the introductory text and paragraph
(a) and remove paragraph (f).
The revisions read as follows:
1652.232-71 Payments--experience-rated contracts.
As prescribed in 1632.172, the following clause shall be inserted
in all experience-rated FEHBP contracts:
(a) OPM will pay to the Carrier, in full settlement of its
obligations under this contract, subject to adjustment for error or
fraud, the subscription charges received for the plan by the
Employees Health Benefits Fund (hereinafter called the Fund) less
the amounts set aside by OPM for the Contingency Reserve and for the
administrative expenses of OPM, amounts for obligations due pursuant
to paragraph (b) of this clause, and the performance-based service
charge described at 1615.404-4, plus any payments made by OPM from
the Contingency Reserve.
* * * * *
[FR Doc. 2014-29224 Filed 12-12-14; 8:45 am]
BILLING CODE 6325-63-P
