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OPM has issued its annual carrier call letter outlining policy goals and initiatives for the 2026 plan year. It emphasizes two main themes: streamlining how FEHB plans work to reduce friction experienced by federal employees and annuitants, and maintaining focus on ongoing healthcare priorities highlighted in previous years. Let’s explore how these areas may affect you in the coming year.
Easing Administrative Burden on FEHB Enrollees
A recent KFF survey revealed that 58% of respondents encountered issues with their health insurance over the past year. These challenges included denied claims, difficulties determining if a doctor was in-network, and problems with pre-authorization. Among those who faced these issues in the survey, 17% were unable to access recommended care, 15% experienced a decline in their health, and 28% ended up paying more than anticipated due to their insurance-related problems.
OPM is requiring FEHB carriers to address some of these issues by making improvements in the following three areas:
- Provider Information – Carriers have been required to offer enrollees an easy-to-use online provider directory for many years. Next year, OPM is asking carriers to have a link prominently displayed on their websites that allows users to search and filter on:
- Provider name,
- Practice or group name,
- Location,
- Network status,
- Gender,
- Specialty,
- Language,
- Whether the provider is accepting new patients,
- And whether the provider offers telemedicine services.
Carriers that offer multiple plans with different networks must make it clear that the user is using the right provider lookup tool for the corresponding plan.
- Out-of-Network Online Claims Filing – For in-network care, medical claims are typically handled directly between the provider and the carrier. However, for out-of-network care, plan members are usually responsible for submitting claims directly to the carrier. Currently, most carriers require members to download a claim form from their website and mail it in. To improve convenience and user experience, OPM is requiring carriers to implement an online claims submission portal by the end of 2026. This portal will serve as an additional option, supplementing the existing mail-based claims submission process.
- Disputed Claims – FEHB enrollees have always had the right to request reconsideration of carrier benefit decisions and to escalate unresolved issues to OPM through the disputed claims process. To improve transparency and accessibility, OPM is directing carriers to enhance available information about this process on their websites by January 1, 2026. Carriers must provide a mobile-friendly fact sheet that includes:
- A detailed explanation of the disputed claims process, including the enrollee’s rights to request reconsideration and to seek OPM review.
- Clear deadlines for requesting reconsideration and filing a disputed claim with OPM.
- Guidance on how members will receive relevant documentation used by the carrier to make its decision.
- A direct link to all forms required for filing an appeal.
These updates aim to ensure enrollees can easily navigate the disputed claims process and access the resources they need.
Preventive Care
Carriers are currently required to cover the following preventive services, at no cost to plan members:
- Preventive services with an “A” or “B” rating by the U.S. Preventive Services Task Force
- Immunizations recommended by the Advisory Committee on Immunization Practices
- Women’s health services specified in guidelines issues by the Health Resources and Services Administration.
The USPSTF has given an “A” rating for clinicians to prescribe HIV preexposure prophylaxis (PrEP) to individuals at increased risk of HIV to decrease that risk. OPM is requiring that next year FEHB carriers cover, at no cost, all FDA-approved drugs indicated for HIV PrEP.
Fertility Benefits
In recent years, IVF benefits for federal employees have significantly expanded. Currently, two nationwide plans—BCBS Standard and GEHA High—offer IVF coverage, along with numerous HMO plans across the country that provide some level of IVF benefits. OPM is encouraging carriers to continue offering and expanding these benefits.
Next year, OPM is mandating that all carriers include fertility preservation coverage for individuals at risk of iatrogenic infertility caused by medically necessary treatments, such as chemotherapy.
Mental Health Parity and Network Adequacy
OPM remains committed to ensuring that federal employees and their families face no barriers to accessing mental health and substance use disorder services under the FEHB program. To address this, OPM is urging carriers to expand their provider networks, reducing appointment wait times and improving access to care. Additionally, carriers are encouraged to enhance out-of-network provider benefits in cases where in-network mental health providers are unavailable or when wait times exceed regulatory standards. These efforts aim to improve the availability and timeliness of critical mental health services for enrollees.
Prevention and Treatment of Obesity – Currently, all FEHB plans must cover at least one GLP-1 drug prescribed for weight loss and at least two additional oral anti-obesity medications. For the upcoming plan year, OPM is encouraging carriers to enhance their obesity management benefits by including the follow requirements:
- Screening and support services.
- Child, adolescent, and family Healthy Weight programming.
- Access to a specialized care team, including a registered dietitian and an obesity-trained physician.
- Intensive behavioral therapy programs available in clinical or community settings.
- Ongoing patient monitoring and medication review.
- Clear, accessible communication about these programs in public-facing carrier materials.
These enhancements aim to provide enrollees with a holistic and supportive framework for managing obesity effectively.
The Final Word – Federal employees and annuitants will see some enhanced FEHB plan benefits next year, with OPM maintaining its focus on key priorities such as preventive care, fertility services, mental health, and obesity prevention and treatment.
In addition, OPM is implementing measures to make FEHB plans more user-friendly. These include easy-to-use provider look-up tools, online submission of out-of-network claims, and clearer guidance for enrollees on how to request reconsideration of denied claims, including escalation to OPM if necessary. These updates aim to provide better overall experiences and improved access to care for plan members.
Kevin Moss is a senior editor with the Guide to Health Plans for Federal Employees provided by Consumers’ Checkbook. Watch more of his free advice and check here to see if the Guide is available for free from your agency. You can also purchase the Guide and save 20% with promo code GOVEXEC.
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