-CITE- 5 USC CHAPTER 89 - HEALTH INSURANCE 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- CHAPTER 89 - HEALTH INSURANCE -MISC1- Sec. 8901. Definitions. 8902. Contracting authority. 8902a. Debarment and other sanctions. 8903. Health benefits plans. 8903a. Additional health benefits plans. 8903b. Authority to readmit an employee organization plan. 8904. Types of benefits. 8905. Election of coverage. 8905a. Continued coverage. 8906. Contributions. 8906a. Temporary employees. 8907. Information to individuals eligible to enroll. 8908. Coverage of restored employees and survivor or disability annuitants. 8909. Employees Health Benefits Fund. 8909a. Postal Service Retiree Health Benefits Fund.(!1) 8910. Studies, reports, and audits. 8911. Advisory committee. 8912. Jurisdiction of courts. 8913. Regulations. 8914. Effect of other statutes. AMENDMENTS 2006 - Pub. L. 109-435, title VIII, Sec. 803(a)(2), Dec. 20, 2006, 120 Stat. 3252, added item 8909a. 1998 - Pub. L. 105-266, Sec. 6(a)(2), Oct. 19, 1998, 112 Stat. 2369, added item 8903b. 1988 - Pub. L. 100-654, title I, Sec. 101(b), title II, Sec. 201(a)(2), title III, Sec. 301(b), Nov. 14, 1988, 102 Stat. 3841, 3845, 3846, added items 8902a, 8905a, and 8906a. Pub. L. 100-238, title I, Sec. 108(a)(3)(B), Jan. 8, 1988, 101 Stat. 1748, added item 8914. 1985 - Pub. L. 99-53, Secs. 1(b)(2), 3(a)(2)(B), June 17, 1985, 99 Stat. 94, 95, added item 8903a and inserted "or disability" after "and survivor" in item 8908. 1984 - Pub. L. 98-615, Sec. 3(8), Nov. 8, 1984, 98 Stat. 3204, substituted "Information to individuals eligible to enroll" for "Information to employees" in item 8907. 1976 - Pub. L. 94-342, Sec. 1(b), July 6, 1976, 90 Stat. 808, substituted "employees and survivor annuitants" for "employee" in item 8908. -FOOTNOTE- (!1) So in original. Does not conform to section catchline. -End- -CITE- 5 USC Sec. 8901 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8901. Definitions -STATUTE- For the purpose of this chapter - (1) "employee" means - (A) an employee as defined by section 2105 of this title; (B) a Member of Congress as defined by section 2106 of this title; (C) a Congressional employee as defined by section 2107 of this title; (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; (!1) (G) an individual employed by a county committee established under section 590h(b) of title 16; (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); and (I) an individual appointed to a position on the office staff of a former President, or a former Vice President under section 4 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; 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) an individual who is not a citizen or national of the United States and whose permanent duty station is outside the United States, unless the individual was an employee for the purpose of this chapter on September 30, 1979, by reason of service in an Executive agency, the United States Postal Service, or the Smithsonian Institution in the area which was then known as the Canal Zone; (iii) an employee of the Tennessee Valley Authority; or (iv) an employee excluded by regulation of the Office of Personnel Management under section 8913(b) of this title; (2) "Government" means the Government of the United States and the government of the District of Columbia; (3) "annuitant" means - (A) an employee who retires - (i) on an immediate annuity under subchapter III of chapter 83 of this title, or another retirement system for employees of the Government, after 5 or more years of service; (ii) under section 8412 or 8414 of this title; (iii) for disability under subchapter III of chapter 83 of this title, chapter 84 of this title, or another retirement system for employees of the Government; or (iv) on an immediate annuity under a retirement system established for employees described in section 2105(c), in the case of an individual who elected under section 8347(q)(2) or 8461(n)(2) to remain subject to such a system; (B) a member of a family who receives an immediate annuity as the survivor of an employee (including a family member entitled to an amount under section 8442(b)(1)(A), whether or not such family member is entitled to an annuity under section 8442(b)(1)(B)) or of a retired employee described by subparagraph (A) of this paragraph; (C) an employee who receives monthly compensation under subchapter I of chapter 81 of this title and who is determined by the Secretary of Labor to be unable to return to duty; and (D) a member of a family who receives monthly compensation under subchapter I of chapter 81 of this title as the surviving beneficiary of - (i) an employee who dies as a result of injury or illness compensable under that subchapter; or (ii) a former employee who is separated after having completed 5 or more years of service and who dies while receiving monthly compensation under that subchapter and who has been held by the Secretary to have been unable to return to duty; (4) "service", as used by paragraph (3) of this section, means service which is creditable under subchapter III of chapter 83 or chapter 84 of this title; (5) "member of family" means the spouse of an employee or annuitant and an unmarried dependent child under 22 years of age, including - (A) an adopted child or recognized natural child; and (B) a stepchild or foster child but only if the child lives with the employee or annuitant in a regular parent-child relationship; or such an unmarried dependent child regardless of age who is incapable of self-support because of mental or physical disability which existed before age 22; (6) "health benefits plan" means a group insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar group arrangements provided by a carrier for the purpose of providing, paying for, or reimbursing expenses for health services; (7) "carrier" means a voluntary association, corporation, partnership, or other nongovernmental organization which is lawfully engaged in providing, paying for, or reimbursing the cost of, health services under group insurance policies or contracts, medical or hospital service agreements, membership or subscription contracts, or similar group arrangements, in consideration of premiums or other periodic charges payable to the carrier, including a health benefits plan duly sponsored or underwritten by an employee organization and an association of organizations or other entities described in this paragraph sponsoring a health benefits plan; (8) "employee organization" means - (A) an association or other organization of employees which is national in scope, or in which membership is open to all employees of a Government agency who are eligible to enroll in a health benefits plan under this chapter and which, after December 31, 1978, and before January 1, 1980, applied to the Office for approval of a plan provided under section 8903(3) of this title; and (B) an association or other organization which is national in scope, in which membership is open only to employees, annuitants, or former spouses, or any combination thereof, and which, during the 90-day period beginning on the date of enactment of section 8903a of this title, applied to the Office for approval of a plan provided under such section; (9) "dependent", in the case of any child, means that the employee or annuitant involved is either living with or contributing to the support of such child, as determined in accordance with such regulations as the Office shall prescribe; (10) "former spouse" means a former spouse of an employee, former employee, or annuitant - (A) who has not remarried before age 55 after the marriage to the employee, former employee, or annuitant was dissolved, (B) who was enrolled in an approved health benefits plan under this chapter as a family member at any time during the 18- month period before the date of the dissolution of the marriage to the employee, former employee, or annuitant, and (C)(i) who is receiving any portion of an annuity under section 8345(j) or 8467 of this title or a survivor annuity under section 8341(h) or 8445 of this title (or benefits similar to either of the aforementioned annuity benefits under a retirement system for Government employees other than the Civil Service Retirement System or the Federal Employees' Retirement System), (ii) as to whom a court order or decree referred to in section 8341(h), 8345(j), 8445, or 8467 of this title (or similar provision of law under any such retirement system other than the Civil Service Retirement System or the Federal Employees' Retirement System) has been issued, or for whom an election has been made under section 8339(j)(3) or 8417(b) of this title (or similar provision of law), or (iii) who is otherwise entitled to an annuity or any portion of an annuity as a former spouse under a retirement system for Government employees, except that such term shall not include any such unremarried former spouse of a former employee whose marriage was dissolved after the former employee's separation from the service (other than by retirement); and (11) "qualified clinical social worker" means an individual - (A) who is licensed or certified as a clinical social worker by the State in which such individual practices; or (B) who, if such State does not provide for the licensing or certification of clinical social workers - (i) is certified by a national professional organization offering certification of clinical social workers; or (ii) meets equivalent requirements (as prescribed by the Office). -SOURCE- (Pub. L. 89-554, Sept. 6, 1966, 80 Stat. 600; Pub. L. 90-83, Sec. 1(95), Sept. 11, 1967, 81 Stat. 219; Pub. L. 91-418, Secs. 2, 3(b), Sept. 25, 1970, 84 Stat. 869; Pub. L. 93-160, Sec. 1(b), Nov. 27, 1973, 87 Stat. 635; Pub. L. 95-368, Sec. 2, Sept. 17, 1978, 92 Stat. 606; Pub. L. 95-454, title IX, Sec. 906(a)(2), (3), Oct. 13, 1978, 92 Stat. 1224; Pub. L. 95-583, Sec. 2, Nov. 2, 1978, 92 Stat. 2482; Pub. L. 96-54, Sec. 2(a)(52), Aug. 14, 1979, 93 Stat. 384; Pub. L. 96-70, title I, Sec. 1209(c), Sept. 27, 1979, 93 Stat. 463; Pub. L. 96-179, Sec. 2, Jan. 2, 1980, 93 Stat. 1299; Pub. L. 98- 615, Sec. 3(1), Nov. 8, 1984, 98 Stat. 3202; Pub. L. 99-53, Sec. 1(a), June 17, 1985, 99 Stat. 93; Pub. L. 99-251, title I, Sec. 105(a), Feb. 27, 1986, 100 Stat. 15; Pub. L. 99-335, title II, Sec. 207(l), June 6, 1986, 100 Stat. 598; Pub. L. 99-556, title V, Sec. 503, Oct. 27, 1986, 100 Stat. 3141; Pub. L. 100-679, Sec. 13(c), Nov. 17, 1988, 102 Stat. 4071; Pub. L. 101-508, title VII, Sec. 7202(l), Nov. 5, 1990, 104 Stat. 1388-339; Pub. L. 102-378, Sec. 2(75), Oct. 2, 1992, 106 Stat. 1355; Pub. L. 105-266, Sec. 3(a), Oct. 19, 1998, 112 Stat. 2366.) -MISC1- HISTORICAL AND REVISION NOTES 1966 ACT -------------------------------------------------------------------- Derivation U.S. Code Revised Statutes and Statutes at Large -------------------------------------------------------------------- 5 U.S.C. 3001. Sept. 28, 1959, Pub. L. 86-382, Sec. 2, 73 Stat. 709. July 8, 1963, Pub. L. 88-59, Sec. 1, 77 Stat. 76. Mar. 17, 1964, Pub. L. 88-284, Sec. 1(1)-(4), 78 Stat. 164. Aug. 31, 1964, Pub. L. 88-531, Sec. 1, 78 Stat. 737. 5 U.S.C. 3002(f) July 1, 1960, Pub. L. (1st sentence, less 86-568, Sec. 115(d) "(f) words between 1st (1st sentence, less words and 2d commas). between 1st and 2d commas)", 74 Stat. 303. -------------------------------------------------------------------- The definition of "employee" in section 2105 of this title is broad enough to cover the officers and employees covered by former section 3001 with the exception of a Member of Congress, the President, an individual employed by the government of the District of Columbia, an individual employed by Gallaudet College, a United States commissioner, and an Official Reporter of Debates of the Senate and an individual employed by him. The first five have been added in paragraphs (1)(B), (D), (E), (F), and (G). The latter are covered by the definition of "Congressional employee" in section 2107 of this title and are included by the addition of a Congressional employee in paragraph (1)(C). In paragraph (1)(ii), the words "the United States" are substituted for "a State of the United States or the District of Columbia". Paragraph (1)(iv) is added for clarity. In paragraph (8), the words "before January 1, 1964" are substituted for "on or before December 31, 1963". The definition of "Commission" in former section 3001(h) is omitted as unnecessary as the full title "Civil Service Commission" is set forth the first time it is used in a section. Standard changes are made to conform with the definitions applicable and the style of this title as outlined in the preface to the report. 1967 ACT -------------------------------------------------------------------- Section of Source (U.S. Code) Source (Statutes at Large) title 5 -------------------------------------------------------------------- 8901(5) 5 App.: 3001(d). July 18, 1966, Pub. L. 89-504, Sec. 601, 80 Stat. 303. -------------------------------------------------------------------- -REFTEXT- REFERENCES IN TEXT Section 1(b) of the Act of August 25, 1958 (72 Stat. 838), referred to in par. (1)(H), is section 1(b) of Pub. L. 85-745 which is set out as a note under section 102 of Title 3, The President. Section 4 of the Presidential Transition Act of 1963, referred to in par. (1)(I), is section 4 of Pub. L. 88-277, which is set out as a note under section 102 of Title 3. The date of enactment of section 8903a of this title, referred to in par. (8)(B), means the date of enactment of Pub. L. 99-53, which enacted section 8903a and which was approved June 17, 1985. -MISC2- AMENDMENTS 1998 - Par. (7). Pub. L. 105-266 substituted "organization and an association of organizations or other entities described in this paragraph sponsoring a health benefits plan;" for "organization;". 1992 - Par. (3)(A)(iv). Pub. L. 102-378, Sec. 2(75)(A), substituted "8347(q)(2)" for "8347(p)(2)". Par. (10)(C)(ii). Pub. L. 102-378, Sec. 2(75)(B), inserted comma after "8341(h)". 1990 - Par. (3)(A)(iv). Pub. L. 101-508 added cl. (iv). 1988 - Par. (1)(H), (I). Pub. L. 100-679 added subpars. (H) and (I). 1986 - Par. (1)(E). Pub. L. 99-335, Sec. 207(l)(1), amended subpar. (E) generally, substituting "first employed" for "employed" and inserting "before October 1, 1987". Par. (3)(A). Pub. L. 99-335, Sec. 207(l)(2), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: "an employee who retires on an immediate annuity under subchapter III of chapter 83 of this title or another retirement system for employees of the Government, after 5 or more years of service or for disability". Par. (3)(B). Pub. L. 99-556 inserted "(including a family member entitled to an amount under section 8442(b)(1)(A), whether or not such family member is entitled to an annuity under section 8442(b)(1)(B))". Par. (4). Pub. L. 99-335, Sec. 207(l)(3), inserted "or chapter 84". Par. (10)(C)(i). Pub. L. 99-335, Sec. 207(l)(4), inserted "or 8467", "or 8445", and "or the Federal Employees' Retirement System". Par. (10)(C)(ii). Pub. L. 99-335, Sec. 207(l)(5), substituted "8345(j), 8445, or 8467" for "or 8345(j)" and inserted "or the Federal Employees' Retirement System" and "or 8417(b)". Par. (11). Pub. L. 99-251 added par. (11). 1985 - Par. (8). Pub. L. 99-53 amended par. (8) generally, designating existing provisions as subpar. (A) and adding subpar. (B). 1984 - Par. (10). Pub. L. 98-615 added par. (10). 1980 - Par. (5). Pub. L. 96-179, Sec. 2(1), inserted "dependent" after "unmarried" in provisions preceding subpar. (A) and in provisions following subpar. (B), inserted "or recognized natural child" after "child" in subpar. (A), and substituted "or foster child but only if the child;" for ", foster child, or recognized natural child who" in subpar. (B). Par. (9). Pub. L. 96-179, Sec. 2(2)-(4), added par. (9). 1979 - Par. (1). Pub. L. 96-70 in cl. (ii) substituted provisions relating to an individual who was an employee for the purpose of this chapter on Sept. 30, 1979, by reason of service in an Executive agency, United States Postal Service, or Smithsonian Institution in area which was then known as Canal Zone for provisions relating to Panama Canal Zone. Pub. L. 96-54 struck out cl. (G) which related to coverage of a United States Commissioner as an "employee", and redesignated cl. (H) as (G). 1978 - Par. (1)(iv). Pub. L. 95-454 substituted "Office of Personnel Management" for "Civil Service Commission". Par. (3)(A). Pub. L. 95-583 reduced period of service to 5 from 12 years. Par. (8). Pub. L. 95-454 substituted "Office" for "Commission". Pub. L. 95-368 substituted "after December 31, 1978, and before January 1, 1980" for "before January 1, 1964". 1973 - Par. (1)(ii). Pub. L. 93-160 excluded from definition of "employee" persons who are not nationals of United States and whose permanent duty station is outside United States and Panama Canal Zone. 1970 - Par. (1)(ii). Pub. L. 91-418, Sec. 3(b), excluded from definition of "employee" a noncitizen employee whose permanent duty station is outside Panama Canal Zone. Par. (3)(B). Pub. L. 91-418, Sec. 2(a), redefined "annuitant" to be a member of a family who receives an immediate annuity as the survivor of an employee rather than as the survivor of an employee who dies after completing 5 or more years of service. Par. (3)(D)(i). Pub. L. 91-418, Sec. 2(b), redefined "annuitant" to be a member of a family who receives monthly compensation as the surviving beneficiary of an employee who dies as a result of a compensable injury or illness rather than as the survivor of an employee who, having completed 5 or more years of service, so dies. -CHANGE- CHANGE OF NAME Gallaudet College, referred to in par. (1)(F), was redesignated Gallaudet University by section 101(a) of Pub. L. 99-371, which is classified to section 4301(a) of Title 20, Education. -MISC3- EFFECTIVE DATE OF 1992 AMENDMENT Amendment by section 2(75)(A) of Pub. L. 102-378 effective Nov. 5, 1990, and amendment by section 2(75)(B) of Pub. L. 102-378 effective Oct. 2, 1992, see section 9(a), (b)(6) of Pub. L. 102- 378, set out as a note under section 6303 of this title. EFFECTIVE DATE OF 1990 AMENDMENT Amendment by Pub. L. 101-508 applicable with respect to any individual who, on or after Jan. 1, 1987, moves from employment in nonappropriated fund instrumentality of Department of Defense or Coast Guard, that is described in section 2105(c) of this title, to employment in Department or Coast Guard, that is not described in section 2105(c), or who moves from employment in Department or Coast Guard, that is not described in section 2105(c), to employment in nonappropriated fund instrumentality of Department or Coast Guard, that is described in section 2105(c), see section 7202(m)(1) of Pub. L. 101-508, set out as a note under section 2105 of this title. EFFECTIVE DATE OF 1986 AMENDMENTS Amendment by Pub. L. 99-335 effective Jan. 1, 1987, see section 702(a) of Pub. L. 99-335, set out as an Effective Date note under section 8401 of this title. Section 105(c) of Pub. L. 99-251 provided that: "The amendments made by subsections (a) and (b) [amending this section and section 8902 of this title] shall be effective with respect to contracts entered into or renewed for calendar years beginning after December 31, 1986." EFFECTIVE DATE OF 1984 AMENDMENT Amendment by Pub. L. 98-615 effective May 7, 1985, with enumerated exceptions, and applicable to any individual who is married to an employee or annuitant on or after that date, see section 4(a)(2) of Pub. L. 98-615, as amended, set out as a note under section 8341 of this title. EFFECTIVE DATE OF 1980 AMENDMENT Amendment by Pub. L. 96-179 effective Jan. 2, 1980, except that no benefits under this chapter that are made available by reason of amendment of this section and section 8341 of this title by Pub. L. 96-179 shall be payable for any period before Oct. 1, 1979, see section 5(a) of Pub. L. 96-179, set out as a note under section 8341 of this title. EFFECTIVE DATE OF 1979 AMENDMENTS Amendment by Pub. L. 96-70 effective Oct. 1, 1979, see section 3304 of Pub. L. 96-70, set out as an Effective Date note under section 3601 of Title 22, Foreign Relations and Intercourse. Amendment by Pub. L. 96-54 effective July 12, 1979, see section 2(b) of Pub. L. 96-54, set out as a note under section 305 of this title. EFFECTIVE DATE OF 1978 AMENDMENTS Amendment by Pub. L. 95-583 effective Nov. 2, 1978, see section 3 of Pub. L. 95-583, set out as a note under section 8706 of this title. 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. SHORT TITLE OF 2000 AMENDMENT Pub. L. 106-394, Sec. 1, Oct. 30, 2000, 114 Stat. 1629, provided that: "This Act [amending sections 8421a and 8905 of this title and enacting provisions set out as a note under section 8421a of this title] may be cited as the 'Federal Employees Health Benefits Children's Equity Act of 2000'." SHORT TITLE OF 1998 AMENDMENT Pub. L. 105-266, Sec. 1, Oct. 19, 1998, 112 Stat. 2363, provided that: "This Act [enacting section 8903b of this title, amending this section and sections 5948, 8902 to 8903, and 8909 of this title, and enacting provisions set out as notes under this section and sections 5948, 8902, 8902a, 8903b, and 8909 of this title] may be cited as the 'Federal Employees Health Care Protection Act of 1998'." SHORT TITLE OF 1988 AMENDMENT Pub. L. 100-654, Sec. 1, Nov. 14, 1988, 102 Stat. 3837, provided that: "This Act [enacting sections 8440a, 8902a, 8905a, and 8906a of this title, amending sections 8902, 8903, 8905, 8909, and 8913 of this title, and enacting provisions set out as notes under sections 8902, 8902a, and 8906a of this title] may be cited as the 'Federal Employees Health Benefits Amendments Act of 1988'." SHORT TITLE OF 1986 AMENDMENT Section 1 of Pub. L. 99-251 provided that: "This Act [amending this section, sections 1103, 3502, 5334, 5924, 6312, 8332, 8339 to 8342, 8345, 8902, 8903, 8905, and 8909 of this title, and section 35 of Title 24, Hospitals and Asylums, enacting provisions set out as notes under this section and sections 7901, 8339, 8341, 8345, 8902, 8904, 8905, and 8909 of this title, and amending provisions set out as notes under sections 8341 and 8902 of this title] may be cited as the 'Federal Employees Benefits Improvement Act of 1986'." CONTINUATION OF HEALTH BENEFITS COVERAGE FOR INDIVIDUALS ENROLLED IN A PLAN ADMINISTERED BY THE OVERSEAS PRIVATE INVESTMENT CORPORATION Pub. L. 107-304, Sec. 4, Nov. 27, 2002, 116 Stat. 2364, provided that: "(a) Enrollment in Chapter 89 Plan. - For purposes of the administration of chapter 89 of title 5, United States Code, any period of enrollment under a health benefits plan administered by the Overseas Private Investment Corporation before the effective date of this Act [probably means Nov. 27, 2002, the date of enactment of Pub. L. 107-304] shall be deemed to be a period of enrollment in a health benefits plan under chapter 89 of such title. "(b) Continued Coverage. - "(1) In general. - Any individual who, as of the enrollment eligibility date, is covered by a health benefits plan administered by the Overseas Private Investment Corporation may enroll in an approved health benefits plan described under section 8903 or 8903a of title 5, United States Code - "(A) either as an individual or for self and family, if such individual is an employee, annuitant, or former spouse as defined under section 8901 of such title; and "(B) for coverage effective on and after such date. "(2) Individuals currently under continued coverage. - An individual who, as of the enrollment eligibility date, is entitled to continued coverage under a health benefits plan administered by the Overseas Private Investment Corporation - "(A) shall be deemed to be entitled to continued coverage under section 8905a of title 5, United States Code, for the same period that would have been permitted under the plan administered by the Overseas Private Investment Corporation; and "(B) may enroll in an approved health benefits plan described under section 8903 or 8903a of such title in accordance with section 8905a of such title for coverage effective on and after such date. "(3) Unmarried dependent children. - An individual who, as of the enrollment eligibility date, is covered as an unmarried dependent child under a health benefits plan administered by the Overseas Private Investment Corporation and who is not a member of family as defined under section 8901(5) of title 5, United States Code - "(A) shall be deemed to be entitled to continued coverage under section 8905a of such title as though the individual had ceased to meet the requirements for being considered an unmarried dependent child under chapter 89 of such title as of such date; and "(B) may enroll in an approved health benefits plan described under section 8903 or 8903a of such title in accordance with section 8905a for continued coverage effective on and after such date. "(c) Transfers to the Employees Health Benefits Fund. - "(1) In general. - The Overseas Private Investment Corporation shall transfer to the Employees Health Benefits Fund established under section 8909 of title 5, United States Code, amounts determined by the Director of the Office of Personnel Management, after consultation with the Overseas Private Investment Corporation, to be necessary to reimburse the Fund for the cost of providing benefits under this section not otherwise paid for by the individuals covered by this section. "(2) Availability of funds. - The amounts transferred under paragraph (1) shall be held in the Fund and used by the Office in addition to amounts available under section 8906(g)(1) of title 5, United States Code. "(d) Administration and Regulations. - The Office of Personnel Management - "(1) shall administer this section to provide for - "(A) a period of notice and open enrollment for individuals affected by this section; and "(B) no lapse of health coverage for individuals who enroll in a health benefits plan under chapter 89 of title 5, United States Code, in accordance with this section; and "(2) may prescribe regulations to implement this section. "(e) Enrollment Eligibility Date. - For purposes of this section, the term 'enrollment eligibility date' means the last day on which coverage under a health benefits plan administered by the Overseas Private Investment Corporation is available. Such date shall be determined by the Office of Personnel Management in consultation with the Overseas Private Investment Corporation." CONTINUED COVERAGE FOR INDIVIDUALS ENROLLED IN PLAN ADMINISTERED BY FEDERAL DEPOSIT INSURANCE CORPORATION OR FOR EMPLOYEES OF BOARD OF GOVERNORS OF FEDERAL RESERVE SYSTEM Pub. L. 105-266, Sec. 4, Oct. 19, 1998, 112 Stat. 2367, provided that: "(a) Enrollment in Chapter 89 Plan. - For purposes of chapter 89 of title 5, United States Code, any period of enrollment - "(1) in a health benefits plan administered by the Federal Deposit Insurance Corporation before the termination of such plan on or before January 2, 1999; or "(2) subject to subsection (c), in a health benefits plan (not under chapter 89 of such title) with respect to which the eligibility of any employees or retired employees of the Board of Governors of the Federal Reserve System terminates on or before January 2, 1999, shall be deemed to be a period of enrollment in a health benefits plan under chapter 89 of such title. "(b) Continued Coverage. - (1) Subject to subsection (c), any individual who, on or before January 2, 1999, is enrolled in a health benefits plan described in subsection (a)(1) or (2) may enroll in an approved health benefits plan under chapter 89 of title 5, United States Code, either as an individual or for self and family, if, after taking into account the provisions of subsection (a), such individual - "(A) meets the requirements of such chapter for eligibility to become so enrolled as an employee, annuitant, or former spouse (within the meaning of such chapter); or "(B) would meet those requirements if, to the extent such requirements involve either retirement system under such title 5, such individual satisfies similar requirements or provisions of the Retirement Plan for Employees of the Federal Reserve System. Any determination under subparagraph (B) shall be made under guidelines which the Office of Personnel Management shall establish in consultation with the Board of Governors of the Federal Reserve System. "(2) Subject to subsection (c), any individual who, on or before January 2, 1999, is entitled to continued coverage under a health benefits plan described in subsection (a)(1) or (2) shall be deemed to be entitled to continued coverage under section 8905a of title 5, United States Code, but only for the same remaining period as would have been allowable under the health benefits plan in which such individual was enrolled on or before January 2, 1999, if - "(A) such individual had remained enrolled in such plan; and "(B) such plan did not terminate, or the eligibility of such individual with respect to such plan did not terminate, as described in subsection (a). "(3) Subject to subsection (c), any individual (other than an individual under paragraph (2)) who, on or before January 2, 1999, is covered under a health benefits plan described in subsection (a)(1) or (2) as an unmarried dependent child, but who does not then qualify for coverage under chapter 89 of title 5, United States Code, as a family member (within the meaning of such chapter) shall be deemed to be entitled to continued coverage under section 8905a of such title, to the same extent and in the same manner as if such individual had, on or before January 2, 1999, ceased to meet the requirements for being considered an unmarried dependent child of an enrollee under such chapter. "(4) Coverage under chapter 89 of title 5, United States Code, pursuant to an enrollment under this section shall become effective on January 3, 1999 or such earlier date as established by the Office of Personnel Management after consultation with the Federal Deposit Insurance Corporation or the Board of Governors of the Federal Reserve System, as appropriate. "(c) Eligibility for FEHBP Limited to Individuals Losing Eligibility Under Former Health Plan. - Nothing in subsection (a)(2) or any paragraph of subsection (b) (to the extent such paragraph relates to the plan described in subsection (a)(2)) shall be considered to apply with respect to any individual whose eligibility for coverage under such plan does not involuntarily terminate on or before January 2, 1999. "(d) Transfers to the Employees Health Benefits Fund. - The Federal Deposit Insurance Corporation and the Board of Governors of the Federal Reserve System shall transfer to the Employees Health Benefits Fund under section 8909 of title 5, United States Code, amounts determined by the Director of the Office of Personnel Management, after consultation with the Federal Deposit Insurance Corporation and the Board of Governors of the Federal Reserve System, to be necessary to reimburse the Fund for the cost of providing benefits under this section not otherwise paid for by the individuals covered by this section. The amounts so transferred shall be held in the Fund and used by the Office of Personnel Management in addition to amounts available under section 8906(g)(1) of such title. "(e) Administration and Regulations. - The Office of Personnel Management - "(1) shall administer the provisions of this section to provide for - "(A) a period of notice and open enrollment for individuals affected by this section; and "(B) no lapse of health coverage for individuals who enroll in a health benefits plan under chapter 89 of title 5, United States Code, in accordance with this section; and "(2) may prescribe regulations to implement this section." CONTINUED COVERAGE FOR INDIVIDUALS ENROLLED IN PLAN ADMINISTERED BY FARM CREDIT ADMINISTRATION Pub. L. 104-37, title VI, Sec. 601, Oct. 21, 1995, 109 Stat. 328, provided that: "(a) For purposes of the administration of chapter 89 of title 5, United States Code, any period of enrollment under a health benefits plan administered by the Farm Credit Administration prior to the effective date of this Act [Oct. 21, 1995] shall be deemed to be a period of enrollment in a health benefits plan under chapter 89 of such title. "(b)(1) An individual who, on September 30, 1995, is covered by a health benefits plan administered by the Farm Credit Administration may enroll in an approved health benefits plan described under section 8903 or 8903a of title 5, United States Code - "(A) either as an individual or for self and family, if such individual is an employee, annuitant, or former spouse as defined under section 8901 of such title; and "(B) for coverage effective on and after September 30, 1995. "(2) An individual who, on September 30, 1995, is entitled to continued coverage under a health benefits plan administered by the Farm Credit Administration - "(A) shall be deemed to be entitled to continued coverage under section 8905a of title 5, United States Code, for the same period that would have been permitted under the plan administered by the Farm Credit Administration; and "(B) may enroll in an approved health benefits plan described under sections 8903 or 8903a of such title in accordance with section 8905A of such title for coverage effective on and after September 30, 1995. "(3) An individual who, on September 30, 1995, is covered as an unmarried dependent child under a health benefits plan administered by the Farm Credit Administration and who is not a member of family as defined under section 8901(5) of title 5, United States Code - "(A) shall be deemed to be entitled to continued coverage under section 8905a of such title as though the individual had, on September 30, 1995, ceased to meet the requirements for being considered an unmarried dependent child under chapter 89 of such title; and "(B) may enroll in an approved health benefits plan described under section 8903 or 8903a of such title in accordance with section 8905a for continued coverage on and after September 30, 1995. "(c) The Farm Credit Administration shall transfer to the Federal Employees Health Benefits Fund established under section 8909 of title 5, United States Code, amounts determined by the Director of the Office of Personnel Management, after consultation with the Farm Credit Administration, to be necessary to reimburse the Fund for the cost of providing benefits under this section not otherwise paid for by the individuals covered by this section. The amount so transferred shall be held in the Fund and used by the Office in addition to the amounts available under section 8906(g)(1) of such title. "(d) The Office of Personnel Management - "(1) shall administer the provisions of this section to provide for - "(A) a period of notice and open enrollment for individuals affected by this section; and "(B) no lapse of health coverage for individuals who enroll in a health benefits plan under chapter 89 of title 5, United States Code, in accordance with this section; and "(2) may prescribe regulations to implement this section." CONTINUED COVERAGE FOR INDIVIDUALS ENROLLED IN PLAN ADMINISTERED BY OFFICE OF THE COMPTROLLER OF THE CURRENCY OR OFFICE OF THRIFT SUPERVISION Pub. L. 103-409, Sec. 5, Oct. 25, 1994, 108 Stat. 4232, provided that: "(a) Enrollment in Chapter 89 Plan. - For purposes of the administration of chapter 89 of title 5, United States Code, any period of enrollment under a health benefits plan administered by the Office of the Comptroller of the Currency or the Office of Thrift Supervision before the termination of such plans on January 7, 1995, shall be deemed to be a period of enrollment in a health benefits plan under chapter 89 of such title. "(b) Continued Coverage. - (1) Any individual who, on January 7, 1995, is covered by a health benefits plan administered by the Office of the Comptroller of the Currency or the Office of Thrift Supervision may enroll in an approved health benefits plan described under section 8903 or 8903a of title 5, United States Code - "(A) either as an individual or for self and family, if such individual is an employee, annuitant, or former spouse as defined under section 8901 of such title; and "(B) for coverage effective on and after January 8, 1995. "(2) An individual who, on January 7, 1995, is entitled to continued coverage under a health benefits plan administered by the Office of the Comptroller of the Currency or the Office of Thrift Supervision - "(A) shall be deemed to be entitled to continued coverage under section 8905a of title 5, United States Code, for the same period that would have been permitted under the plan administered by the Office of the Comptroller of the Currency or the Office of Thrift Supervision; and "(B) may enroll in an approved health benefits plan described under section 8903 or 8903a of such title in accordance with section 8905a of such title for coverage effective on and after January 8, 1995. "(3) An individual who, on January 7, 1995, is covered as an unmarried dependent child under a health benefits plan administered by the Office of the Comptroller of the Currency or the Office of Thrift Supervision and who is not a member of family as defined under section 8901(5) of title 5, United States Code - "(A) shall be deemed to be entitled to continued coverage under section 8905a of such title as though the individual had, on January 7, 1995, ceased to meet the requirements for being considered an unmarried dependent child under chapter 89 of such title; and "(B) may enroll in an approved health benefits plan described under section 8903 or 8903a of such title in accordance with section 8905a for continued coverage effective on and after January 8, 1995. "(c) Transfers to the Employees Health Benefits Fund. - The Office of the Comptroller of the Currency and the Office of Thrift Supervision shall transfer to the Employees Health Benefits Fund established under section 8909 of title 5, United States Code, amounts determined by the Director of the Office of Personnel Management, after consultation with the Office of the Comptroller of the Currency and the Office of Thrift Supervision, to be necessary to reimburse the Fund for the cost of providing benefits under this section not otherwise paid for by the individuals covered by this section. The amounts so transferred shall be held in the Fund and used by the Office in addition to amounts available under section 8906(g)(1) of such title. "(d) Administration and Regulations. - The Office of Personnel Management - "(1) shall administer the provisions of this section to provide for - "(A) a period of notice and open enrollment for individuals affected by this section; and "(B) no lapse of health coverage for individuals who enroll in a health benefits plan under chapter 89 of title 5, United States Code, in accordance with this section; and "(2) may prescribe regulations to implement this section." CONTINUED COVERAGE UNDER CERTAIN FEDERAL EMPLOYEE BENEFIT PROGRAMS FOR CERTAIN EMPLOYEES OF SAINT ELIZABETHS HOSPITAL For provisions relating to treatment of certain Federal employees of Saint Elizabeths Hospital under certain Federal employee benefit programs, see section 207(o) of Pub. L. 99-335, set out as a note under section 8331 of this title. -FOOTNOTE- (!1) See Change of Name note below. -End- -CITE- 5 USC Sec. 8902 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8902. Contracting authority -STATUTE- (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 5 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, 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 plan may be withdrawn only after notice and opportunity for hearing to the carrier concerned without regard to subchapter II of chapter 5 and chapter 7 of this title. The Office may terminate the contract of a carrier effective at the end of the contract term, if the Office finds that at no time during the preceding two contract terms did the carrier have 300 or more employees and annuitants, exclusive of family members, enrolled in the plan. (f) A contract may not be made or a plan approved which excludes an individual because of race, sex, health status, or, at the time of the first opportunity to enroll, because of age. (g) A contract may not be made or a plan approved which does not offer to each employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title whose enrollment in the plan is ended, except by a cancellation of enrollment, a temporary extension of coverage during which he may exercise the option to convert, without evidence of good health, to a nongroup contract providing health benefits. An employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title who exercises this option shall pay the full periodic charges of the nongroup contract. (h) The benefits and coverage made available under subsection (g) of this section are noncancelable by the carrier except for fraud, over-insurance, or nonpayment of periodic charges. (i) Rates charged under health benefits plans described by section 8903 or 8903a of this title shall reasonably and equitably reflect the cost of the benefits provided. Rates under health benefits plans described by section 8903(1) and (2) of this title shall be determined on a basis which, in the judgment of the Office, is consistent with the lowest schedule of basic rates generally charged for new group health benefit plans issued to large employers. The rates determined for the first contract term shall be continued for later contract terms, except that they may be readjusted for any later term, based on past experience and benefit adjustments under the later contract. Any readjustment in rates shall be made in advance of the contract term in which they will apply and on a basis which, in the judgment of the Office, is consistent with the general practice of carriers which issue group health benefit plans to large employers. (j) Each contract under this chapter shall require the carrier to agree to pay for or provide a health service or supply in an individual case if the Office finds that the employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title is entitled thereto under the terms of the contract. (k)(1) When a contract under this chapter requires payment or reimbursement for services which may be performed by a clinical psychologist, optometrist, nurse midwife, nursing school administered clinic, or nurse practitioner/clinical specialist, licensed or certified as such under Federal or State law, as applicable, or by a qualified clinical social worker as defined in section 8901(11), an employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title covered by the contract shall be free to select, and shall have direct access to, such a clinical psychologist, qualified clinical social worker, optometrist, nurse midwife, nursing school administered clinic, or nurse practitioner/nurse clinical specialist without supervision or referral by another health practitioner and shall be entitled under the contract to have payment or reimbursement made to him or on his behalf for the services performed. (2) Nothing in this subsection shall be considered to preclude a health benefits plan from providing direct access or direct payment or reimbursement to a provider in a health care practice or profession other than a practice or profession listed in paragraph (1), if such provider is licensed or certified as such under Federal or State law. (3) The provisions of this subsection shall not apply to comprehensive medical plans as described in section 8903(4) of this title. (l) The Office shall contract under this chapter for a plan described in section 8903(4) of this title with any qualified health maintenance carrier which offers such a plan. For the purpose of this subsection, "qualified health maintenance carrier" means any qualified carrier which is a qualified health maintenance organization within the meaning of section 1310(d)(1) (!1) of title XIII of the Public Health Service Act (42 U.S.C. 300c-9(d)). (m)(1) The terms of any contract under this chapter which relate to the nature, provision, or extent of coverage or benefits (including payments with respect to benefits) shall supersede and preempt any State or local law, or any regulation issued thereunder, which relates to health insurance or plans. (2)(A) Notwithstanding the provisions of paragraph (1) of this subsection, if a contract under this chapter provides for the provision of, the payment for, or the reimbursement of the cost of health services for the care and treatment of any particular health condition, the carrier shall provide, pay, or reimburse up to the limits of its contract for any such health service properly provided by any person licensed under State law to provide such service if such service is provided to an individual covered by such contract in a State where 25 percent or more of the population is located in primary medical care manpower shortage areas designated pursuant to section 332 of the Public Health Service Act (42 U.S.C. 254e). (B) The provisions of subparagraph (A) shall not apply to contracts entered into providing prepayment plans described in section 8903(4) of this title. (n) A contract for a plan described by section 8903(1), (2), or (3), or section 8903a, shall require the carrier - (1) to implement hospitalization-cost-containment measures, such as measures - (A) for verifying the medical necessity of any proposed treatment or surgery; (B) for determining the feasibility or appropriateness of providing services on an outpatient rather than on an inpatient basis; (C) for determining the appropriate length of stay (through concurrent review or otherwise) in cases involving inpatient care; and (D) involving case management, if the circumstances so warrant; and (2) to establish incentives to encourage compliance with measures under paragraph (1). (o) A contract may not be made or a plan approved which includes coverage for any benefit, item, or service for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. -SOURCE- (Pub. L. 89-554, Sept. 6, 1966, 80 Stat. 601; Pub. L. 93-246, Sec. 3, Jan. 31, 1974, 88 Stat. 4; Pub. L. 93-363, Sec. 1, July 30, 1974, 88 Stat. 398; Pub. L. 94-183, Sec. 2(43), Dec. 31, 1975, 89 Stat. 1059; Pub. L. 94-460, title I, Sec. 110(b), Oct. 8, 1976, 90 Stat. 1952; Pub. L. 95-368, Sec. 1, Sept. 17, 1978, 92 Stat. 606; Pub. L. 95-454, title IX, Sec. 906(a)(2), (3), Oct. 13, 1978, 92 Stat. 1224; Pub. L. 96-179, Sec. 3, Jan. 2, 1980, 93 Stat. 1299; Pub. L. 98-615, Sec. 3(2), Nov. 8, 1984, 98 Stat. 3203; Pub. L. 99- 53, Sec. 2(a), June 17, 1985, 99 Stat. 94; Pub. L. 99-251, title I, Secs. 105(b), 106(a)(3), Feb. 27, 1986, 100 Stat. 15, 16; Pub. L. 100-202, Sec. 101(m) [title VI, Sec. 626], Dec. 22, 1987, 101 Stat. 1329-390, 1329-430; Pub. L. 100-654, title II, Secs. 201(b), 202(a), Nov. 14, 1988, 102 Stat. 3845; Pub. L. 101-508, title VII, Sec. 7002(a), Nov. 5, 1990, 104 Stat. 1388-329; Pub. L. 101-509, title IV, Sec. 1, Nov. 5, 1990, 104 Stat. 1421; Pub. L. 102-393, title V, Sec. 537(a), (b), Oct. 6, 1992, 106 Stat. 1765; Pub. L. 105-12, Sec. 9(g), Apr. 30, 1997, 111 Stat. 27; Pub. L. 105-266, Secs. 3(c), 8, Oct. 19, 1998, 112 Stat. 2366, 2370.) -MISC1- HISTORICAL AND REVISION NOTES -------------------------------------------------------------------- Derivation U.S. Code Revised Statutes and Statutes at Large -------------------------------------------------------------------- 5 U.S.C. 3005. Sept. 28, 1959, Pub. L. 86-382, Sec. 6, 73 Stat. 712. Mar. 17, 1964, Pub. L. 88-284, Sec. 1(7)-(9), 78 Stat. 165. -------------------------------------------------------------------- Standard changes are made to conform with the definitions applicable and the style of this title as outlined in the preface to the report. -REFTEXT- REFERENCES IN TEXT Section 1310(d)(1) of title XIII of the Public Health Service Act (42 U.S.C. 300c-9(d)), referred to in subsec. (l), probably is intended as a reference to section 300e-9(d) of Title 42, The Public Health and Welfare. Section 300e-9(d) of Title 42 was redesignated section 300e-9(c) of Title 42 by Pub. L. 100-517, Sec. 7(b), Oct. 24, 1988, 102 Stat. 2580. The Assisted Suicide Funding Restriction Act of 1997, referred to in subsec. (o), is Pub. L. 105-12, Apr. 30, 1997, 111 Stat. 23, which is classified principally to chapter 138 (Sec. 14401 et seq.) of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see Short Title note set out under section 14401 of Title 42 and Tables. -COD- CODIFICATION Another section 1 of title IV of Pub. L. 101-509, 104 Stat. 1416, enacted sections 2701 to 2706 of Title 44, Public Printing and Documents, and provisions set out as a note under section 2102 of Title 44. -MISC2- AMENDMENTS 1998 - Subsec. (k)(2), (3). Pub. L. 105-266, Sec. 8, added par. (2) and redesignated former par. (2) as (3). Subsec. (m)(1). Pub. L. 105-266, Sec. 3(c), added par. (1) and struck out former par. (1) which read as follows: "The provisions of any contract under this chapter which relate to the nature or extent of coverage or benefits (including payments with respect to benefits) shall supersede and preempt any State or local law, or any regulation issued thereunder, which relates to health insurance or plans to the extent that such law or regulation is inconsistent with such contractual provisions." 1997 - Subsec. (o). Pub. L. 105-12 added subsec. (o). 1992 - Pub. L. 102-393 amended subsec. (k) generally. Prior to amendment, subsec. (k) read as follows: "(1) When a contract under this chapter requires payment or reimbursement for services which may be performed by a clinical psychologist, optometrist, nurse midwife, or nurse practitioner/clinical specialist, licensed or certified as such under Federal or State law, as applicable, or by a qualified clinical social worker as defined in section 8901(11), an employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title covered by the contract shall be free to select, and shall have direct access to, such a clinical psychologist, qualified clinical social worker, optometrist, nurse midwife, or nurse practitioner/nurse clinical specialist without supervision or referral by another health practitioner and shall be entitled under the contract to have payment or reimbursement made to him or on his behalf for the services performed. "(2) The provisions of this subsection shall not apply to group practice prepayment plans." 1990 - Subsec. (k)(1). Pub. L. 101-509 substituted "performed by a clinical psychologist, optometrist, nurse midwife, or nurse practitioner/clinical specialist" for "performed by a clinical psychologist or optometrist" and "qualified clinical social worker, optometrist, nurse midwife, or nurse practitioner/nurse clinical specialist" for "qualified clinical social worker or optometrist". Subsec. (n). Pub. L. 101-508 added subsec. (n). 1988 - Subsecs. (g), (j), (k)(1). Pub. L. 100-654 substituted "former spouse, or person having continued coverage under section 8905a of this title" for "or former spouse" wherever appearing. 1987 - Subsec. (k)(1). Pub. L. 100-202, Sec. 101(m) [title VI, Sec. 626(1), (2)], inserted "or by a qualified clinical social worker as defined in section 8901(11)," after "as applicable,", and ", qualified clinical social worker" after "such a clinical psychologist". Subsec. (k)(2), (3). Pub. L. 100-202, Sec. 101(m) [title VI, Sec. 626(3)], redesignated par. (3) as (2) and struck out former par. (2) which read as follows: "When a contract under this chapter requires payment or reimbursement for services which may be performed by a qualified clinical social worker, an employee, annuitant, family member, or former spouse covered by the contract shall be entitled under the contract to have payment or reimbursement made to him or on his behalf for the services performed. As a condition for the payment or reimbursement, the contract - "(A) may require that the services be performed pursuant to a referral by a psychiatrist; but "(B) may not require that the services be performed under the supervision of a psychiatrist or other health practitioner." Subsec. (m)(2)(A). Pub. L. 100-202, Sec. 101(m) [title VI, Sec. 626(4)], struck out "This paragraph shall apply with respect to a qualified clinical social worker covered by subsection (k)(2) of this section without regard to whether such contract contains the requirement authorized by clause (i) of the second sentence of subparagraph (A) of such subsection (k)(2)." 1986 - Subsec. (k). Pub. L. 99-251, Sec. 105(b), designated existing provisions as par. (1), struck out last sentence providing that the provisions of this subsection shall not apply to group practice prepayment plans, and added pars. (2) and (3). Subsec. (m)(2)(A). Pub. L. 99-251, Sec. 106(a)(3), inserted last sentence relating to applicability of this paragraph with respect to a qualified clinical social worker covered by subsection (k)(2) of this section. 1985 - Subsecs. (a), (e), (i). Pub. L. 99-53 inserted reference to section 8903a of this title. 1984 - Subsec. (g). Pub. L. 98-615, Sec. 3(2)(A), substituted "employee, annuitant, family member, or former spouse" for "employee or annuitant" in two places. Subsecs. (j), (k). Pub. L. 98-615, Sec. 3(2)(B), substituted "family member, or former spouse" for "or family member". 1980 - Subsec. (m)(2)(A). Pub. L. 96-179 substituted "in a State where 25 percent or more of the population is located in primary medical care manpower shortage areas designated pursuant to section 332 of the Public Health Service Act (42 U.S.C. 254e)" for "who is a member of a medically underserved population (within the meaning of section 1302(7) of the Public Health Service Act (42 U.S.C. 300e- 17))". 1978 - Subsecs. (a), (c) to (e), (i), (j), (l). Pub. L. 95-454 substituted "Office of Personnel Management" for "Civil Service Commission" and "Office" for "Commission" wherever appearing. Subsec. (m). Pub. L. 95-368 added subsec. (m). 1976 - Subsec. (l). Pub. L. 94-460 added subsec. (l). 1975 - Subsecs. (j), (k). Pub. L. 94-183 redesignated subsec. (j), added by Pub. L. 93-363 and relating to services performed by a clinical psychologist or optometrist, as (k). 1974 - Subsec. (j). Pub. L. 93-363 added subsec. (j) covering services performed by a clinical psychologist or optometrist. Pub. L. 93-246 added subsec. (j) requiring the carrier to pay for or provide a health service or supply in specified cases. EFFECTIVE DATE OF 1997 AMENDMENT Amendment by Pub. L. 105-12 effective Apr. 30, 1997, and applicable to Federal payments made pursuant to obligations incurred after Apr. 30, 1997, for items and services provided on or after such date, subject to also being applicable with respect to contracts entered into, renewed, or extended after Apr. 30, 1997, as well as contracts entered into before Apr. 30, 1997, to the extent permitted under such contracts, see section 11 of Pub. L. 105-12, set out as an Effective Date note under section 14401 of Title 42, The Public Health and Welfare. EFFECTIVE DATE OF 1992 AMENDMENT Section 537(c) of Pub. L. 102-393 provided that: "The amendments made by this section [amending this section] shall be effective with respect to contract years beginning after the date of enactment of this Act [Oct. 6, 1992]." EFFECTIVE DATE OF 1990 AMENDMENT Section 7002(g) of Pub. L. 101-508 provided that: "Except as provided in subsection (f) [set out as a note under section 8904 of this title], the amendments made by this section [amending this section, sections 8904, 8909, and 8910 of this title, and provisions set out as a note under section 8906 of this title] shall apply with respect to contract years beginning on or after January 1, 1991." EFFECTIVE DATE OF 1988 AMENDMENT Section 203 of title II of Pub. L. 100-654 provided that: "(a) In General. - The amendments made by this title [enacting section 8905a of this title and amending this section and sections 8903, 8905, and 8909 of this title] shall apply with respect to - "(1) any calendar year beginning, and contracts entered into or renewed for any calendar year beginning, after the end of the 9- month period beginning on the date of the enactment of this Act [Nov. 14, 1988]; and "(2) any qualifying event occurring on or after the first day of the first calendar year beginning after the end of the 9-month period referred to in paragraph (1). "(b) Definition. - For the purpose of this section, the term 'qualifying event' means any of the following events: "(1) A separation from Government service. "(2) A divorce, annulment, or legal separation. "(3) Any change in circumstances which causes an individual to become ineligible to be considered an unmarried dependent child under chapter 89 of such title [section 8901 et seq. of this title]." EFFECTIVE DATE OF 1986 AMENDMENT Amendment by section 105(b) of Pub. L. 99-251 effective with respect to contracts entered into or renewed for calendar years beginning after Dec. 31, 1986, see section 105(c) of Pub. L. 99- 251, set out as a note under section 8901 of this title. Section 106(b) of Pub. L. 99-251 provided that: "The amendments made by subsection (a) [amending this section and provisions set out as notes under this section] shall take effect with respect to services provided after December 31, 1984." EFFECTIVE DATE OF 1984 AMENDMENT Amendment by Pub. L. 98-615 effective May 7, 1985, with enumerated exceptions, and applicable to any individual who is married to an employee or annuitant on or after that date, see section 4(a)(2) of Pub. L. 98-615, as amended, set out as a note under section 8341 of this title. EFFECTIVE DATE OF 1980 AMENDMENT Section 5(b) of Pub. L. 96-179, as amended by Pub. L. 99-251, title I, Sec. 106(a)(2), Feb. 27, 1986, 100 Stat. 16, provided that: "The amendments made by section 3 [amending this section] shall apply to services provided after December 31, 1979, under any contract entered into or renewed after December 31, 1979." EFFECTIVE DATE OF 1978 AMENDMENTS 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. Section 3 of Pub. L. 95-368, as amended by Pub. L. 99-251, title I, Sec. 106(a)(1), Feb. 27, 1986, 100 Stat. 16, provided that: "The provisions of section 8902(m)(2) of title 5, United States Code, as added by the first section of this Act, shall apply to services provided under any contract entered into or renewed after December 31, 1979." EFFECTIVE DATE OF 1976 AMENDMENT Amendment by Pub. L. 94-460 effective Oct. 8, 1976, see section 118 of Pub. L. 94-460, set out as a note under section 300e of Title 42, The Public Health and Welfare. EFFECTIVE DATE OF 1974 AMENDMENTS Section 2 of Pub. L. 93-363 provided that: "The amendment made by this Act [amending this section] shall become effective with respect to any contract entered into or renewed on or after the date of enactment of this Act [July 30, 1974]." Section 4(c) of Pub. L. 93-246 provided that: "Section 3 [amending this section] shall become effective with respect to any contract entered into or renewed on or after the date of enactment of this Act [Jan. 31, 1974]." FULL DISCLOSURE IN HEALTH PLAN CONTRACTS Pub. L. 105-266, Sec. 5, Oct. 19, 1998, 112 Stat. 2368, provided that: "The Office of Personnel Management shall encourage carriers offering health benefits plans described by section 8903 or section 8903a of title 5, United States Code, with respect to contractual arrangements made by such carriers with any person for purposes of obtaining discounts from providers for health care services or supplies furnished to individuals enrolled in such plan, to seek assurance that the conditions for such discounts are fully disclosed to the providers who grant them." RATE REDUCTION FOR MEDICARE ELIGIBLE FEDERAL ANNUITANTS Pub. L. 100-360, title IV, Sec. 422, July 1, 1988, 102 Stat. 810, which directed the Office of Personnel Management to reduce the rates charged medicare eligible individuals participating in health benefit plans by a prorated amount, was repealed by Pub. L. 101- 234, title III, Sec. 301(a), Dec. 13, 1989, 103 Stat. 1985. AUTHORITY OF CARRIER TO CONTRACT FOR COMPREHENSIVE MEDICAL SERVICES FROM A GROUP PRACTICE UNIT OR ORGANIZATION Pub. L. 91-515, title IV, Sec. 401, Oct. 30, 1970, 84 Stat. 1309, authorized Secretary of Health, Education, and Welfare to permit any carrier which is a party to a contract entered into under this chapter or under the Retired Federal Employees Health Benefits Act, or which participates in carrying out of any such contract, to issue in any State contracts entitling any person as a beneficiary to receive comprehensive medical services from a group practice unit or organization with which such carrier has contracted or otherwise arranged for the provision of such services. -FOOTNOTE- (!1) See References in Text note below. -End- -CITE- 5 USC Sec. 8902a 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8902a. Debarment and other sanctions -STATUTE- (a)(1) For the purpose of this section - (A) the term "provider of health care services or supplies" or "provider" means a physician, hospital, or other individual or entity which furnishes health care services or supplies; (B) the term "individual covered under this chapter" or "covered individual" means an employee, annuitant, family member, or former spouse covered by a health benefits plan described by section 8903 or 8903a; (C) an individual or entity shall be considered to have been "convicted" of a criminal offense if - (i) a judgment of conviction for such offense has been entered against the individual or entity by a Federal, State, or local court; (ii) there has been a finding of guilt against the individual or entity by a Federal, State, or local court with respect to such offense; (iii) a plea of guilty or nolo contendere by the individual or entity has been accepted by a Federal, State, or local court with respect to such offense; or (iv) in the case of an individual, the individual has entered a first offender or other program pursuant to which a judgment of conviction for such offense has been withheld; without regard to the pendency or outcome of any appeal (other than a judgment of acquittal based on innocence) or request for relief on behalf of the individual or entity; and (D) the term "should know" means that a person, with respect to information, acts in deliberate ignorance of, or in reckless disregard of, the truth or falsity of the information, and no proof of specific intent to defraud is required; (!1) (2)(A) Notwithstanding section 8902(j) or any other provision of this chapter, if, under subsection (b), (c), or (d) a provider is barred from participating in the program under this chapter, no payment may be made by a carrier pursuant to any contract under this chapter (either to such provider or by reimbursement) for any service or supply furnished by such provider during the period of the debarment. (B) Each contract under this chapter shall contain such provisions as may be necessary to carry out subparagraph (A) and the other provisions of this section. (b) The Office of Personnel Management shall bar the following providers of health care services or supplies from participating in the program under this chapter: (1) Any provider that has been convicted, under Federal or State law, of a criminal offense relating to fraud, corruption, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of a health care service or supply. (2) Any provider that has been convicted, under Federal or State law, of a criminal offense relating to neglect or abuse of patients in connection with the delivery of a health care service or supply. (3) Any provider that has been convicted, under Federal or State law, in connection with the interference with or obstruction of an investigation or prosecution of a criminal offense described in paragraph (1) or (2). (4) Any provider that has been convicted, under Federal or State law, of a criminal offense relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. (5) Any provider that is currently debarred, suspended, or otherwise excluded from any procurement or nonprocurement activity (within the meaning of section 2455 of the Federal Acquisition Streamlining Act of 1994). (c) The Office may bar the following providers of health care services from participating in the program under this chapter: (1) 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 competence, professional performance, or financial integrity; 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. (2) Any provider that is an entity directly or indirectly owned, or with a control interest of 5 percent or more held, by an individual who has been convicted of any offense described in subsection (b), against whom a civil monetary penalty has been assessed under subsection (d), or who has been debarred from participation under this chapter. (3) Any individual who directly or indirectly owns or has a control interest in a sanctioned entity and who knows or should know of the action constituting the basis for the entity's conviction of any offense described in subsection (b), assessment with a civil monetary penalty under subsection (d), or debarment from participation under this chapter. (4) Any provider that the Office determines, in connection with claims presented under this chapter, has charged for health care services or supplies in an amount substantially in excess of such provider's customary charge for such services or supplies (unless the Office finds there is good cause for such charge), 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. (5) Any provider that the Office determines has committed acts described in subsection (d). Any determination under paragraph (4) relating to whether a charge for health care services or supplies is substantially in excess of the needs of the covered individual shall be made by trained reviewers based on written medical protocols developed by physicians. In the event such a determination cannot be made based on such protocols, a physician in an appropriate specialty shall be consulted. (d) Whenever the Office determines - (1) in connection with claims presented under this chapter, that a provider has charged for a health care service or supply which the provider knows or should have known involves - (A) an item or service not provided as claimed; (B) charges in violation of applicable charge limitations under section 8904(b); or (C) an item or service furnished during a period in which the provider was debarred from participation under this chapter pursuant to a determination by the Office under this section, other than as permitted under subsection (g)(2)(B); (2) that a provider of health care services or supplies has knowingly made, or caused to be made, any false statement or misrepresentation of a material fact which is reflected in a claim presented under this chapter; or (3) that a provider of health care services or supplies has knowingly failed to provide any information required by a carrier or by the Office to determine whether a payment or reimbursement is payable under this chapter or the amount of any such payment or reimbursement; the Office may, in addition to any other penalties that may be prescribed by law, and after consultation with the Attorney General, impose a civil monetary penalty of not more than $10,000 for any item or service involved. In addition, such a provider shall be subject to an assessment of not more than twice the amount claimed for each such item or service. In addition, the Office may make a determination in the same proceeding to bar such provider from participating in the program under this chapter. (e) The Office - (1) may not initiate any debarment proceeding against a provider, based on such provider's having been convicted of a criminal offense, later than 6 years after the date on which such provider is so convicted; and (2) may not initiate any action relating to a civil penalty, assessment, or debarment under this section, in connection with any claim, later than 6 years after the date the claim is presented, as determined under regulations prescribed by the Office. (f) In making a determination relating to the appropriateness of imposing or the period of any debarment under this section (where such debarment is not mandatory), or the appropriateness of imposing or the amount of any civil penalty or assessment under this section, the Office shall take into account - (1) the nature of any claims involved and the circumstances under which they were presented; (2) the degree of culpability, history of prior offenses or improper conduct of the provider involved; and (3) such other matters as justice may require. (g)(1)(A) Except as provided in subparagraph (B), debarment of a provider under subsection (b) or (c) shall be effective at such time and upon such reasonable notice to such provider, and to carriers and covered individuals, as shall be specified in regulations prescribed by the Office. Any such provider that is debarred from participation may request a hearing in accordance with subsection (h)(1). (B) Unless the Office determines that the health or safety of individuals receiving health care services warrants an earlier effective date, the Office shall not make a determination adverse to a provider under subsection (c)(5) or (d) until such provider has been given reasonable notice and an opportunity for the determination to be made after a hearing as provided in accordance with subsection (h)(1). (2)(A) Except as provided in subparagraph (B), a debarment shall be effective with respect to any health care services or supplies furnished by a provider on or after the effective date of such provider's debarment. (B) A debarment shall not apply with respect to inpatient institutional services furnished to an individual who was admitted to the institution before the date the debarment would otherwise become effective until the passage of 30 days after such date, unless the Office determines that the health or safety of the individual receiving those services warrants that a shorter period, or that no such period, be afforded. (3) Any notice of debarment referred to in paragraph (1) shall specify the date as of which debarment becomes effective and the minimum period of time for which such debarment is to remain effective. 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). (4)(A) A provider barred from participating in the program under this chapter may, after the expiration of the minimum period of debarment referred to in paragraph (3), apply to the Office, in such manner as the Office may by regulation prescribe, for termination of the debarment. (B) The Office may - (i) terminate the debarment of a provider, pursuant to an application filed by such provider after the end of the minimum debarment period, if the Office determines, based on the conduct of the applicant, that - (I) there is no basis under subsection (b), (c), or (d) for continuing the debarment; and (II) there are reasonable assurances that the types of actions which formed the basis for the original debarment have not recurred and will not recur; or (ii) notwithstanding any provision of subparagraph (A), terminate the debarment of a provider, pursuant to an application filed by such provider before the end of the minimum debarment period, if the Office determines that - (I) based on the conduct of the applicant, the requirements of subclauses (I) and (II) of clause (i) have been met; and (II) early termination under this clause is warranted based on the fact that the provider is the sole community provider or the sole source of essential specialized services in a community, or other similar circumstances. (5) The Office shall - (A) promptly notify the appropriate State or local agency or authority having responsibility for the licensing or certification of a provider barred from participation in the program under this chapter of the fact of the debarment, as well as the reasons for such debarment; (B) request that appropriate investigations be made and sanctions invoked in accordance with applicable law and policy; and (C) request that the State or local agency or authority keep the Office fully and currently informed with respect to any actions taken in response to the request. (h)(1) Any provider of health care services or supplies that is the subject of an adverse determination by the Office under this section shall be entitled to reasonable notice and an opportunity to request a hearing of record, and to judicial review as provided in this subsection after the Office renders a final decision. The Office shall grant a request for a hearing upon a showing that due process rights have not previously been afforded with respect to any finding of fact which is relied upon as a cause for an adverse determination under this section. Such hearing shall be conducted without regard to subchapter II of chapter 5 and chapter 7 of this title by a hearing officer who shall be designated by the Director of the Office and who shall not otherwise have been involved in the adverse determination being appealed. A request for a hearing under this subsection shall be filed within such period and in accordance with such procedures as the Office shall prescribe by regulation. (2) Any provider adversely affected by a final decision under paragraph (1) made after a hearing to which such provider was a party may seek review of such decision in the United States District Court for the District of Columbia or for the district in which the plaintiff resides or has his or her principal place of business by filing a notice of appeal in such court within 60 days after the date the decision is issued, and by simultaneously sending copies of such notice by certified mail to the Director of the Office and to the Attorney General. In answer to the appeal, the Director of the Office shall promptly file in such court a certified copy of the transcript of the record, if the Office conducted a hearing, and other evidence upon which the findings and decision complained of are based. The court shall have power to enter, upon the pleadings and evidence of record, a judgment affirming, modifying, or setting aside, in whole or in part, the decision of the Office, with or without remanding the case for a rehearing. The district court shall not set aside or remand the decision of the Office unless there is not substantial evidence on the record, taken as whole, to support the findings by the Office of a cause for action under this section or unless action taken by the Office constitutes an abuse of discretion. (3) Matters that were raised or that could have been raised in a hearing under paragraph (1) or an appeal under paragraph (2) may not be raised as a defense to a civil action by the United States to collect a penalty or assessment imposed under this section. (i) A civil action to recover civil monetary penalties or assessments under subsection (d) shall be brought by the Attorney General in the name of the United States, and may be brought in the United States district court for the district where the claim involved was presented or where the person subject to the penalty resides. Amounts recovered under this section shall be paid to the Office for deposit into the Employees Health Benefits Fund. The amount of a penalty or assessment as finally determined by the Office, or other amount the Office may agree to in compromise, 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. (j) The Office shall prescribe regulations under which, with respect to services or supplies furnished by a debarred provider to a covered individual during the period of such provider's debarment, payment or reimbursement under this chapter may be made, notwithstanding the fact of such debarment, if such individual did not know or could not reasonably be expected to have known of the debarment. In any such instance, the carrier involved shall take appropriate measures to ensure that the individual is informed of the debarment and the minimum period of time remaining under the terms of the debarment. -SOURCE- (Added Pub. L. 100-654, title I, Sec. 101(a), Nov. 14, 1988, 102 Stat. 3837; amended Pub. L. 105-266, Sec. 2(a), Oct. 19, 1998, 112 Stat. 2363.) -REFTEXT- REFERENCES IN TEXT Section 2455 of the Federal Acquisition Streamlining Act of 1994, referred to in subsec. (b)(5), is section 2455 of Pub. L. 103-355, which is set out as a note under section 6101 of Title 31, Money and Finance. -MISC1- AMENDMENTS 1998 - Subsec. (a)(1)(D). Pub. L. 105-266, Sec. 2(a)(1)(A), added subpar. (D). Subsec. (a)(2)(A). Pub. L. 105-266, Sec. 2(a)(1)(B), substituted "subsection (b), (c), or (d)" for "subsection (b) or (c)". Subsec. (b). Pub. L. 105-266, Sec. 2(a)(2)(A), substituted "shall" for "may" in introductory provisions. Subsec. (b)(5). Pub. L. 105-266, Sec. 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 competence, professional performance, or financial integrity; 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, Sec. 2(a)(3), added subsec. (c). Former subsec. (c) redesignated (d). Subsec. (d). Pub. L. 105-266, Sec. 2(a)(3), redesignated subsec. (c) as (d). Former subsec. (d) redesignated (e). Subsec. (d)(1). Pub. L. 105-266, Sec. 2(a)(4), amended par. (1) generally. Prior to amendment, par. (1) read as follows: "in connection with a claim presented under this chapter, that a provider of health care services or supplies - "(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 provider's customary charges for such services or supplies, 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, Sec. 2(a)(3), redesignated subsec. (d) as (e). Former subsec. (e) redesignated (f). Subsec. (f). Pub. L. 105-266, Sec. 2(a)(3), (5), redesignated subsec. (e) as (f) and inserted "(where such debarment is not mandatory)" after "debarment under this section". Former subsec. (f) redesignated (g). Subsec. (g). Pub. L. 105-266, Sec. 2(a)(3), redesignated subsec. (f) as (g). Former subsec. (g) redesignated (h). Subsec. (g)(1). Pub. L. 105-266, Sec. 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 reasonable 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, Sec. 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, Sec. 2(a)(6)(C), substituted "subsection (b), (c), or (d)" for "subsection (b) or (c)". Subsec. (g)(6). Pub. L. 105-266, Sec. 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 participating 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, Sec. 2(a)(3), redesignated subsec. (g) as (h). Former subsec. (h) redesignated (i). Subsec. (h)(1), (2). Pub. L. 105-266, Sec. 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 adversely 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 written 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, Sec. 2(a)(3), (8), redesignated subsec. (h) as (i), substituted "subsection (d)" for "subsection (c)", and inserted at end "The amount of a penalty or assessment as finally determined by the Office, or other amount the Office may agree to in compromise, 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, Sec. 2(a)(3), redesignated subsec. (i) as (j). EFFECTIVE DATE OF 1998 AMENDMENT Pub. L. 105-266, Sec. 2(b), Oct. 19, 1998, 112 Stat. 2366, provided 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 debarment 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 furnished 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 convictions occurring after the date of the enactment of this Act." EFFECTIVE DATE; PRIOR CONDUCT Section 102 of title I of Pub. L. 100-654 provided that: "(a) Applicability. - The amendments made by this title [enacting this section] shall be effective with respect to any calendar year beginning, and contracts entered 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 carrying out section 8902a of title 5, United States Code, as added by this title, no debarment, civil monetary penalty, or assessment may be imposed under such section based on any criminal or other conduct occurring before the beginning of the first calendar year which begins after the date of the enactment of this Act [Nov. 14, 1988]." -FOOTNOTE- (!1) So in original. The semicolon probably should be a period. -End- -CITE- 5 USC Sec. 8903 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8903. Health benefits plans -STATUTE- 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 two levels of benefits, 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, 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. (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. (3) Employee Organization Plans. - Employee organization plans which offer benefits of the types referred to by section 8904(3) of this title, which are sponsored or underwritten, and are administered, in whole or substantial part, by employee organizations described in section 8901(8)(A) of this title, which are available only to individuals, and members of their families, who at the time of enrollment 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 professional services thereunder provided by physicians practicing as a group in a common center or centers. The group shall include at least 3 physicians who receive all or a substantial part of their professional income from the prepaid funds and who represent 1 or more medical specialties appropriate and necessary for the population proposed 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 professional services thereunder provided by individual 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 before 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 described in subparagraph (B). -SOURCE- (Pub. L. 89-554, Sept. 6, 1966, 80 Stat. 602; Pub. L. 95-454, title IX, Sec. 906(a)(2), (3), Oct. 13, 1978, 92 Stat. 1224; Pub. L. 98- 615, Sec. 3(3), Nov. 8, 1984, 98 Stat. 3203; Pub. L. 99-53, Sec. 2(b), June 17, 1985, 99 Stat. 94; Pub. L. 99-251, title I, Secs. 102, 111, Feb. 27, 1986, 100 Stat. 14, 19; Pub. L. 100-654, title II, Sec. 202(b), Nov. 14, 1988, 102 Stat. 3845; Pub. L. 105-266, Sec. 3(b), Oct. 19, 1998, 112 Stat. 2366.) -MISC1- 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, Sec. 4, 73 Stat. 711. July 8, 1963, Pub. L. 88-59, Sec. 1(b), 77 Stat. 77. -------------------------------------------------------------------- Standard changes are made to conform with the definitions applicable and the style of this title as outlined in the preface to the report. AMENDMENTS 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, Sec. 102, amended second sentence generally, substituting "at least 3 physicians" for "physicians representing at least three major medical 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, Sec. 111, added subpar. (C). 1985 - Par. (3). Pub. L. 99-53 inserted "described in section 8901(8)(A) of this title" after "employee organizations". 1984 - Par. (1). Pub. L. 98-615, Sec. 3(3), substituted "employees, annuitants, members of their families, or former spouses" for "employees or annuitants, or members of their families" and "employee, annuitant, family member, or former spouse" for "employee or annuitant or member of his family". 1978 - Pub. L. 95-454 substituted "Office of Personnel Management" and "Office" for "Civil Service Commission" and "Commission", respectively, wherever appearing. EFFECTIVE DATE OF 1988 AMENDMENT Amendment by Pub. L. 100-654 applicable with respect to any calendar year beginning, and contracts entered 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 individual who is married to an employee or annuitant on or after that date, see section 4(a)(2) of Pub. L. 98-615, 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. -End- -CITE- 5 USC Sec. 8903a 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8903a. Additional health benefits plans -STATUTE- (a) In addition to any plan under section 8903 of this title, 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; (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 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 eligible to exercise all rights and privileges incident to full membership in such organization (determined without regard to the right to hold elected office). -SOURCE- (Added Pub. L. 99-53, Sec. 1(b)(1), June 17, 1985, 99 Stat. 93.) -End- -CITE- 5 USC Sec. 8903b 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8903b. Authority to readmit an employee organization plan -STATUTE- (a) In the event that a plan described by section 8903(3) or 8903a is discontinued under this chapter (other than in the circumstance described in section 8909(d)), that discontinuation shall be disregarded, for purposes of any determination as to that plan's eligibility to be considered 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 delivery within a managed care system (including provider networks) throughout the United States; and (2) if the carrier involved would not otherwise be subject to the requirement set forth in section 8903a(c)(1), to satisfy such requirement. -SOURCE- (Added Pub. L. 105-266, Sec. 6(a)(1), Oct. 19, 1998, 112 Stat. 2368.) -MISC1- EFFECTIVE DATE Pub. L. 105-266, Sec. 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], including with respect to any plan which has been discontinued as of such date. "(B) Transition rule. - For purposes of applying section 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 beginning before January 1, 2000, such section shall be applied by substituting 'second contract year' for 'third contract year'." -End- -CITE- 5 USC Sec. 8904 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8904. Types of benefits -STATUTE- (a) The benefits to be provided under plans described by section 8903 of this title 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, 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 et seq.), to pay a charge imposed by any health care provider, for inpatient hospital services which are covered for purposes of benefit payments under this chapter and part A of title XVIII of the Social Security Act, to the extent that such charge exceeds applicable limitations on hospital charges established for Medicare purposes under section 1886 of the Social Security Act (42 U.S.C. 1395ww). Hospital providers who have in force participation agreements with the Secretary of Health and Human Services consistent with sections 1814(a) and 1866 of the Social Security Act (42 U.S.C. 1395f(a) and 1395cc), whereby the participating provider accepts Medicare benefits as full payment for covered items and services after applicable patient copayments under section 1813 of such Act (42 U.S.C. 1395e) have been satisfied, shall accept equivalent benefit payments and enrollee copayments under this chapter as full payment for services described in the preceding sentence. The Office of Personnel Management shall notify the Secretary of Health and Human Services if a hospital is found to knowingly and willfully violate this subsection on a repeated basis and the Secretary may invoke appropriate sanctions in accordance with section 1866(b)(2) of the Social Security Act (42 U.S.C. 1395cc(b)(2)) and applicable regulations. (B)(i) A plan, other than a prepayment plan described in section 8903(4), may not provide benefits, in the case of any retired enrolled individual who is age 65 or older and is not entitled to Medicare supplementary medical insurance benefits under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.), to pay a charge imposed for physicians' services (as defined in section 1848(j) of such Act, 42 U.S.C. 1395w-4(j)) which are covered for purposes of benefit payments under this chapter and under such part, to the extent that such charge exceeds the fee schedule amount under section 1848(a) of such Act (42 U.S.C. 1395w- 4(a)). (ii) Physicians and suppliers who have in force participation agreements with the Secretary of Health and Human Services consistent with section 1842(h)(1) of such Act (42 U.S.C. 1395u(h)(1)), whereby the participating provider accepts Medicare benefits (including allowable deductible and coinsurance amounts) as full payment for covered items and services shall accept equivalent benefit and enrollee cost-sharing under this chapter as full payment for services described in clause (i). Physicians and suppliers who are nonparticipating physicians and suppliers for purposes of part B of title XVIII of such Act shall not impose charges that exceed the limiting charge under section 1848(g) of such Act (42 U.S.C. 1395w-4(g)) with respect to services described in clause (i) provided to enrollees described in such clause. The Office of Personnel Management shall notify a physician or supplier who is found to have violated this clause and inform them of the requirements of this clause and sanctions for such a violation. The Office of Personnel Management shall notify the Secretary of Health and Human Services if a physician or supplier is found to knowingly and willfully violate this clause on a repeated basis and the Secretary of Health and Human Services may invoke appropriate sanctions in accordance with sections 1128A(a) and 1848(g)(1) of such Act (42 U.S.C. 1320a-7a(a), 1395w-4(g)(1)) and applicable regulations. (C) If the Secretary of Health and Human Services determines that a violation of this subsection warrants excluding a provider from participation for a specified period under title XVIII of the Social Security Act, the Office shall enforce a corresponding exclusion of such provider for purposes of this chapter. (2) Notwithstanding any other provision of law, the Secretary of Health and Human Services and the Director of the Office of Personnel Management, and their agents, shall exchange any information necessary to implement this subsection. (3)(A) Not later than December 1, 1991, and periodically thereafter, the Secretary of Health and Human Services (in consultation with the Director of the Office of Personnel Management) shall supply to carriers of plans described in paragraphs (1) through (3) of section 8903 the Medicare program information necessary for them to comply with paragraph (1). (B) For purposes of this paragraph, the term "Medicare program information" includes (i) the limitations on hospital charges established for Medicare purposes under section 1886 of the Social Security Act (42 U.S.C. 1395ww) and the identity of hospitals which have in force agreements with the Secretary of Health and Human Services consistent with section 1814(a) and 1866 of the Social Security Act (42 U.S.C. 1395f(a) and 1395cc), and (ii) the fee schedule amounts and limiting charges for physicians' services established under section 1848 of such Act (42 U.S.C. 1395w-4) and the identity of participating physicians and suppliers who have in force agreements with such Secretary under section 1842(h) of such Act (42 U.S.C. 1395u(h)). (4) The Director of the Office of Personnel Management shall enter into an arrangement with the Secretary of Health and Human Services, to be effective before the first day of the fifth month that begins before each contract year, under which - (A) physicians and suppliers (whether or not participating) under the Medicare program will be notified of the requirements of paragraph (1)(B); (B) enforcement procedures will be in place to carry out such paragraph (including enforcement of protections against overcharging of beneficiaries); and (C) Medicare program information described in paragraph (3)(B)(ii) will be supplied to carriers under paragraph (3)(A). -SOURCE- (Pub. L. 89-554, Sept. 6, 1966, 80 Stat. 603; Pub. L. 101-508, title VII, Sec. 7002(f)(1), Nov. 5, 1990, 104 Stat. 1388-330; Pub. L. 102-378, Sec. 2(76), Oct. 2, 1992, 106 Stat. 1355; Pub. L. 103- 66, title XI, Sec. 11003(a), Aug. 10, 1993, 107 Stat. 409.) -MISC1- HISTORICAL AND REVISION NOTES -------------------------------------------------------------------- Derivation U.S. Code Revised Statutes and Statutes at Large -------------------------------------------------------------------- 5 U.S.C. 3004. Sept. 28, 1959, Pub. L. 86-382, Sec. 5, 73 Stat. 712. -------------------------------------------------------------------- Standard changes are made to conform with the definitions applicable and the style of this title as outlined in the preface to the report. -REFTEXT- REFERENCES IN TEXT The Social Security Act, referred to in subsec. (b)(1), is act Aug. 14, 1935, ch. 531, 49 Stat. 620, as amended. Title XVIII of the Act is classified generally to subchapter XVIII (Sec. 1395 et seq.) of chapter 7 of Title 42, The Public Health and Welfare. Parts A and B of title XVIII of the Act are classified generally to part A (Sec. 1395c et seq.) and part B (Sec. 1395j et seq.), respectively, of subchapter XVIII of chapter 7 of Title 42. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. -MISC2- AMENDMENTS 1993 - Subsec. (b)(1). Pub. L. 103-66, Sec. 11003(a)(1), designated existing provisions as subpar. (A) and added subpars. (B) and (C). Subsec. (b)(3)(B). Pub. L. 103-66, Sec. 11003(a)(2), inserted cl. (i) designation and added cl. (ii). Subsec. (b)(4). Pub. L. 103-66, Sec. 11003(a)(3), added par. (4). 1992 - Subsec. (a). Pub. L. 102-378 substituted "this subsection" for "this section" in pars. (3) and (4) and in last sentence. 1990 - Pub. L. 101-508 designated existing provisions as subsec. (a) and added subsec. (b). EFFECTIVE DATE OF 1993 AMENDMENT Section 11003(b) of Pub. L. 103-66 provided that: "The amendments made by subsection (a) [amending this section] shall apply with respect to contract years beginning on or after January 1, 1995." EFFECTIVE DATE OF 1990 AMENDMENT Section 7002(f)(2) of Pub. L. 101-508 provided that: "The amendments made by this subsection [amending this section] shall apply with respect to contract years beginning on or after January 1, 1992." MENTAL HEALTH, ALCOHOLISM, AND DRUG ADDICTION BENEFITS; CONGRESSIONAL FINDINGS; SENSE OF CONGRESS Pub. L. 99-251, title I, Sec. 107, Feb. 27, 1986, 100 Stat. 16, provided that: "(a) Findings. - The Congress finds that - "(1) the treatment of mental illness, alcoholism, and drug addiction are basic health care services which are needed by approximately 40,000,000 Americans each year; "(2) treatment of mental illness, alcoholism, and drug addiction is increasingly successful; "(3) timely and appropriate treatment of mental illness, alcoholism, and drug addiction is cost effective in terms of restored productivity, reduced utilization of other health services, and reduced social dependence; and "(4) mental illness is a problem of grave concern to the people of the United States and is widely but unnecessarily feared and misunderstood. "(b) Sense of the Congress. - It is the sense of the Congress - "(1) that participants in the Federal employees health benefits program should receive adequate benefits coverage for treatment of mental illness, alcoholism, and drug addiction; and "(2) that the Office of Personnel Management should encourage participating health benefits plans to provide adequate benefits relating to treatment of mental illness, alcoholism, and drug addiction (including benefits relating to coverage for inpatient and outpatient treatment and catastrophic protection benefits)." -End- -CITE- 5 USC Sec. 8905 01/03/2007 -EXPCITE- TITLE 5 - GOVERNMENT ORGANIZATION AND EMPLOYEES PART III - EMPLOYEES Subpart G - Insurance and Annuities CHAPTER 89 - HEALTH INSURANCE -HEAD- Sec. 8905. Election of coverage -STATUTE- (a) An employee may enroll in an approved health benefits plan described by section 8903 or 8903a of this title either as an individual or 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 (!1) (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 section 8339(j)(3) or 8417(b) of this title for such former spouse by the retired employee, enroll in an approved health benefits plan described by section 8903 or 8903a of this title as an individual or for self and family as provided in paragraph (2) of this subsection, subject to agreement to pay the full subscription charge of the enrollment, including the amounts determined by the Office to be necessary for administration and reserves pursuant to section 8909(b) of this title. The former spouse shall submit an enrollment application and make premium payments to the agency which, at the time of divorce or annulment, employed the employee to whom the former spouse was married or, in the case of a former spouse who is receiving annuity payments under section 8341(h), 8345(j), 8445, or 8467 of this title, to the Office of Personnel Management. (2) Coverage for self and family under this subsection