5 U.S.C. § 8904 : US Code - Section 8904: Types of benefits

Search 5 U.S.C. § 8904 : US Code - Section 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).