+-----------------------------------------+----------------------------+
| ###### FEHB Program Carrier Letter      | **U.S. Office of Personnel |
|                                         | Management**               |
| **Experience-Rated HMOs**               |                            |
|                                         | **Office of Insurance      |
|                                         | Programs**                 |
+-----------------------------------------+----------------------------+
| > **Letter No. 2000-43B** **Date:**     |                            |
| > September 8, 2000                     |                            |
| >                                       |                            |
| > Fee-for-service \[ \-- \]             |                            |
| > Experience-rated HMO \[ 40 \]         |                            |
| > Community-rated \[ \-- \]             |                            |
+-----------------------------------------+----------------------------+

> **SUBJECT: Amendments to the Standard Contract for Experience-Rated
> HMOs**
>
> Please review the enclosed Parts I through IV of the Standard Contract
> for experience-rated HMOs for Contract Year 2001. New language is in
> **boldface** and language to be deleted is in ~~strikeout.~~ We are
> sending you a full contract this year that will incorporate in one
> document all contract changes made through December 31, 2000. You
> should limit your review to the changes only. Please keep in mind that
> the FEHBAR clauses went through the regulatory process before being
> incorporated into the contract. Therefore, recommended changes to
> FEHBAR clauses will be considered for the regulatory process and the
> 2002 contract. So that we can consider your comments, we must receive
> them no later than September 29, 2000.

#### 

> In Section 1.7, Statistics and Special Studies, we have deleted the
> reference to Appendix C, which we have reserved, and have made a
> general reference to instructions from OPM. OPM currently issues
> guidance to you through a variety of media, such as, Carrier Letters,
> benefits and rating instructions, and the Audit Guide, and we will
> continue doing so. Offices to which you should send statistics and
> special studies will be noted in our guidance.
>
> We also have revised Section 1.8, Notice, to delete the reference to
> Appendix C and to make it clear that, unless otherwise specified in
> correspondence, instructions, or contract clauses, you should send
> written notice to your Contracting Officer.
>
> Section 1.9, FEHB Quality Assurance, is reorganized and updated, but
> very little is changed. We added new sections on health care quality
> and reducing medical errors, and placed them up front to emphasize
> these new initiatives. We updated the paragraph on surveys and also
> stipulate that, as with survey costs, the costs you incur in
> collecting or contracting with a vendor to collect quality measures
> are your responsibility. With one exception, all of the required
> standards remain intact. The exception is that we now include as a
> standard the long-standing requirement to process ID cards for new
> members within fifteen calendar days of receiving the enrollment from
> the agency or retirement system.
>
> In Section 1.24, Transitional Care, we added language directed at
> mental health and substance abuse parity that addresses situations
> where you must provide transitional care.
>
> Section 2.6, Coordination of Benefits, updates the NAIC reference from
> "Model Guidelines for Coordination of Benefits" to "Group Coordination
> of Benefits Model Regulation, Rules for Coordination of Benefits." The
> NAIC has rewritten the Rules for Coordination of Benefits in plain
> language, and you will receive a copy as Appendix E when we send you
> your 2001 standard contracts. We will update this FEHBAR clause in the
> near future to reflect the name change. The Rules for Coordination of
> Benefits include the Medicare coordination of benefits rules. Except
> as otherwise noted in your contract, we remind you to follow these
> rules when determining the order of benefit payments.
>
> We revised Section 2.11, Claims Processing, to remove the reference to
> the year 2000, because the target date for the majority of your
> provider claims to be submitted electronically has passed. We replaced
> the term "physician" with "provider" to reflect the fact that claims
> are submitted by a broad range of providers that extends beyond
> physicians.
>
> Section 3.1, Payments, reflects revisions made to the FEHBAR in the
> 3-Year DoD Demonstration Project regulations published in the Federal
> Register June 8, 2000.
>
> Section 3.2, Accounting and Allowable Cost, reflects revisions made to
> the FEHBAR in the 3-Year DoD Demonstration Project regulations
> published in the Federal Register June 8, 2000.
>
> In Section 3.10, Audit, Financial, and Other Information, the
> reference to Appendix C is deleted and replaced with a general
> reference to instructions from OPM.
>
> Section 3.12, Taxpayer Identification Number, is a new FEHBAR clause
> that was published in the Federal Register on June 8, 2000. It
> requires you to submit information to comply with debt collection
> requirements of 31 U.S.C. 7701(c) and 3325(d), reporting requirements,
> of 26 U.S.C. 6041, 6041A, and 6050M, and implementing regulations
> issued by the Internal Revenue Service.
>
> Appendix C is removed and reserved because alternative methods of
> collecting the information
>
> are now in place.
>
> In Appendix E, we have updated the name to "Rules for Coordination of
> Benefits."
>
> When we send you the final contract, we will update Federal
> Acquisition Regulation clauses that have been revised during the past
> year. New or revised FEHBAR clauses will show the date the clause or
> revision was originally effective. All new and revised non-FEHBAR
> clauses will show the date "JAN 2001." Revised FAR clauses will show
> the date of the FAR revision.
>
> Please forward your comments to Mary Ann Mercer at OPM or fax them to
> (202) 606-0633. I look forward to working with you during contract
> year 2001.
>
> Sincerely,
>
> Frank D. Titus
>
> Assistant Director
>
> for Insurance Programs
>
> Enclosures