Returned Peace Corps Volunteers: Labor and Peace Corps Need Joint Approach to Monitor Access to and Quality of Health Care Benefits
Released: 2012-11-19T00:00:00

Letter

Background

After volunteers separate from the Peace Corps they typically return to the United States, and may transition into new employment. As they make this employment transition, the Peace Corps offers various health care services and benefits to returned volunteers. First, each volunteer receives a close-of-service medical evaluation that assesses their health status as they complete their service. The Peace Corps also has a contract with an insurance company to make a health insurance policy— AfterCorps—available for volunteers to purchase. This policy covers non-service-connected illnesses or injuries. The Peace Corps also pays for certain health examinations for 6 months after a volunteer’s service is completed. Finally, volunteers may also be eligible for reimbursements under the FECA program for medical expenses associated with service- connected illnesses or injuries, such as those identified during the physical conducted at the close-of-service medical evaluation.

FECA Eligibility

The FECA program provides health benefits—reimbursement for medical expenses related to illnesses or injuries that DOL determines are service connected—as well as other benefits, such as wage-loss (death and disability) compensation. To receive benefits through FECA, a volunteer must establish that, among other things, he or she was in the performance of duty at the time the illness or injury occurred. Under the FECA program, volunteers are considered to be in the performance of duty 24 hours a day while abroad during the period of their Peace Corps service. DOL requires that if an illness or injury is first discovered after a volunteer has returned from service, then the medical evidence must show that the injury or illness was sustained while overseas or in the performance of duty. In order to be eligible for FECA health care benefits for preexisting illnesses or injuries—a condition that existed prior to service—the volunteer’s medical evidence must demonstrate that the volunteer’s service was the proximate cause of or aggravated, accelerated, or precipitated the illness or injury. Further, volunteers must apply for FECA benefits within 3 years of the date of injury or illness, or within 3 years after they recognize that a health condition is service- connected. In 2010, the FECA program provided about $2.8 billion in health and other benefits to about 251,000 federal and postal employees—including volunteers—who suffered a service related illness or injury.

Application Process for FECA Program Benefits for Volunteers

Volunteers who apply for FECA benefits typically go through the following steps: 1. Each volunteer is informed of the availability of FECA benefits at the close-of-service medical evaluation. a. Each volunteer is expected to receive a close-of-service medical evaluation that assesses his or her health status prior to leaving service to document any service-connected illnesses or injuries. Should a volunteer terminate service early—before completing his or her assignment—the volunteer will also undergo a complete medical and dental exam to identify any unmet health care needs and potential medical issues. 2. Volunteers complete a FECA application and submit it to DOL through the Peace Corps’ Post-Service Unit.a. The Peace Corps—through its Post-Service Unit—assists volunteers applying for benefits by helping them to complete the appropriate forms and providing the appropriate medical evidence from volunteers’ Peace Corps medical records. b. The Peace Corps’ Post-Service Unit sends all FECA applications—which includes information on the injury or illness reported by the volunteer—to DOL for review and eligibility determination. 3. FECA applications submitted for volunteers are reviewed by DOL, and the agency then makes an eligibility determination. a. For those applications that do not include sufficient information and require further development, volunteers are given approximately 30 days to submit additional information to support their request for FECA benefits. If the additional information submitted is sufficient, the application is approved. If the additional information is not sufficient, the FECA application is denied and medical treatment is not authorized. b. For those applications that are approved, DOL assigns a medical diagnosis on the basis of medical evidence submitted in the FECA application. This assigned medical diagnosis defines the medical treatment and services for which the volunteer is eligible for FECA reimbursement. 4. Typically, after benefits are approved by DOL, a volunteer obtains health care services through a medical provider. After receiving these services, the volunteer or the volunteer’s medical provider submits a bill to DOL for reimbursement. DOL provides reimbursement for medical expenses. 5. On an annual basis, DOL requires the Peace Corps to pay DOL back for these reimbursements.

From 2009 through 2011, DOL Provided about $36 Million in Health Care and Other Benefits for Volunteers

From 2009 through 2011, DOL provided a total of about $36 million in FECA benefits for volunteers, providing about $22 million in health care benefits—reimbursements for medical expenses to treat service- connected injuries and illnesses for Peace Corps volunteers—and $13.8 million in other benefits. During this period, almost 1,400 volunteers each year received health care benefits. The average reimbursement for medical expenses per volunteer was about $5,000 in 2009, and about $5,600 in 2011. The most-common medical conditions for which DOL provided health care benefits—reimbursements for medical services— were mental, emotional, and nervous conditions; dental; other/nonclassified diseases; and infectious or parasitic diseases.These four medical conditions represented about 40 percent of all medical conditions and accounted for about $5.9 million—or more than a quarter—of all medical reimbursements for volunteers under FECA between 2009 and 2011. See table 1 for the medical conditions for which DOL provided reimbursements for volunteers under FECA.

In addition to health care benefits, volunteers also received other benefits—such as wage-loss compensation and reimbursement for travel to receive medical treatment. Specifically, from 2009 through 2011, these other benefits received by volunteers totaled about $13.8 million. In 2011, the total reimbursements for both health care and other benefits were about $12 million, which represents about 3.3 percent of the Peace Corps’ 2012 appropriation of $375 million. According to Peace Corps officials, these health care and other expenses represent a growing portion of its annual budget. These officials explained that from 2009 through 2011 these expenses have increased a total of approximately 7.2 percent.

Volunteers who received FECA benefits from 2009 through 2011 are unique in several ways when compared to other recipients of these benefits. Specifically, our analysis of DOL’s FECA program claims data found that the volunteers were generally younger and more likely to be female when compared to others who received benefits under the FECA program. Volunteers were, on average, 12 years younger than others who received FECA benefits. About two-thirds of volunteers receiving FECA benefits were female, whereas less than half of others receiving FECA benefits were female. These differences in age and gender are consistent with the overall demographics of these two populations—the volunteers and federal workers.

In addition, the medical conditions for which volunteers received FECA benefits were different than those for others who received FECA benefits. For example, volunteers were more likely than others to receive FECA benefits for mental, emotional, or nervous conditions; dental conditions; other/nonclassified diseases; and infectious or parasitic diseases. While these four medical conditions represented 40 percent of the conditions for volunteers, they represented less than 2 percent for the others receiving FECA benefits.

The Peace Corps Uses Information on Volunteers’ Awareness of FECA, but Neither DOL Nor the Peace Corps Use Other Available Information to Monitor Access and Quality

The Peace Corps uses information it has to monitor volunteers’ awareness of the FECA program; however, in general, neither DOL nor the Peace Corps use information in the remaining three areas in our review to monitor the accessibility and quality of FECA benefits for volunteers. These areas are (1) information on volunteers’ knowledge of FECA program and application requirements, such as medical documentation that is required to be submitted with an application; (2) information on DOL’s timeliness in reviewing FECA applications and reimbursing medical expenses, and on the level of customer satisfaction with the FECA program; and (3) information on the availability of FECA- Table 2 summarizes the extent to which registered medical providers.DOL and the Peace Corps use information available in the four key areas to monitor the accessibility and quality of FECA benefits for volunteers.

As shown in table 2, the Peace Corps uses information related to volunteers’ awareness of the FECA program. Specifically, to monitor volunteers’ awareness, the Peace Corps currently documents that volunteers have acknowledged that they have been informed of their potential eligibility for FECA during their close-of-service evaluation. Peace Corps officials told us the agency uses this information to help ensure all volunteers are made aware of their possible eligibility for FECA benefits.

While the Peace Corps uses information on volunteer awareness, neither DOL nor the Peace Corps use available information related to the remaining three areas of our review to monitor the accessibility and quality of FECA benefits for volunteers.

Volunteers’ knowledge of FECA program and application requirements. As table 2 shows, neither DOL nor the Peace Corps use available information, such as data on FECA application denial rates, and information on reasons for denials, in order to monitor the accessibility and quality of FECA benefits for volunteers. DOL officials told us that it is not their responsibility to use this information for this type of monitoring. However, by not using this available information to review volunteers’ level of knowledge of the FECA requirements, DOL and the Peace Corps may be unaware, for example, of the extent to which volunteers experience difficulties accessing FECA benefits because of limited understanding of certain application requirements, such as in (a) providing appropriate and sufficient medical evidence and (b) establishing a service connection for the illness or injury for which the volunteer is seeking FECA benefits.

According to volunteer advocates, volunteers and their physicians may lack knowledge of certain FECA documentation requirements, such as the need to include a medical diagnosis rather than just the symptoms of an injury or illness in the FECA application. Furthermore, our examination of a limited number of FECA denial letters confirms that these difficulties are often a contributing factor in the FECA applications that were not approved from 2009 through 2011. For example, our review of denial letters showed that the most-common reasons for denial were lack of sufficient medical documentation and inability to establish a service connection. Further, DOL and the Peace Corps also do not work together to use the information available to them on volunteers’ knowledge of program and application requirements.

DOL maintains metrics for measuring performance for the overall FECA program, including those that are part of the Protecting Our Workers and Ensuring Reemployment (POWER) Initiative, the Government Performance and Results Act of 1993 (GPRA), as amended, and measures outlined in DOL’s Operational Plan. The POWER Initiative established goals related to FECA—such as the timeliness of filing a FECA application. Under GPRA, DOL established customer satisfaction measures for the FECA program. Under its Operational Plan, DOL established additional timeliness and customer satisfaction measures, such as those to monitor the timeliness of the FECA application review process. of the overall FECA population. Instead, DOL’s focus has been on using the data in order to monitor FECA program timeliness and customer satisfaction for all individuals who receive FECA benefits. While it is reasonable that DOL focus on the entire FECA program, DOL and the Peace Corps also do not work together to use the timeliness and customer satisfaction information to help the Peace Corps gauge whether volunteers are receiving FECA benefits in a timely and satisfactory manner. For example, Peace Corps officials told us that a survey of former volunteers specifically about access and satisfaction issues would be useful. According to Peace Corps officials, the results of such a survey could help clarify whether volunteers have access to the care they need and what the volunteers think about the quality of the care they receive. Without this information, DOL and the Peace Corps may be unable to determine volunteers’ level of satisfaction with the FECA program.

Our review of DOL timeliness data suggests that between 2009 and 2011, the agency met its timeliness benchmarks related to review of FECA applications for volunteers. these data to determine the timeliness in reviewing volunteers’ FECA applications, DOL may not be able to determine whether or to what extent its performance on timeliness is sustained in the future. Furthermore, a lack of ongoing examinations of timeliness may make it difficult for DOL to identify problems if they should arise in the future or to provide information to alleviate the concerns of advocates and Peace Corps officials regarding the timeliness of the review of FECA applications.

For example, our review of information showed that DOL reviewed about 97 percent of all volunteers’ applications related to traumatic cases within 45 days of receiving the application—meeting its benchmark to review 90 percent within that time frame. geographic areas and for certain medical specialties.information DOL has on the geographic location and medical specialty of FECA-registered providers, DOL and the Peace Corps cannot determine the extent to which there are limitations in the availability of FECA- registered providers in certain geographic areas and for certain medical specialties.

DOL’s available information on FECA-registered providers suggests that volunteers may face some challenges accessing registered providers. Officials stated that although it is the responsibility of the volunteer to find a FECA-registered provider, DOL publishes an online search tool that contains a partial listing of the available FECA-registered providers as a service to FECA beneficiaries, including volunteers, to help locate providers. Officials also noted the agency does not actively manage or Although the online search tool is recognized by DOL as update the list. incomplete, it does provide some partial information about the availability of FECA-registered providers. We reviewed this online search tool and found, for example, that as of June 2012 there were no FECA-registered providers in the online search tool listed as mental health specialists in Peace any of the 10 states with the largest population of volunteers.Corps officials and volunteer advocates also noted there are a limited number of FECA-registered providers in some geographic locations and medical specialties. In addition, Peace Corps officials told us that they have assisted volunteers in finding and enrolling providers, and have had difficulty in doing so. Although the information on FECA-registered providers in the online search tool that DOL provides as a resource to volunteers may be incomplete, it includes information that could be used to help identify potential access issues and areas for monitoring the accessibility of FECA benefits for volunteers.

Conclusions

The Peace Corps and DOL both have certain responsibilities related to the provision of FECA benefits for eligible volunteers who return from service abroad. Specifically, DOL administers the FECA program and the Peace Corps pays for the expenses incurred by volunteers in the program. From DOL’s perspective, volunteers do not represent a large proportion of the overall FECA population. However, FECA is a relatively larger issue from the Peace Corps’ perspective. The volunteers are a unique population compared to others who receive benefits under FECA—for example, they are more likely to have mental, emotional, or nervous conditions that are service-connected—and, according to Peace Corps officials, the amount the Peace Corps pays DOL for FECA reimbursements represents an increasing portion of the Peace Corps’ annual budget. Because both of the agencies have certain responsibilities related to the provision of FECA benefits for eligible volunteers who return from service abroad, it is especially important that the Peace Corps and DOL jointly monitor the accessibility and quality of the FECA program to ensure that the FECA program is achieving its intended objectives— including ensuring that eligible volunteers receive needed FECA health care benefits.

The Peace Corps and DOL have information available to them in the four key areas we reviewed that could be used to monitor the accessibility and quality of FECA benefits for volunteers: (1) volunteers’ awareness of FECA; (2) volunteers’ knowledge of program and application requirements; (3) DOL’s timeliness in reviewing FECA applications and reimbursing medical expenses, and the level of customer satisfaction with the FECA program; and (4) availability of FECA-registered medical providers. However, in general, the two agencies are not using this information for such monitoring. For example, the agencies do not use the information they have to determine whether there is a gap in the number and geographic location of FECA-registered providers, such as the potential gap we identified in the number and geographic location of FECA-registered providers who treat mental health conditions—the most common medical condition for which volunteers received reimbursement.

While information is available to DOL and the Peace Corps that could be used for monitoring, the agencies are generally not working together to use the available information to monitor the accessibility and quality of FECA benefits for volunteers. Working together is important because neither agency has all the information to monitor the program on its own. Finally, because the information we identified under the four areas is not a comprehensive list of all the information the agencies could use to monitor FECA benefits for volunteers, the Peace Corps and DOL may be able to identify other information that could be used for this purpose. Unless the two agencies work together on monitoring, they will miss the opportunity to make use of the available information to help ensure the accessibility and quality of FECA benefits for volunteers.

Recommendation for Executive Action

We recommend that the Secretary of Labor and the Director of the Peace Corps jointly develop and implement an approach for working together to use available information to monitor the access to and quality of FECA benefits provided to returned volunteers.

Agency Comments and Our Evaluation

We provided a draft of this report to the Department of Labor (DOL) and the Peace Corps for review. Peace Corps provided written comments (reprinted in app. I), and both provided technical comments, which we incorporated as appropriate. Neither DOL nor the Peace Corps indicated whether or not they agreed with our recommendation. Instead, among other things, DOL’s technical comments identified examples of the agency’s collaboration with the Peace Corps to provide benefits under the FECA program. For example, DOL noted that officials from both agencies have met multiple times over the last 2 years to try to improve the handling of volunteers’ claims, and that DOL officials are available to work with the Peace Corps to improve the process of providing benefits to volunteers. In contrast, the Peace Corps noted specific improvements that it believes could assist returned volunteers, but stated that it cannot make these reforms on its own and needs action from DOL. DOL’s and the Peace Corps’ comments further underscore that the two agencies do not have a joint approach for monitoring the quality and accessibility of benefits for returned volunteers under the FECA program. As a result, we are concerned that the two agencies are missing opportunities to collaborate. We also remain convinced that DOL and the Peace Corps should, as we recommended, work together and develop an approach for using available agency information to monitor the accessibility and quality of FECA benefits for returned volunteers.

We are sending copies of this report to the Secretary of Labor, the Director of the Peace Corps, and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at kohnl@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix II.

Appendix I: Comments from the Peace Corps

Appendix II: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Will Simerl and Cynthia Grant, Assistant Directors; N. Rotimi Adebonojo; Melinda Cordero; Carolyn Fitzgerald; Krister Friday; Marina Klimenko; Amy Leone; and Jennifer Whitworth made key contributions to this report.