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5 U.S.C. § 8903a — Additional health benefits plans

Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8903a — Additional health benefits plans

**(a)** In addition to any plan under [section 8903 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903&num=0&edition=prelim), the Office of Personnel Management may contract for or approve one or more health benefits plans under this section. **(b)** A plan under this section may not be contracted for or approved unless it— (1) is sponsored or underwritten, and administered, in whole or substantial part, by an employee organization described in [section 8901(8)(B) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8901/8/B&num=0&edition=prelim); (2) offers benefits of the types named by paragraph (1) or (2) of [section 8904 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8904&num=0&edition=prelim) or both; (3) provides for benefits only by paying for, or providing reimbursement for, the cost of such benefits (as provided for under paragraph (1) or (2) of [section 8903 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903&num=0&edition=prelim)) or a combination thereof; and (4) is available only to individuals who, at the time of enrollment, are full members of the organization and to members of their families. **(c)** A contract for a plan approved under this section shall require the carrier— (1) to enter into an agreement approved by the Office with an underwriting subcontractor licensed to issue group health insurance in all the States and the District of Columbia; or (2) to demonstrate ability to meet reasonable minimum financial standards prescribed by the Office. **(d)** For the purpose of this section, an individual shall be considered a full member of an organization if such individual is e

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Source file: Laws/federal/codes/united-states-code/title-5/section-8903a-additional-health-benefits-plans--78a57db4bf.md
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Source location: Title 5, Chapter 89, § 8903a; chapter-089-health-insurance.md

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8903 — Health benefits plans

The Office of Personnel Management may contract for or approve the following health benefits plans: (1) **Service Benefit Plan.—** — One Government-wide plan, which may be underwritten by participating affiliates licensed in any number of States, offering at least 2 levels of benefits for enrollees under this chapter generally and at least 2 levels of benefits for enrollees under the Postal Service Health Benefits Program established under section 8903c, under which payment is made by a carrier under contracts with physicians, hospitals, or other providers of health services for benefits of the types described by [section 8904(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8904/1&num=0&edition=prelim) given to employees, annuitants, members of their families, former spouses, or persons having continued coverage under [section 8905a of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8905a&num=0&edition=prelim), or, under certain conditions, payment is made by a carrier to the employee, annuitant, family member, former spouse, or person having continued coverage under [section 8905a of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8905a&num=0&edition=prelim). (2) **Indemnity Benefit Plan.—** — One Government-wide plan, offering two levels of benefits, under which a carrier agrees to pay certain sums of money, not in excess of the actual expenses incurred, for benefits of the types described by [section 8904(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8904/2&num=0&edition=prelim). (3) **Employee Organization Plans.—** — Employee organization plans which offer benefits of the types referred to by [s

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8904 — Types of benefits

**(a)** The benefits to be provided under plans described by [section 8903 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903&num=0&edition=prelim) may be of the following types: (1) **Service Benefit Plan.—** (A) Hospital benefits. (B) Surgical benefits. (C) In-hospital medical benefits. (D) Ambulatory patient benefits. (E) Supplemental benefits. (F) Obstetrical benefits. (2) **Indemnity Benefit Plan.—** (A) Hospital care. (B) Surgical care and treatment. (C) Medical care and treatment. (D) Obstetrical benefits. (E) Prescribed drugs, medicines, and prosthetic devices. (F) Other medical supplies and services. (3) **Employee Organization Plans.—** — Benefits of the types named under paragraph (1) or (2) of this subsection or both. (4) **Comprehensive Medical Plans.—** — Benefits of the types named under paragraph (1) or (2) of this subsection or both. All plans contracted for under paragraphs (1) and (2) of this subsection shall include benefits both for costs associated with care in a general hospital and for other health services of a catastrophic nature. **(b)** (1) (A) A plan, other than a prepayment plan described in [section 8903(4) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903/4&num=0&edition=prelim), may not provide benefits, in the case of any retired enrolled individual who is age 65 or older and is not covered to receive Medicare hospital and insurance benefits under part A of title XVIII of the Social Security Act ([42 U.S.C. 1395c](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395c&num=0&edition=prelim) et seq.), to pay a charge imposed by any health care provider, for inpatient hospital serv

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42 U.S.C. § 1395w–6 — Payment of premiums

**(a) Deductions from section 402 or 423 monthly benefits** (1) In the case of an individual who is entitled to monthly benefits under section 402 or 423 of this title, his monthly premiums under this part shall (except as provided in subsections (b)(1) and (c)) be collected by deducting the amount thereof from the amount of such monthly benefits. Such deduction shall be made in such manner and at such times as the Commissioner of Social Security shall by regulation prescribe. Such regulations shall be prescribed after consultation with the Secretary. (2) The Secretary of the Treasury shall, from time to time, transfer from the Federal Old-Age and Survivors Insurance Trust Fund or the Federal Disability Insurance Trust Fund to the Federal Supplementary Medical Insurance Trust Fund the aggregate amount deducted under paragraph (1) for the period to which such transfer relates from benefits under section 402 or 423 of this title which are payable from such Trust Fund. Such transfer shall be made on the basis of a certification by the Commissioner of Social Security and shall be appropriately adjusted to the extent that prior transfers were too great or too small. **(b) Deductions from railroad retirement annuities or pensions** (1) In the case of an individual who is entitled to receive for a month an annuity under the Railroad Retirement Act of 1974 [[45 U.S.C. 231](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title45-section231&num=0&edition=prelim) et seq.] (whether or not such individual is also entitled for such month to a monthly insurance benefit under [section 402 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section402&num=0&edition=prelim)), his monthly premiums under this part shall (except as provided i

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8901 — Definitions

For the purpose of this chapter— (1) “employee” means— (A) an employee as defined by [section 2105 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section2105&num=0&edition=prelim); (B) a Member of Congress as defined by [section 2106 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section2106&num=0&edition=prelim); (C) a Congressional employee as defined by [section 2107 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section2107&num=0&edition=prelim); (D) the President; (E) an individual first employed by the government of the District of Columbia before October 1, 1987; (F) an individual employed by Gallaudet College; 11 See Change of Name note below. (G) an individual employed by a county committee established under [section 590h(b) of title 16](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title16-section590h/b&num=0&edition=prelim); (H) an individual appointed to a position on the office staff of a former President under section 1(b) of the Act of August 25, 1958 (72 Stat. 838); (I) an individual appointed to a position on the office staff of a former President, or a former Vice President under section 5 of the Presidential Transition Act of 1963, as amended (78 Stat. 153), who immediately before the date of such appointment was an employee as defined under any other subparagraph of this paragraph; and (J) an individual who is employed by the Roosevelt Campobello International Park Commission and is a citizen of the United States, but does not include— (i) an employee of a corporation supervised by the Farm Credit Administration if private interests elect or appoint a member of the board of directors; (ii) a

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8902 — Contracting authority

**(a)** The Office of Personnel Management may contract with qualified carriers offering plans described by section 8903 or 8903a of this title, without regard to section 6101(b) to (d) of title 41 or other statute requiring competitive bidding. Each contract shall be for a uniform term of at least 1 year, but may be made automatically renewable from term to term in the absence of notice of termination by either party. **(b)** To be eligible as a carrier for the plan described by [section 8903(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903/2&num=0&edition=prelim), a company must be licensed to issue group health insurance in all the States and the District of Columbia. **(c)** A contract for a plan described by section 8903(1) or (2) of this title shall require the carrier— (1) to reinsure with other companies which elect to participate, under an equitable formula based on the total amount of their group health insurance benefit payments in the United States during the latest year for which the information is available, to be determined by the carrier and approved by the Office; or (2) to allocate its rights and obligations under the contract among its affiliates which elect to participate, under an equitable formula to be determined by the carrier and the affiliates and approved by the Office. **(d)** Each contract under this chapter shall contain a detailed statement of benefits offered and shall include such maximums, limitations, exclusions, and other definitions of benefits as the Office considers necessary or desirable. **(e)** The Office may prescribe reasonable minimum standards for health benefits plans described by section 8903 or 8903a of this title and for carriers offering the plans. Approval of a pla

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8905 — Election of coverage

**(a)** An employee may enroll in an approved health benefits plan described in section 8903 or 8903a— (1) as an individual; (2) for self plus one; or (3) for self and family. **(b)** An annuitant who at the time he becomes an annuitant was enrolled in a health benefits plan under this chapter— (1) as an employee for a period of not less than— (A) the 5 years of service immediately before retirement; (B) the full period or periods of service between the last day of the first period, as prescribed by regulations of the Office of Personnel Management, in which he is eligible to enroll in the plan and the date on which he becomes an annuitant; or (C) the full period or periods of service beginning with the enrollment which became effective before January 1, 1965, and ending with the date on which he becomes an annuitant; whichever is shortest; or (2) as a member of the family of an employee or annuitant; may continue his enrollment under the conditions of eligibility prescribed by regulations of the Office. The Office may, in its sole discretion, waive the requirements of this subsection in the case of an individual who fails to satisfy such requirements if the Office determines that, due to exceptional circumstances, it would be against equity and good conscience not to allow such individual to be enrolled as an annuitant in a health benefits plan under this chapter 11 So in original. Probably should be followed by a period. **(c)** (1) A former spouse may— (A) within 60 days after the dissolution of the marriage, or (B) in the case of a former spouse of a former employee whose marriage was dissolved after the employee’s retirement, within 60 days after the dissolution of the marriage or, if later, within 60 days after an election is made under se

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8907 — Information to individuals eligible to enroll

**(a)** The Office of Personnel Management shall make available to each individual eligible to enroll in a health benefits plan under this chapter such information, in a form acceptable to the Office after consultation with the carrier, as may be necessary to enable the individual to exercise an informed choice among the types of plans described by sections 8903 and 8903a of this title. **(b)** Each enrollee in a health benefits plan shall be issued an appropriate document setting forth or summarizing the— (1) services or benefits, including maximums, limitations, and exclusions, to which the enrollee or the enrollee and any eligible family members are entitled thereunder; (2) procedure for obtaining benefits; and (3) principal provisions of the plan affecting the enrollee and any eligible family members.

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8908 — Coverage of restored employees and survivor or disability annuitants

**(a)** An employee enrolled in a health benefits plan under this chapter who is removed or suspended without pay and later reinstated or restored to duty on the ground that the removal or suspension was unjustified or unwarranted may, at his option, enroll as a new employee or have his coverage restored, with appropriate adjustments made in contributions and claims, to the same extent and effect as though the removal or suspension had not taken place. **(b)** A surviving spouse whose survivor annuity under this title was terminated because of remarriage and is later restored may, under such regulations as the Office of Personnel Management may prescribe, enroll in a health benefits plan described by section 8903 or 8903a of this title if such spouse was covered by any such plan immediately before such annuity was terminated. **(c)** A disability annuitant whose disability annuity under [section 8337 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8337&num=0&edition=prelim) was terminated and is later restored under the second or third sentence of subsection (e) of such section may, under regulations prescribed by the Office, enroll in a health benefits plan described by section 8903 or 8903a of this title if such annuitant was covered by any such plan immediately before such annuity was terminated. **(d)** A surviving child whose survivor annuity under section 8341(e) or 8443(b) was terminated and is later restored under paragraph (4) of section 8341(e) or the last sentence of section 8443(b) may, under regulations prescribed by the Office, enroll in a health benefits plan described by section 8903 or 8903a if such surviving child was covered by any such plan immediately before such annuity was terminated.

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8913 — Regulations

**(a)** The Office of Personnel Management may prescribe regulations necessary to carry out this chapter. **(b)** The regulations of the Office may prescribe the time at which and the manner and conditions under which an employee is eligible to enroll in an approved health benefits plan described by section 8903 or 8903a of this title. The regulations may exclude an employee on the basis of the nature and type of his employment or conditions pertaining to it, such as short-term appointment, seasonal or intermittent employment, and employment of like nature. The Office may not exclude— (1) an employee or group of employees solely on the basis of the hazardous nature of employment; (2) a teacher in the employ of the Board of Education of the District of Columbia, whose pay is fixed by [section 1501 of title 31](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title31-section1501&num=0&edition=prelim), District of Columbia Code, on the basis of the fact that the teacher is serving under a temporary appointment if the teacher has been so employed by the Board for a period or periods totaling not less than two school years; (3) an employee who is occupying a position on a part-time career employment basis (as defined in [section 3401(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section3401/2&num=0&edition=prelim)); or (4) an employee who is employed on a temporary basis and is eligible under section 8906a(a). **(c)** The regulations of the Office shall provide for the beginning and ending dates of coverage of employees, annuitants, members of their families, and former spouses under health benefits plans. The regulations may permit the coverage to continue, exclusive of the temporary extension of coverage described b

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Federal law — U.S. Code and appendices · legal_authorities

5 U.S.C. § 8903a — Additional health benefits plans

Page 1249 TITLE 5—GOVERNMENT ORGANIZATION AND EMPLOYEES § 8903c as amended, set out as a note under section 8341 of this title. EFFECTIVE DATE OF 1978 AMENDMENT Amendment by Pub. L. 95–454 effective 90 days after Oct. 13, 1978, see section 907 of Pub. L. 95–454, set out as a note under section 1101 of this title. § 8903a. Additional health benefits plans (a) In addition to any plan under section 8903 of this title, the Office of Personnel Manage- ment may contract for or approve one or more health benefits plans under this section. (b) A plan under this section may not be con- tracted for or approved unless it— (1) is sponsored or underwritten, and admin- istered, in whole or substantial part, by an employee organization described in section 8901(8)(B) of this title; (2) offers benefits of the types named by paragraph (1) or (2) of section 8904 of this title or both; (3) provides for benefits only by paying for, or providing reimbursement for, the cost of such benefits (as provided for under paragraph (1) or (2) of section 8903 of this title) or a com- bination thereof; and (4) is available only to individuals who, at the time of enrollment, are full members of the organization and to members of their fam- ilies. (c) A contract for a plan approved under this section shall require the carrier— (1) to enter into an agreement approved by the Office with an underwriting subcontractor licensed to issue group health insurance in all the States and the District of Columbia; or (2) to demonstrate ability to meet reason- able minimum financial standards prescribed by the Office. (d) For the purpose of this section, an indi- vidual shall be considered a full member of an organization if such individual is eligible to ex- ercise all rights and privile

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