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

Page 1247 TITLE 5—GOVERNMENT ORGANIZATION AND EMPLOYEES § 8903 of Pub. L. 103–355, which is set out as a note under sec- tion 6101 of Title 31, Money and Finance. AMENDMENTS 1998—Subsec. (a)(1)(D). Pub. L. 105–266, § 2(a)(1)(A), added subpar. (D). Subsec. (a)(2)(A). Pub. L. 105–266, § 2(a)(1)(B), sub- stituted ‘‘subsection (b), (c), or (d)’’ for ‘‘subsection (b) or (c)’’. Subsec. (b). Pub. L. 105–266, § 2(a)(2)(A), substituted ‘‘shall’’ for ‘‘may’’ in introductory provisions. Subsec. (b)(5). Pub. L. 105–266, § 2(a)(2)(B), amended par. (5) generally. Prior to amendment, par. (5) read as follows: ‘‘Any provider— ‘‘(A) whose license to provide health care services or supplies has been revoked, suspended, restricted, or not renewed, by a State licensing authority for reasons relating to the provider’s professional com- petence, professional performance, or financial integ- rity; or ‘‘(B) that surrendered such a license while a formal disciplinary proceeding was pending before such an authority, if the proceeding concerned the provider’s professional competence, professional performance, or financial integrity.’’ Subsec. (c). Pub. L. 105–266, § 2(a)(3), added subsec. (c). Former subsec. (c) redesignated (d). Subsec. (d). Pub. L. 105–266, § 2(a)(3), redesignated sub- sec. (c) as (d). Former subsec. (d) redesignated (e). Subsec. (d)(1). Pub. L. 105–266, § 2(a)(4), amended par. (1) generally. Prior to amendment, par. (1) read as fol- lows: ‘‘in connection with a claim presented under this chapter, that a provider of health care services or sup- plies— ‘‘(A) has charged for health care services or supplies that the provider knows or should have known were not provided as claimed; or ‘‘(B) has charged for health care services or supplies in an amount substantially in excess of such pro- vider’s customary charges for such services or sup- plies, or charged for health care services or supplies which are substantially in excess of the needs of the covered individual or which are of a quality that fails to meet professionally recognized standards for such services or supplies;’’. Subsec. (e). Pub. L. 105–266, § 2(a)(3), redesignated sub- sec. (d) as (e). Former subsec. (e) redesignated (f). Subsec. (f). Pub. L. 105–266, § 2(a)(3), (5), redesignated subsec. (e) as (f) and inserted ‘‘(where such debarment is not mandatory)’’ after ‘‘debarment under this sec- tion’’. Former subsec. (f) redesignated (g). Subsec. (g). Pub. L. 105–266, § 2(a)(3), redesignated sub- sec. (f) as (g). Former subsec. (g) redesignated (h). Subsec. (g)(1). Pub. L. 105–266, § 2(a)(6)(A), added par. (1) and struck out former par. (1) which read as follows: ‘‘The debarment of a provider under subsection (b) or (c) shall be effective at such time and upon such rea- sonable notice to such provider, and to carriers and covered individuals, as may be specified in regulations prescribed by the Office.’’ Subsec. (g)(3). Pub. L. 105–266, § 2(a)(6)(B), inserted ‘‘of debarment’’ after ‘‘notice’’ and inserted at end ‘‘In the case of a debarment under paragraph (1), (2), (3), or (4) of subsection (b), the minimum period of debarment shall not be less than 3 years, except as provided in paragraph (4)(B)(ii).’’ Subsec. (g)(4)(B)(i)(I). Pub. L. 105–266, § 2(a)(6)(C), sub- stituted ‘‘subsection (b), (c), or (d)’’ for ‘‘subsection (b) or (c)’’. Subsec. (g)(6). Pub. L. 105–266, § 2(a)(6)(D), struck out par. (6) which read as follows: ‘‘The Office shall, upon written request and payment of a reasonable charge to defray the cost of complying with such request, furnish a current list of any providers barred from partici- pating in the program under this chapter, including the minimum period of time remaining under the terms of each provider’s debarment.’’ Subsec. (h). Pub. L. 105–266, § 2(a)(3), redesignated sub- sec. (g) as (h). Former subsec. (h) redesignated (i). Subsec. (h)(1), (2). Pub. L. 105–266, § 2(a)(7), added pars. (1) and (2) and struck out former pars. (1) and (2) which read as follows: ‘‘(1) The Office may not make a determination under subsection (b) or (c) adverse to a provider of health care services or supplies until such provider has been given written notice and an opportunity for a hearing on the record. A provider is entitled to be represented by counsel, to present witnesses, and to cross-examine witnesses against the provider in any such hearing. ‘‘(2) Notwithstanding section 8912, any person ad- versely affected by a final decision under paragraph (1) may obtain review of such decision in the United States Court of Appeals for the Federal Circuit. A writ- ten petition requesting that the decision be modified or set aside must be filed within 60 days after the date on which such person is notified of such decision.’’ Subsec. (i). Pub. L. 105–266, § 2(a)(3), (8), redesignated subsec. (h) as (i), substituted ‘‘subsection (d)’’ for ‘‘sub- section (c)’’, and inserted at end ‘‘The amount of a pen- alty or assessment as finally determined by the Office, or other amount the Office may agree to in com- promise, may be deducted from any sum then or later owing by the United States to the party against whom the penalty or assessment has been levied.’’ Former subsec. (i) redesignated (j). Subsec. (j). Pub. L. 105–266, § 2(a)(3), redesignated sub- sec. (i) as (j). Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1998 AMENDMENT Pub. L. 105–266, § 2(b), Oct. 19, 1998, 112 Stat. 2366, pro- vided that: ‘‘(1) IN GENERAL.—Except as provided in paragraph (2), the amendments made by this section [amending this section] shall take effect on the date of the enactment of this Act [Oct. 19, 1998]. ‘‘(2) EXCEPTIONS.—(A) Paragraphs (2), (3), and (5) of section 8902a(c) of title 5, United States Code, as amended by subsection (a)(3), shall apply only to the extent that the misconduct which is the basis for de- barment under paragraph (2), (3), or (5), as applicable, occurs after the date of the enactment of this Act. ‘‘(B) Paragraph (1)(B) of section 8902a(d) of title 5, United States Code, as amended by subsection (a)(4), shall apply only with respect to charges which violate section 8904(b) of such title for items or services fur- nished after the date of the enactment of this Act. ‘‘(C) Paragraph (3) of section 8902a(g) of title 5, United States Code, as amended by subsection (a)(6)(B), shall apply only with respect to debarments based on convic- tions occurring after the date of the enactment of this Act.’’ EFFECTIVE DATE; PRIOR CONDUCT Pub. L. 100–654, title I, § 102, Nov. 14, 1988, 102 Stat. 3841, provided that: ‘‘(a) APPLICABILITY.—The amendments made by this title [enacting this section] shall be effective with re- spect to any calendar year beginning, and contracts en- tered into or renewed for any calendar year beginning, after the date of the enactment of this Act [Nov. 14, 1988]. ‘‘(b) PRIOR CONDUCT NOT TO BE CONSIDERED.—In car- rying out section 8902a of title 5, United States Code, as added by this title, no debarment, civil monetary pen- alty, or assessment may be imposed under such section based on any criminal or other conduct occurring be- fore the beginning of the first calendar year which be- gins after the date of the enactment of this Act [Nov. 14, 1988].’’ § 8903. Health benefits plans The Office of Personnel Management may con- tract for or approve the following health bene- fits plans: (1) SERVICE BENEFIT PLAN.—One Govern- ment-wide plan, which may be underwritten by participating affiliates licensed in any number of States, offering at least 2 levels of Page 1248 TITLE 5—GOVERNMENT ORGANIZATION AND EMPLOYEES § 8903 benefits for enrollees under this chapter gen- erally and at least 2 levels of benefits for en- rollees under the Postal Service Health Bene- fits 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 given to employees, annuitants, members of their families, former spouses, or persons having continued coverage under section 8905a of this title, or, under certain conditions, pay- ment is made by a carrier to the employee, an- nuitant, family member, former spouse, or person having continued coverage under sec- tion 8905a of this title. (2) INDEMNITY BENEFIT PLAN.—One Govern- ment-wide plan, offering two levels of benefits, under which a carrier agrees to pay certain sums of money, not in excess of the actual ex- penses incurred, for benefits of the types de- scribed by section 8904(2) of this title. (3) EMPLOYEE ORGANIZATION PLANS.—Em- ployee organization plans which offer benefits of the types referred to by section 8904(3) of this title, which are sponsored or under- written, and are administered, in whole or sub- stantial part, by employee organizations de- scribed in section 8901(8)(A) of this title, which are available only to individuals, and members of their families, who at the time of enroll- ment are members of the organization. (4) COMPREHENSIVE MEDICAL PLANS.— (A) GROUP-PRACTICE PREPAYMENT PLANS.— Group-practice prepayment plans which offer health benefits of the types referred to by section 8904(4) of this title, in whole or in substantial part on a prepaid basis, with pro- fessional services thereunder provided by physicians practicing as a group in a com- mon center or centers. The group shall in- clude at least 3 physicians who receive all or a substantial part of their professional in- come from the prepaid funds and who rep- resent 1 or more medical specialties appro- priate and necessary for the population pro- posed to be served by the plan. (B) INDIVIDUAL-PRACTICE PREPAYMENT PLANS.—Individual-practice prepayment plans which offer health services in whole or substantial part on a prepaid basis, with pro- fessional services thereunder provided by in- dividual physicians who agree, under certain conditions approved by the Office, to accept the payments provided by the plans as full payment for covered services given by them including, in addition to in-hospital services, general care given in their offices and the patients’ homes, out-of-hospital diagnostic procedures, and preventive care, and which plans are offered by organizations which have successfully operated similar plans be- fore approval by the Office of the plan in which employees may enroll. (C) MIXED MODEL PREPAYMENT PLANS.— Mixed model prepayment plans which are a combination of the type of plans described in subparagraph (A) and the type of plans de- scribed in subparagraph (B). (Pub. L. 89–554, Sept. 6, 1966, 80 Stat. 602; Pub. L. 95–454, title IX, § 906(a)(2), (3), Oct. 13, 1978, 92 Stat. 1224; Pub. L. 98–615, § 3(3), Nov. 8, 1984, 98 Stat. 3203; Pub. L. 99–53, § 2(b), June 17, 1985, 99 Stat. 94; Pub. L. 99–251, title I, §§ 102, 111, Feb. 27, 1986, 100 Stat. 14, 19; Pub. L. 100–654, title II, § 202(b), Nov. 14, 1988, 102 Stat. 3845; Pub. L. 105–266, § 3(b), Oct. 19, 1998, 112 Stat. 2366; Pub. L. 117–108, title I, § 101(a)(2)(A), Apr. 6, 2022, 136 Stat. 1135.) HISTORICAL AND REVISION NOTES Derivation U.S. Code Revised Statutes and Statutes at Large .................. 5 U.S.C. 3003. Sept. 28, 1959, Pub. L. 86–382, § 4, 73 Stat. 711. July 8, 1963, Pub. L. 88–59, § 1(b), 77 Stat. 77. Standard changes are made to conform with the defi- nitions applicable and the style of this title as outlined in the preface to the report. Editorial Notes AMENDMENTS 2022—Par. (1). Pub. L. 117–108 substituted ‘‘at least 2 levels of benefits for enrollees under this chapter gen- erally and at least 2 levels of benefits for enrollees under the Postal Service Health Benefits Program es- tablished under section 8903c’’ for ‘‘two levels of bene- fits’’. 1998—Par. (1). Pub. L. 105–266 substituted ‘‘plan, which may be underwritten by participating affiliates licensed in any number of States,’’ for ‘‘plan,’’. 1988—Par. (1). Pub. L. 100–654 substituted ‘‘former spouses, or persons having continued coverage under section 8905a of this title,’’ for ‘‘or former spouses,’’ and ‘‘former spouse, or person having continued coverage under section 8905a of this title.’’ for ‘‘or former spouse.’’ 1986—Par. (4)(A). Pub. L. 99–251, § 102, amended second sentence generally, substituting ‘‘at least 3 physicians’’ for ‘‘physicians representing at least three major med- ical specialties’’ and inserted ‘‘and who represent 1 or more medical specialties appropriate and necessary for the population proposed to be served by the plan’’. Par. (4)(C). Pub. L. 99–251, § 111, added subpar. (C). 1985—Par. (3). Pub. L. 99–53 inserted ‘‘described in sec- tion 8901(8)(A) of this title’’ after ‘‘employee organiza- tions’’. 1984—Par. (1). Pub. L. 98–615, § 3(3), substituted ‘‘em- ployees, annuitants, members of their families, or former spouses’’ for ‘‘employees or annuitants, or mem- bers of their families’’ and ‘‘employee, annuitant, fam- ily member, or former spouse’’ for ‘‘employee or annu- itant or member of his family’’. 1978—Pub. L. 95–454 substituted ‘‘Office of Personnel Management’’ and ‘‘Office’’ for ‘‘Civil Service Commis- sion’’ and ‘‘Commission’’, respectively, wherever ap- pearing. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1988 AMENDMENT Amendment by Pub. L. 100–654 applicable with re- spect to any calendar year beginning, and contracts en- tered into or renewed for any calendar year beginning, after end of 9-month period beginning Nov. 14, 1988, and with respect to any qualifying event occurring on or after first day of first calendar year beginning after end of such 9-month period, see section 203 of Pub. L. 100–654, set out as a note under section 8902 of this title. EFFECTIVE DATE OF 1984 AMENDMENT Amendment by Pub. L. 98–615 effective May 7, 1985, with enumerated exceptions, and applicable to any in- dividual who is married to an employee or annuitant on or after that date, see section 4(a)(2) of Pub. L. 98–615, 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 privileges incident to full membership in such organization (determined without regard to the right to hold elected of- fice). (Added Pub. L. 99–53, § 1(b)(1), June 17, 1985, 99 Stat. 93.) § 8903b. Authority to readmit an employee orga- nization plan (a) In the event that a plan described by sec- tion 8903(3) or 8903a is discontinued under this chapter (other than in the circumstance de- scribed in section 8909(d)), that discontinuation shall be disregarded, for purposes of any deter- mination as to that plan’s eligibility to be con- sidered an approved plan under this chapter, but only for purposes of any contract year later than the third contract year beginning after such plan is so discontinued. (b) A contract for a plan approved under this section shall require the carrier— (1) to demonstrate experience in service de- livery within a managed care system (includ- ing provider networks) throughout the United States; and (2) if the carrier involved would not other- wise be subject to the requirement set forth in section 8903a(c)(1), to satisfy such require- ment. (Added Pub. L. 105–266, § 6(a)(1), Oct. 19, 1998, 112 Stat. 2368.) Statutory Notes and Related Subsidiaries EFFECTIVE DATE Pub. L. 105–266, § 6(a)(3), Oct. 19, 1998, 112 Stat. 2369, provided that: ‘‘(A) IN GENERAL.—The amendments made by this subsection [enacting this section] shall apply as of the date of the enactment of this Act [Oct. 19, 1998], includ- ing with respect to any plan which has been discon- tinued as of such date. ‘‘(B) TRANSITION RULE.—For purposes of applying sec- tion 8903b(a) of title 5, United States Code (as amended by this subsection) with respect to any plan seeking to be readmitted for purposes of any contract year begin- ning before January 1, 2000, such section shall be ap- plied by substituting ‘second contract year’ for ‘third contract year’.’’ § 8903c. Postal Service Health Benefits Program (a) DEFINITIONS.—In this section— (1) the term ‘‘covered Medicare individual’’ means an individual who is entitled to benefits under Medicare part A, but excluding an indi- vidual who is eligible to enroll under such part under section 1818 or 1818A of the Social Secu- rity Act (42 U.S.C. 1395i–2, 1395i–2a); (2) the term ‘‘initial contract year’’ means the contract year beginning in January of 2025; (3) the term ‘‘initial participating carrier’’ means a carrier that enters into a contract with the Office to participate in the Program during the initial contract year; (4) the term ‘‘Medicare part A’’ means part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.); (5) the term ‘‘Medicare part B’’ means part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.); (6) the term ‘‘Office’’ means the Office of Personnel Management; (7) the term ‘‘Postal Service’’ means the United States Postal Service; (8) the term ‘‘Postal Service annuitant’’ means an annuitant enrolled in a health bene- fits plan under this chapter whose Government contribution is required to be paid under sec- tion 8906(g)(2); (9) the term ‘‘Postal Service employee’’ means an employee of the Postal Service en- rolled in a health benefits plan under this chapter whose Government contribution is paid by the Postal Service; (10) the term ‘‘Postal Service Medicare cov- ered annuitant’’ means an individual who— (A) is a Postal Service annuitant; and (B) is a covered Medicare individual; (11) the term ‘‘Program’’ means the Postal Service Health Benefits Program established under subsection (c) within the Federal Em- ployees Health Benefits Program; (12) the term ‘‘Program plan’’ means a health benefits plan offered under the Pro- gram; and (13) the definitions set forth in section 8901 shall apply, and for the purposes of applying