
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 2, 2001]
[Document not affected by Public Laws enacted between
  January 2, 2001 and January 28, 2002]
[CITE: 5USC8904]

 
             TITLE 5--GOVERNMENT ORGANIZATION AND EMPLOYEES
 
                           PART III--EMPLOYEES
 
                   Subpart G--Insurance and Annuities
 
                      CHAPTER 89--HEALTH INSURANCE
 
Sec. 8904. Types of benefits

    (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).

(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.)

                      Historical and Revision Notes
------------------------------------------------------------------------
                                                    Revised Statutes and
     Derivation                U.S. Code             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.

                       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.


                               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).''

                  Section Referred to in Other Sections

    This section is referred to in sections 8902a, 8903, 8903a of this 
title.
