USC Chapter 89

in effect

5 U.S.C. § 8901 Definitions

For the purpose of this chapter— (1) “employee” means—(A) an employee as defined by section 2105 of this title; (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; 11 See Change of Name note below. (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); (I) an individual appointed to a position on the office staff of a former President, or a former Vice President under section 5 of the Presidential Transition Act of 1963, as amended (78 Stat. 153), who immediately before the date of such appointment was an employee as defined under any other subparagraph of this paragraph; and (J) an individual who is employed by the Roosevelt Campobello International Park Commission and is a citizen of the United States, but does not include— (i) an employee of a corporation supervised by the Farm Credit Administration if private interests elect or appoint a member of the board of directors; (ii) 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 arrangement 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).

5 U.S.C. § 8902 Contracting authority

(a) The Office of Personnel Management may contract with qualified carriers offering plans described by section 8903 or 8903a of this title, without regard to section 6101(b) to (d) of title 41 or other statute requiring competitive bidding. Each contract shall be for a uniform term of at least 1 year, but may be made automatically renewable from term to term in the absence of notice of termination by either party. (b) To be eligible as a carrier for the plan described by section 8903(2) of this title, 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) 11 See References in Text note below. 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. (p) Each contract under this chapter shall require the carrier to comply with requirements described in the provisions of sections 2799A–1, 2799A–2, and 2799A–7 of the Public Health Service Act, sections 716, 717, and 722 of the Employee Retirement Income Security Act of 1974, and sections 9816, 9817, and 9822 of the Internal Revenue Code of 1986 (as applicable) in the same manner as such provisions apply to a group health plan or health insurance issuer offering group or individual health insurance coverage, as described in such sections. The provisions of sections 2799B–1, 2799B–2, 2799B–3, and 2799B–5 of the Public Health Service Act shall apply to a health care provider and facility and an air ambulance provider described in such respective sections with respect to an enrollee in a health benefits plan under this chapter in the same manner as such provisions apply to such a provider and facility with respect to an enrollee in a group health plan or group or individual health insurance coverage offered by a health insurance issuer, as described in such sections.

5 U.S.C. § 8902a Debarment and other sanctions

(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; 11 So in original. The semicolon probably should be a period. (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.

5 U.S.C. § 8903 Health benefits plans

The Office of Personnel Management may contract for or approve the following health benefits plans: (1) Service Benefit Plan.—One Government-wide plan, which may be underwritten by participating affiliates licensed in any number of States, offering at least 2 levels of benefits for enrollees under this chapter generally and at least 2 levels of benefits for enrollees under the Postal Service Health Benefits Program established under section 8903c, under which payment is made by a carrier under contracts with physicians, hospitals, or other providers of health services for benefits of the types described by section 8904(1) of this title 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).

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

(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).

5 U.S.C. § 8903b Authority to readmit an employee organization plan

(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.

5 U.S.C. § 8903c Postal Service Health Benefits Program

(a) Definitions.—In this section—(1) the term “covered Medicare individual” means an individual who is entitled to benefits under Medicare part A, but excluding an individual who is eligible to enroll under such part under section 1818 or 1818A of the Social Security Act (42 U.S.C. 1395i–2, 1395i–2a); (2) the term “initial contract year” means the contract year beginning in January of 2025; (3) the term “initial participating carrier” means a carrier that enters into a contract with the Office to participate in the Program during the initial contract year; (4) the term “Medicare part A” means part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.); (5) the term “Medicare part B” means part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.); (6) the term “Office” means the Office of Personnel Management; (7) the term “Postal Service” means the United States Postal Service; (8) the term “Postal Service annuitant” means an annuitant enrolled in a health benefits plan under this chapter whose Government contribution is required to be paid under section 8906(g)(2); (9) the term “Postal Service employee” means an employee of the Postal Service enrolled in a health benefits plan under this chapter whose Government contribution is paid by the Postal Service; (10) the term “Postal Service Medicare covered annuitant” means an individual who—(A) is a Postal Service annuitant; and (B) is a covered Medicare individual; (11) the term “Program” means the Postal Service Health Benefits Program established under subsection (c) within the Federal Employees Health Benefits Program; (12) the term “Program plan” means a health benefits plan offered under the Program; and (13) the definitions set forth in section 8901 shall apply, and for the purposes of applying such definitions in carrying out this section, a Postal Service employee and Postal Service annuitant shall be treated in the same manner as an employee and an annuitant (as those terms are defined in paragraphs (1) and (3), respectively, of section 8901), consistent with the requirements of this section. (b) Application.—The requirements under this section shall—(1) apply to the initial contract year and each contract year thereafter; and (2) supersede any other provision of this chapter inconsistent with such requirements, as determined by the Office. (c) Establishment of the Postal Service Health Benefits Program.—(1) In general.—(A) Establishment.—The Office shall establish the Postal Service Health Benefits Program within the Federal Employees Health Benefits Program under this chapter, under which the Office may contract with carriers to offer health benefits plans as described under this section. (B) Applicability of chapter requirements to contracts.—Except as otherwise provided in this section, any contract described in subparagraph (A) shall be consistent with the requirements of this chapter for contracts under section 8902 with carriers to offer health benefits plans other than under this section. (C) Program plans and participation.—The Program shall—(i) to the greatest extent practicable—(I) with respect to each plan provided by a carrier under this subchapter in which the total enrollment includes, in the contract year beginning in January 2023, 1,500 or more enrollees who are Postal Service employees or Postal Service annuitants, include a plan offered by that carrier with equivalent benefits and cost-sharing requirements as provided under paragraph (2), except that the Director of the Office may exempt any comprehensive medical plan from this requirement; and (II) include plans offered by any other carrier determined appropriate by the Office; (ii) provide for enrollment in Program plans of Postal Service employees and Postal Service annuitants, in accordance with subsection (d); (iii) provide for enrollment in a Program plan as an individual, for self plus one, or for self and family; and (iv) not provide for enrollment in a Program plan of an individual who is not a Postal Service employee or Postal Service annuitant (except as a member of family of such an employee or annuitant or as provided under paragraph (4)). (2) Coverage with equivalent benefits and cost-sharing.—In the initial contract year, the Office shall ensure that each carrier participating in the Program provides under the Program plans offered by the carrier benefits and cost-sharing requirements that are equivalent to the benefits and cost-sharing requirements under the health benefits plans offered by the carrier under this chapter that are not Program plans, except that prescription drug benefits and cost-sharing requirements may differ between the Program plans and other health benefits plans offered by the carrier under this chapter to the extent needed to integrate the Medicare part D prescription drug benefits coverage required under subsection (h)(2). (3) Applicability of federal employees health benefits program requirements.—Except as otherwise set forth in this section, the provisions of this chapter applicable to health benefits plans offered by carriers under section 8903 or 8903a shall apply to plans offered under the Program. (4) Application of continuation coverage.—In accordance with rules established by the Office, section 8905a shall apply to health benefits plans offered under this section in the same manner as such section applies to other health benefits plans offered under this chapter. (d) Election of Coverage.—Each Postal Service employee and Postal Service annuitant who elects to receive health benefits coverage under this chapter—(1) shall be subject to the requirements of this section; and (2) may not enroll in any other health benefits plan offered under any other section of this chapter. (e) Requirement of Medicare Enrollment for Certain Annuitants and Their Family Members.—(1) Medicare covered annuitants.—Except as provided under paragraph (3), a Postal Service Medicare covered annuitant may not enroll in a Program plan unless the annuitant is entitled to benefits under Medicare part A and enrolled in Medicare part B. (2) Medicare covered family members.—Except as provided under paragraph (3), in the case of a Postal Service annuitant who is entitled to benefits under Medicare part A and required under this subsection to enroll in Medicare part B to enroll under the Program, if a member of family of such Postal Service annuitant is a covered Medicare individual, that member of family may not enroll under the Program as a member of family of the Postal Service annuitant unless that member of family is entitled to benefits under Medicare part A and enrolled in Medicare part B. (3) Exceptions.—(A) In general.—The requirements under paragraphs (1) and (2), as applicable, shall not apply with respect to an individual in the following cases:(i) Current postal service annuitants.—The individual, as of January 1, 2025, is a Postal Service annuitant who is not both entitled to benefits under Medicare part A and enrolled in Medicare part B. (ii) Current employees aged 64 and over.—The individual, as of January 1, 2025, is a Postal Service employee and is at least 64 years of age. (iii) Postal service medicare covered annuitants and family members residing abroad.—For any contract year with respect to which the individual is a Postal Service Medicare covered annuitant or a member of family of a Postal Service Medicare covered annuitant and resides outside the United States (which includes the States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands), provided that the individual demonstrates such residency to the Postal Service in accordance with regulations issued by the Postal Service. (iv) Postal service medicare covered annuitants and family members enrolled under va coverage.—The individual—(I) is a Postal Service Medicare covered annuitant or a member of family of a Postal Service Medicare covered annuitant; and (II) is enrolled in health care benefits provided by the Department of Veterans Affairs under subchapter II of chapter 17 of title 38, United States Code. (v) Postal service medicare covered annuitants and family members eligible for ihs health services.—The individual—(I) is a Postal Service Medicare covered annuitant or a member of family of a Postal Service Medicare covered annuitant; and (II) is eligible for health services from the Indian Health Service. (B) Regulations for va and ihs exceptions.—Not later than 1 year after the date of enactment of this section, the Office shall, in consultation with the Secretary of Veterans Affairs, the Secretary of Health and Human Services, and the Postmaster General, promulgate any regulations necessary to implement clauses (iv) and (v) of subparagraph (A). (C) List of individuals residing abroad.—The Postal Service shall provide a list of individuals who satisfy the exception under subparagraph (A)(iii) to the Office. (4) Process for information collection and dissemination.—The Postal Service and the Office, in consultation with the Social Security Administration and the Centers for Medicare & Medicaid Services, shall establish a process that will enable the Postal Service to timely inform Postal Service employees, Postal Service annuitants, and members of family of such employees and annuitants of the requirements described in paragraphs (1) and (2) in order to be eligible to enroll in Program plans under this section. (f) Transitional Open Season.—(1) Definitions.—In this subsection—(A) the term “current option”, with respect to an individual, means the option under a plan under this chapter in which the individual is enrolled during the contract year preceding the initial contract year; and (B) the term “current plan”, with respect to an individual, means the plan under this chapter in which the individual is enrolled during the contract year preceding the initial contract year. (2) Automatic enrollment.—(A) In general.—Subject to subparagraphs (B) and (C), in the case of an individual who is a Postal Service employee or Postal Service annuitant eligible to enroll in a Program plan under subsection (d), who is enrolled in a current plan, and who does not enroll in a Program plan during the open season that immediately precedes the initial contract year, the Office shall automatically enroll the individual, as of the start of the initial contract year, in a Program plan offered by the carrier of the individual’s current plan. (B) Carriers offering multiple program plans or options.—If the carrier of the current plan of an individual described in subparagraph (A) offers more than 1 Program plan or option, the Office, in carrying out subparagraph (A), shall automatically enroll the individual in the plan and option that provide coverage with equivalent benefits and cost sharing, as described in subsection (c)(2), to the individual’s current plan and current option. (C) Carriers not offering program plans.—If the carrier of the current plan of an individual described in subparagraph (A) does not offer a Program plan, the Office, in carrying out subparagraph (A), shall automatically enroll the individual in the lowest-cost nationwide plan option within the Program that is not a high deductible health plan and does not charge an association or membership fee. (g) OPM Regulations.—(1) In general.—Not later than 1 year after the date of enactment of this section, the Director of the Office shall issue regulations to carry out this section. (2) Consultation.—In issuing regulations under paragraph (1), the Director of the Office shall consult, as necessary, with the Secretary of Health and Human Services, the Secretary of Veterans Affairs, the Commissioner of Social Security, and the Postmaster General. (3) Contents.—The regulations issued under paragraph (1) shall include—(A) any provisions necessary to implement this section; (B) a process under which Postal Service annuitants and affected family members are timely informed of the enrollment requirements and may request, in writing, any additional enrollment information; (C) provisions under which a Postal Service employee or Postal Service annuitant enrolled under the Program may request a belated change of plan and may be prospectively enrolled in the plan of the employee’s or annuitant’s choice; and (D) provisions for individuals to cancel coverage under the Program in writing to the Postal Service because the individuals choose not to enroll in, or to disenroll from, Medicare part B. (h) Medicare Coordination.—(1) In general.—The Office shall require each Program plan to provide benefits for covered Medicare individuals pursuant to a coordination of benefits method approved by the Office. (2) Medicare part d prescription drug benefits.—The Office shall require each Program plan to provide prescription drug benefits to any Postal Service annuitant and member of family of such annuitant who is a part D eligible individual (as defined in section 1860D–1(a)(3)(A) of the Social Security Act) through employment-based retiree health coverage (as defined in section 1860D–22(c)(1) of such Act) through—(A) a prescription drug plan (as defined in section 1860D–41(a)(14) of such Act); or (B) contracts between such a Program plan and PDP sponsor, as defined in section 1860D–41(a)(13) of such Act, of such a prescription drug plan. (i) Postal Service Contribution.—(1) In general.—Subject to subsection (k), for purposes of applying section 8906(b) to the Postal Service, the weighted average shall be calculated in accordance with paragraphs (2) and (3). (2) Weighted average calculation.—Not later than October 1 of each year (beginning with 2024), the Office shall determine the weighted average of the rates established pursuant to subsection (c)(2) for Program plans that will be in effect during the following contract year with respect to—(A) enrollments for self only; (B) enrollments for self plus one; and (C) enrollments for self and family. (3) Weighting in computing rates for initial contract year.—In determining such weighted average of the rates for the initial contract year, the Office shall take into account (for purposes of section 8906(a)(2)) the enrollment of Postal Service employees and annuitants in the health benefits plans offered by the initial participating carriers as of March 31, 2023. (4) Payment of late enrollment penalties.—The Postal Service may direct the Office to pay the amounts required by an agreement between the United States Postal Service and the Secretary of the Department of Health and Human Services under section 1839(e)(1) of the Social Security Act (42 U.S.C. 1395r(e)(1)) from the Postal Service Retiree Health Benefits Fund established under section 8909a until depleted and thereafter shall pay such amounts from the Postal Service Fund established under section 2003 of title 39. (j) Reserves.—(1) Separate reserves.—(A) In general.—The Office shall ensure that each Program plan maintains separate reserves (including a separate contingency reserve) with respect to the enrollees in the Program plan in accordance with section 8909. (B) Applicability of section 8909 to contingency reserves.—All provisions of section 8909 relating to contingency reserves shall apply to contingency reserves of Program plans in the same manner as to the contingency reserves of other plans under this chapter, except to the extent that such provisions are inconsistent with the requirements of this subsection. (C) References.—For purposes of the Program, each reference to “the Government” in section 8909 shall be deemed to be a reference to the Postal Service. (D) Amounts to be credited.—The reserves (including the separate contingency reserve) maintained for each Program plan shall be credited with a proportionate amount of the funds in the reserves for health benefits plans offered by the carrier. (2) Discontinuation of program plan.—In applying section 8909(e) relating to a Program plan that is discontinued, the Office shall credit the separate Postal Service contingency reserve maintained under paragraph (1) for that plan only to the separate Postal Service contingency reserves of the Program plans continuing under this chapter. (k) No Effect on Existing Law.—Nothing in this section shall be construed as affecting section 1005(f) of title 39 regarding variations, additions, or substitutions to the provisions of this chapter. (l) Health Benefits Education Program.—(1) Definition.—In this subsection, the term “navigator” means an employee of the Postal Service or of a contractor of the Postal Service who is designated by the Postal Service or contractor to carry out activities under paragraph (5). (2) Establishment.—Not later than 18 months after the date of enactment of this section, the Postal Service shall establish a Health Benefits Education Program. (3) Requirements.—In carrying out the Health Benefits Education Program established under paragraph (2), the Postal Service shall—(A) notify Postal Service annuitants and Postal Service employees about the Postal Service Health Benefits Program established under subsection (c)(1); (B) provide information regarding the Postal Service Health Benefits Program and the requirements of this section to Postal Service annuitants and Postal Service employees, including—(i) a description of the health care options available under such Program; (ii) the enrollment provisions of subsection (d); and (iii) the requirement that Postal Service annuitants and their family members be enrolled in Medicare under subsection (e); (C) respond and provide answers to any inquiry from such employees and annuitants about the Postal Service Health Benefits Program, in consultation with the Office as necessary; (D) in consultation with the Centers for Medicare & Medicaid Services and the Social Security Administration, provide information to individuals about enrollment under the Medicare program under title XVIII of the Social Security Act, and refer individuals to the Centers for Medicare & Medicaid Services and the Social Security Administration as necessary for additional enrollment information; and (E) carry out, or provide for through contract or other arrangement, the activities described in paragraph (5). (4) Information.—(A) Information from opm.—The Office shall timely provide the Postal Service with such information as necessary to conduct the Health Benefits Education Program. (B) Coordination with opm.—The Postal Service shall coordinate with the Office, in consultation with the Centers for Medicare & Medicaid Services and the Social Security Administration, to obtain and confirm the accuracy of information as the Postal Service determines to be necessary to conduct the Health Benefits Education Program. (5) Navigator activities.—(A) Activities.—The activities described in this paragraph, with respect to Program plans and the health care options available under the Program, are the following:(i) Educational activities for annuitants and employees of the Postal Service to raise awareness of the availability of Program plans and requirements for enrolling in such plans, including requirements to be entitled to Medicare part A and enroll in Medicare part B. (ii) Distribution of fair and impartial information concerning enrollment in such plans. (iii) Facilitation of enrollment in such plans. (iv) Provision of information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Program plans. (B) Standards.—(i) In general.—The Postal Service shall establish standards for navigators carrying out the activities under this paragraph to—(I) engage in the navigator activities described in subparagraph (A); and (II) avoid conflicts of interest. (ii) Contents.—The standards established under clause (i) shall provide that a navigator may not—(I) be a health insurance carrier; or (II) receive any consideration directly or indirectly from any health insurance carrier in connection with the enrollment of any individual in a Program plan. (C) Fair and impartial information and services.—The Postal Service, in consultation as necessary with the Office and the Centers for Medicare & Medicaid Services, shall develop standards to ensure that information made available by navigators under this paragraph is fair, accurate, and impartial. (6) Regulations.—(A) In general.—Not later than 18 months after the date of enactment of this section, the Postmaster General shall issue regulations to establish the Health Benefits Education Program required under this subsection. (B) Contents.—The regulations issued under subparagraph (A) shall include—(i) provisions for the notification of Postal Service annuitants and Postal Service employees about the Program, including a description of the available health benefits options, including a process for notifying Postal Service employees who become eligible for Medicare part B and Postal Service Medicare covered annuitants about their choices; (ii) provisions for notifying Postal Service annuitants, Postal Service employees, and their family members of the requirements under subsection (e) to enroll in Medicare as a condition of eligibility to enroll in the Program; and (iii) a process, developed in consultation with the Social Security Administration, the Centers for Medicare & Medicaid Services, and the Office, for addressing any inquiry from Postal Service annuitants and Postal Service employees about the Program or Medicare enrollment.

5 U.S.C. § 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).

5 U.S.C. § 8905 Election of coverage

(a) An employee may enroll in an approved health benefits plan described in section 8903 or 8903a—(1) as an individual; (2) for self plus one; or (3) for self and family. (b) An annuitant who at the time he becomes an annuitant was enrolled in a health benefits plan under this chapter—(1) as an employee for a period of not less than—(A) the 5 years of service immediately before retirement; (B) the full period or periods of service between the last day of the first period, as prescribed by regulations of the Office of Personnel Management, in which he is eligible to enroll in the plan and the date on which he becomes an annuitant; or (C) the full period or periods of service beginning with the enrollment which became effective before January 1, 1965, and ending with the date on which he becomes an annuitant; whichever is shortest; or (2) as a member of the family of an employee or annuitant; may continue his enrollment under the conditions of eligibility prescribed by regulations of the Office. The Office may, in its sole discretion, waive the requirements of this subsection in the case of an individual who fails to satisfy such requirements if the Office determines that, due to exceptional circumstances, it would be against equity and good conscience not to allow such individual to be enrolled as an annuitant in a health benefits plan under this chapter 11 So in original. Probably should be followed by a period. (c)(1) A former spouse may—(A) within 60 days after the dissolution of the marriage, or (B) in the case of a former spouse of a former employee whose marriage was dissolved after the employee’s retirement, within 60 days after the dissolution of the marriage or, if later, within 60 days after an election is made under 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 22 So in original. The word “for” probably should precede “self and family”. for self plus one or 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 plus one or for self and family under this subsection shall be limited to—(A) the former spouse; and (B) unmarried dependent natural or adopted children (or, in the case of self plus one coverage, not more than 1 such child) of the former spouse and the employee who are—(i) under 22 years of age; or (ii) incapable of self-support because of mental or physical disability which existed before age 22. (d) An individual whom the Secretary of Defense determines is an eligible beneficiary under subsection (b) of section 1108 of title 10 may enroll, as part of the demonstration project under such section, in a health benefits plan under this chapter in accordance with the agreement under subsection (a) of such section between the Secretary and the Office and applicable regulations under this chapter. (e) If an employee, annuitant, or other individual eligible to enroll in a health benefits plan under this chapter has a spouse who is also eligible to enroll, either spouse, but not both, may enroll for self and family, or for a self plus one enrollment that covers the spouse, or each spouse may enroll as an individual or for a self plus one enrollment that does not cover the other spouse or a child who is covered under the enrollment of the other spouse. However, an individual may not be enrolled both as an employee, annuitant, or other individual eligible to enroll and as a member of the family. (f) An employee, annuitant, former spouse, or person having continued coverage under section 8905a of this title enrolled in a health benefits plan under this chapter may change his coverage or that of himself and members of his family by an application filed within 60 days after a change in family status or at other times and under conditions prescribed by regulations of the Office. (g)(1) Under regulations prescribed by the Office, the Office shall, before the start of any contract term in which—(A) an adjustment is made in any of the rates charged or benefits provided under a health benefits plan described by section 8903 or 8903a of this title, (B) a newly approved health benefits plan is offered, or (C) an existing plan is terminated, provide a period of not less than 3 weeks during which any employee, annuitant, former spouse, or person having continued coverage under section 8905a of this title enrolled in a health benefits plan described by such section shall be permitted to transfer that individual’s enrollment to another such plan or to cancel such enrollment. (2) In addition to any opportunity afforded under paragraph (1) of this subsection, an employee, annuitant, former spouse, or person having continued coverage under section 8905a of this title enrolled in a health benefits plan under this chapter shall be permitted to transfer that individual’s enrollment to another such plan, or to cancel such enrollment, at such other times and subject to such conditions as the Office may prescribe in regulations. (3)(A) In addition to any informational requirements otherwise applicable under this chapter, the regulations shall include provisions to ensure that each employee eligible to enroll in a health benefits plan under this chapter (whether actually enrolled or not) is notified in writing as to the rights afforded under section 8905a of this title. (B) Notification under this paragraph shall be provided by employing agencies at an appropriate point in time before each period under paragraph (1) so that employees may be aware of their rights under section 8905a of this title when making enrollment decisions during such period. (h)(1) An unenrolled employee who is required by a court or administrative order to provide health insurance coverage for 1 or more children who meets the requirements of section 8901(5) may enroll for self plus one or self and family coverage, as necessary to provide health insurance coverage for each child who is covered under the order, in a health benefits plan under this chapter. If such employee fails to enroll for self plus one or self and family coverage, as necessary to provide health insurance coverage for each child who is covered under the order, in a health benefits plan that provides full benefits and services in the location in which the child or children reside, and the employee does not provide documentation showing that such coverage has been provided through other health insurance, the employing agency shall enroll the employee in a self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, in the option which provides the lower level of coverage under the Service Benefit Plan. (2) An employee who is enrolled as an individual in a health benefits plan under this chapter and who is required by a court or administrative order to provide health insurance coverage for 1 or more children who meets the requirements of section 8901(5) may change to a self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, in the same or another health benefits plan under this chapter. If such employee fails to change to a self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, and the employee does not provide documentation showing that such coverage has been provided through other health insurance, the employing agency shall change the enrollment of the employee to a self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, in the plan in which the employee is enrolled if that plan provides full benefits and services in the location where the child or children reside. If the plan in which the employee is enrolled does not provide full benefits and services in the location in which the child or children reside, or, if the employee fails to change to a self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, in a plan that provides full benefits and services in the location where the child or children reside, the employing agency shall change the coverage of the employee to a self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, in the option which provides the lower level of coverage under the Service Benefits Plan. (3) The employee may not discontinue the self plus one or self and family enrollment, as necessary to provide health insurance coverage for each child who is covered under the order, in a plan that provides full benefits and services in the location in which the child or children reside for so long as the court or administrative order remains in effect and the child or children continue to meet the requirements of section 8901(5), unless the employee provides documentation showing that such coverage has been provided through other health insurance. (i) Any services by an officer or employee under this chapter relating to enrolling individuals in a health benefits plan under this chapter, or changing the enrollment of an individual already so enrolled, shall be deemed, for purposes of section 1342 of title 31, services for emergencies involving the safety of human life or the protection of property.

5 U.S.C. § 8905a Continued coverage

(a) Any individual described in subsection (b) may elect to continue coverage under this chapter in accordance with the provisions of this section. (b) This section applies with respect to—(1) any employee who—(A) is separated from service, whether voluntarily or involuntarily, except that if the separation is involuntary, this section shall not apply if the separation is for gross misconduct (as defined under regulations which the Office of Personnel Management shall prescribe); and (B) would not otherwise be eligible for any benefits under this chapter (determined without regard to any temporary extension of coverage and without regard to any benefits available under a nongroup contract); (2) any individual who—(A) ceases to meet the requirements for being considered an unmarried dependent child under this chapter; (B) on the day before so ceasing to meet the requirements referred to in subparagraph (A), was covered under a health benefits plan under this chapter as a member of the family of an employee or annuitant; and (C) would not otherwise be eligible for any benefits under this chapter (determined without regard to any temporary extension of coverage and without regard to any benefits available under a nongroup contract); and (3) any employee who—(A) is enrolled in a health benefits plan under this chapter; (B) is a member of a reserve component of the armed forces; (C) is called or ordered to active duty in support of a contingency operation (as defined in section 101(a)(13) of title 10); (D) is placed on leave without pay or separated from service to perform active duty; and (E) serves on active duty for a period of more than 30 consecutive days. (c)(1) The Office shall prescribe regulations and provide for the inclusion of appropriate terms in contracts with carriers to provide that—(A) with respect to an employee who becomes (or will become) eligible for continued coverage under this section as a result of separation from service, the separating agency shall, before the end of the 30-day period beginning on the date as of which coverage (including any temporary extensions of coverage) would otherwise end, notify the individual of such individual’s rights under this section; and (B) with respect to a child of an employee or annuitant who becomes eligible for continued coverage under this section as a result of ceasing to meet the requirements for being considered a member of the employee’s or annuitant’s family—(i) the employee or annuitant may provide written notice of the child’s change in status (complete with the child’s name, address, and such other information as the Office may by regulation require)—(I) to the employee’s employing agency; or (II) in the case of an annuitant, to the Office; and (ii) if the notice referred to in clause (i) is received within 60 days after the date as of which the child involved first ceases to meet the requirements involved, the employing agency or the Office (as the case may be) must, within 14 days after receiving such notice, notify the child of such child’s rights under this section. (2) In order to obtain continued coverage under this section, an appropriate written election (submitted in such manner as the Office by regulation prescribes) must be made—(A) in the case of an individual seeking continued coverage based on a separation from service, before the end of the 60-day period beginning on the later of—(i) the effective date of the separation; or (ii) the date the separated individual receives the notice required under paragraph (1)(A); or (B) in the case of an individual seeking continued coverage based on a change in circumstances making such individual ineligible for coverage as an unmarried dependent child, before the end of the 60-day period beginning on the later of—(i) the date as of which such individual first ceases to meet the requirements for being considered an unmarried dependent child; or (ii) the date such individual receives notice under paragraph (1)(B)(ii); except that if a parent fails to provide the notice required under paragraph (1)(B)(i) in timely fashion, the 60-day period under this subparagraph shall be based on the date under clause (i), irrespective of whether or not any notice under paragraph (1)(B)(ii) is provided. (d)(1)(A) Except as provided in paragraphs (4), (5), and (6), an individual receiving continued coverage under this section shall be required to pay currently into the Employees Health Benefits Fund, under arrangements satisfactory to the Office, an amount equal to the sum of—(i) the employee and agency contributions which would be required in the case of an employee enrolled in the same health benefits plan and level of benefits; and (ii) an amount, determined under regulations prescribed by the Office, necessary for administrative expenses, but not to exceed 2 percent of the total amount under clause (i). (B) Payments under this section to the Fund shall—(i) in the case of an individual whose continued coverage is based on such individual’s separation, be made through the agency which last employed such individual; or (ii) in the case of an individual whose continued coverage is based on a change in circumstances referred to in subsection (c)(2)(B), be made through—(I) the Office, if, at the time coverage would (but for this section) otherwise have been discontinued, the individual was covered as the child of an annuitant; or (II) if, at the time referred to in subclause (I), the individual was covered as the child of an employee, the employee’s employing agency as of such time. (2) If an individual elects to continue coverage under this section before the end of the applicable period under subsection (c)(2), but after such individual’s coverage under this chapter (including any temporary extensions of coverage) expires, coverage shall be restored retroactively, with appropriate contributions (determined in accordance with paragraph (1), (4), or (5), as the case may be) and claims (if any), to the same extent and effect as though no break in coverage had occurred. (3)(A) An individual making an election under subsection (c)(2)(B) may, at such individual’s option, elect coverage either as an individual or, if appropriate, for self plus one or for self and family. (B) For the purpose of this paragraph, members of an individual’s family shall be determined in the same way as would apply under this chapter in the case of an enrolled employee. (C) Nothing in this paragraph shall be considered to limit an individual making an election under subsection (c)(2)(A) to coverage for self alone. (4)(A) If the basis for continued coverage under this section is an involuntary separation from a position, or a voluntary separation from a surplus position, in or under the Department of Defense due to a reduction in force, or the Department of Energy due to a reduction in force resulting from the establishment of the National Nuclear Security Administration—(i) the individual shall be liable for not more than the employee contributions referred to in paragraph (1)(A)(i); and (ii) the agency which last employed the individual shall pay the remaining portion of the amount required under paragraph (1)(A). (B) This paragraph shall apply with respect to any individual whose continued coverage is based on a separation occurring on or after the date of enactment of this paragraph and before—(i) December 31, 2016; or (ii) February 1, 2017, if specific notice of such separation was given to such individual before December 31, 2016. (C) For the purpose of this paragraph, “surplus position” means a position which is identified in pre-reduction-in-force planning as no longer required, and which is expected to be eliminated under formal reduction-in-force procedures. (5)(A) If the basis for continued coverage under this section is an involuntary separation from a position in or under the Department of Veterans Affairs due to a reduction in force or a title 38 staffing readjustment, or a voluntary or involuntary separation from a Department of Energy position at a Department of Energy facility at which the Secretary is carrying out a closure project selected under section 442111 See References in Text note below. of the Atomic Energy Defense Act—(i) the individual shall be liable for not more than the employee contributions referred to in paragraph (1)(A)(i); and (ii) the agency which last employed the individual shall pay the remaining portion of the amount required under paragraph (1)(A). (B) This paragraph shall only apply with respect to individuals whose continued coverage is based on a separation occurring on or after the date of the enactment of this paragraph. (6)(A) If the basis for continued coverage under this section is, as a result of the termination of the Space Shuttle Program, an involuntary separation from a position due to a reduction-in-force or declination of a directed reassignment or transfer of function, or a voluntary separation from a surplus position in the National Aeronautics and Space Administration—(i) the individual shall be liable for not more than the employee contributions referred to in paragraph (1)(A)(i); and (ii) the National Aeronautics and Space Administration shall pay the remaining portion of the amount required under paragraph (1)(A). (B) This paragraph shall only apply with respect to individuals whose continued coverage is based on a separation occurring on or after the date of enactment of this paragraph and before December 31, 2010. (C) For purposes of this paragraph, “surplus position” means a position which is—(i) identified in pre-reduction-in-force planning as no longer required, and which is expected to be eliminated under formal reduction-in-force procedures as a result of the termination of the Space Shuttle Program; or (ii) encumbered by an employee who has received official certification from the National Aeronautics and Space Administration consistent with the Administration’s career transition assistance program regulations that the position is being abolished as a result of the termination of the Space Shuttle Program. (e)(1) Continued coverage under this section may not extend beyond—(A) in the case of an individual whose continued coverage is based on separation from service, the date which is 18 months after the effective date of the separation; (B) in the case of an individual whose continued coverage is based on ceasing to meet the requirements for being considered an unmarried dependent child, the date which is 36 months after the date on which the individual first ceases to meet those requirements, subject to paragraph (2); or (C) in the case of an employee described in subsection (b)(3), the date which is 24 months after the employee is placed on leave without pay or separated from service to perform active duty. (2) In the case of an individual who—(A) ceases to meet the requirements for being considered an unmarried dependent child; (B) as of the day before so ceasing to meet the requirements referred to in subparagraph (A), was covered as the child of a former employee receiving continued coverage under this section based on the former employee’s separation from service; and (C) so ceases to meet the requirements referred to in subparagraph (A) before the end of the 18-month period beginning on the date of the former employee’s separation from service, extended coverage under this section may not extend beyond the date which is 36 months after the separation date referred to in subparagraph (C). (f)(1) The Office shall prescribe regulations under which, in addition to any individual otherwise eligible for continued coverage under this section, and to the extent practicable, continued coverage may also, upon appropriate written application, be afforded under this section—(A) to any individual who—(i) if subparagraphs (A) and (C) of paragraph (10) of section 8901 were disregarded, would be eligible to be considered a former spouse within the meaning of such paragraph; but (ii) would not, but for this subsection, be eligible to be so considered; and (B) to any individual whose coverage as a family member would otherwise terminate as a result of a legal separation. (2) The terms and conditions for coverage under the regulations shall include—(A) consistent with subsection (c), any necessary notification provisions, and provisions under which an election period of at least 60 days’ duration is afforded; (B) terms and conditions identical to those under subsection (d), except that contributions to the Employees Health Benefits Fund shall be made through such agency as the Office by regulation prescribes; (C) provisions relating to the termination of continued coverage, except that continued coverage under this section may not (subject to paragraph (3)) extend beyond the date which is 36 months after the date on which the qualifying event under this subsection (the date of divorce, annulment, or legal separation, as the case may be) occurs; and (D) provisions designed to ensure that any coverage pursuant to this subsection does not adversely affect any eligibility for coverage which the individual involved might otherwise have under this chapter (including as a result of any change in personal circumstances) if this subsection had not been enacted. (3) In the case of an individual—(A) who becomes eligible for continued coverage under this subsection based on a divorce, annulment, or legal separation from a person who, as of the day before the date of the divorce, annulment, or legal separation (as the case may be) was receiving continued coverage under this section based on such person’s separation from service under a self plus one enrollment that covered the individual or under a self and family enrollment; and (B) whose divorce, annulment, or legal separation (as the case may be) occurs before the end of the 18-month period beginning on the date of the separation from service referred to in subparagraph (A), extended coverage under this section may not extend beyond the date which is 36 months after the date of the separation from service, as referred to in subparagraph (A).

5 U.S.C. § 8906 Contributions

(a)(1) Not later than October 1 of each year, the Office of Personnel Management shall determine the weighted average of the subscription charges that will be in effect during the following contract year with respect to—(A) enrollments under this chapter for self alone; (B) enrollments under this chapter for self plus one; and (C) enrollments under this chapter for self and family. (2) In determining each weighted average under paragraph (1), the weight to be given to a particular subscription charge shall, with respect to each plan (and option) to which it is to apply, be commensurate with the number of enrollees enrolled in such plan (and option) as of March 31 of the year in which the determination is being made. (3) For purposes of paragraph (2), the term “enrollee” means any individual who, during the contract year for which the weighted average is to be used under this section, will be eligible for a Government contribution for health benefits. (b)(1) Except as provided in paragraphs (2), (3), and (4), the biweekly Government contribution for health benefits for an employee or annuitant enrolled in a health benefits plan under this chapter is adjusted to an amount equal to 72 percent of the weighted average under subsection (a)(1)(A) or (B), as applicable. For an employee, the adjustment begins on the first day of the employee’s first pay period of each year. For an annuitant, the adjustment begins on the first day of the first period of each year for which an annuity payment is made. (2) The biweekly Government contribution for an employee or annuitant enrolled in a plan under this chapter shall not exceed 75 percent of the subscription charge. (3) In the case of an employee who is occupying a position on a part-time career employment basis (as defined in section 3401(2) of this title), the biweekly Government contribution shall be equal to the percentage which bears the same ratio to the percentage determined under this subsection (without regard to this paragraph) as the average number of hours of such employee’s regularly scheduled workweek bears to the average number of hours in the regularly scheduled workweek of an employee serving in a comparable position on a full-time career basis (as determined under regulations prescribed by the Office). (4) In the case of persons who are enrolled in a health benefits plan as part of the demonstration project under section 1108 of title 10, the Government contribution shall be subject to the limitation set forth in subsection (i) of that section. (c) There shall be withheld from the pay of each enrolled employee and (except as provided in subsection (i) of this section) the annuity of each enrolled annuitant and there shall be contributed by the Government, amounts, in the same ratio as the contributions of the employee or annuitant and the Government under subsection (b) of this section, which are necessary for the administrative costs and the reserves provided for by section 8909(b) of this title. (d) The amount necessary to pay the total charge for enrollment, after the Government contribution is deducted, shall be withheld from the pay of each enrolled employee and (except as provided in subsection (i) of this section) from the annuity of each enrolled annuitant. The withholding for an annuitant shall be the same as that for an employee enrolled in the same health benefits plan and level of benefits. (e)(1)(A) An employee enrolled in a health benefits plan under this chapter who is placed in a leave without pay status may have his coverage and the coverage of members of his family continued under the plan for not to exceed 1 year under regulations prescribed by the Office. (B) During each pay period in which an enrollment continues under subparagraph (A)—(i) employee and Government contributions required by this section shall be paid on a current basis; and (ii) if necessary, the head of the employing agency shall approve advance payment, recoverable in the same manner as under section 5524a(c), of a portion of basic pay sufficient to pay current employee contributions. (C) Each agency shall establish procedures for accepting direct payments of employee contributions for the purposes of this paragraph. (2) An employee who enters on approved leave without pay to serve as a full-time officer or employee of an organization composed primarily of employees as defined by section 8901 of this title, within 60 days after entering on that leave without pay, may file with his employing agency an election to continue his health benefits enrollment and arrange to pay currently into the Employees Health Benefits Fund, through his employing agency, both employee and agency contributions from the beginning of leave without pay. The employing agency shall forward the enrollment charges so paid to the Fund. If the employee does not so elect, his enrollment will continue during nonpay status and end as provided by paragraph (1) of this subsection and implementing regulations. (3)(A) An employing agency may pay both the employee and Government contributions, and any additional administrative expenses otherwise chargeable to the employee, with respect to health care coverage for an employee described in subparagraph (B) and the family of such employee. (B) An employee referred to in subparagraph (A) is an employee who—(i) is enrolled in a health benefits plan under this chapter; (ii) is a member of a reserve component of the armed forces; (iii) is called or ordered to active duty in support of a contingency operation (as defined in section 101(a)(13) of title 10); (iv) is placed on leave without pay or separated from service to perform active duty; and (v) serves on active duty for a period of more than 30 consecutive days. (C) Notwithstanding the one-year limitation on coverage described in paragraph (1)(A), payment may be made under this paragraph for a period not to exceed 24 months. (f) The Government contribution, and any additional payments under subsection (e)(3)(A), for health benefits for an employee shall be paid—(1) in the case of employees generally, from the appropriation or fund which is used to pay the employee; (2) in the case of an elected official, from an appropriation or fund available for payment of other salaries of the same office or establishment; (3) in the case of an employee of the legislative branch who is paid by the Chief Administrative Officer of the House of Representatives, from the applicable accounts of the House of Representatives; and (4) in the case of an employee in a leave without pay status, from the appropriation or fund which would be used to pay the employee if he were in a pay status. (g)(1) Except as provided in paragraphs (2) and (3), the Government contributions authorized by this section for health benefits for an annuitant shall be paid from annual appropriations which are authorized to be made for that purpose and which may be made available until expended. (2)(A) The Government contributions authorized by this section for health benefits for an individual who first becomes an annuitant by reason of retirement from employment with the United States Postal Service on or after July 1, 1971, or for a survivor of such an individual or of an individual who died on or after July 1, 1971, while employed by the United States Postal Service, shall through September 30, 2016, be paid by the United States Postal Service, and thereafter shall be paid first from the Postal Service Retiree Health Benefits Fund up to the amount contained in the Fund, with any remaining amount paid by the United States Postal Service. (B) In determining any amount for which the Postal Service is liable under this paragraph, the amount of the liability shall be prorated to reflect only that portion of total service which is attributable to civilian service performed (by the former postal employee or by the deceased individual referred to in subparagraph (A), as the case may be) after June 30, 1971, as estimated by the Office of Personnel Management. (3) The Government contribution for persons enrolled in a health benefits plan as part of the demonstration project under section 1108 of title 10 shall be paid as provided in subsection (i) of that section. (h) The Office shall provide for conversion of biweekly rates of contribution specified by this section to rates for employees and annuitants paid on other than a biweekly basis, and for this purpose may provide for the adjustment of the converted rate to the nearest cent. (i) An annuitant whose annuity is insufficient to cover the withholdings required for enrollment in a particular health benefits plan may enroll (or remain enrolled) in such plan, notwithstanding any other provision of this section, if the annuitant elects, under conditions prescribed by regulations of the Office, to pay currently into the Employees Health Benefits Fund, through the retirement system that administers the annuitant’s health benefits enrollment, an amount equal to the withholdings that would otherwise be required under this section.

5 U.S.C. § 8906a Temporary employees

(a)(1) The Office of Personnel Management shall prescribe regulations to provide for offering health benefits plans to temporary employees (who meet the requirements of paragraph (2)) under the provisions of this chapter. (2) To be eligible to participate in a health benefits plan offered under this section a temporary employee shall have completed 1 year of current continuous employment, excluding any break in service of 5 days or less. (b) Notwithstanding the provisions of section 8906—(1) any temporary employee enrolled in a health benefits plan under this section shall have an amount withheld from the pay of such employee, as determined by the Office of Personnel Management, equal to—(A) the amount withheld from the pay of an employee under the provisions of section 8906; and (B) the amount of the Government contribution for an employee under section 8906; and (2) the employing agency of any such temporary employee shall not pay the Government contribution under the provisions of section 8906.

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

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

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

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

5 U.S.C. § 8909 Employees Health Benefits Fund

(a) There is in the Treasury of the United States an Employees Health Benefits Fund which is administered by the Office of Personnel Management. The contributions of enrollees and the Government described by section 8906 of this title shall be paid into the Fund. The Fund is available—(1) without fiscal year limitation for all payments to approved health benefits plans; and (2) to pay expenses for administering this chapter within the limitations that may be specified annually by Congress, except that the amounts required to be set aside under subsection (b)(2) shall not be subject to the limitations that may be specified annually by Congress. Payments from the Fund to a plan participating in a letter-of-credit arrangement under this chapter shall, in connection with any payment or reimbursement to be made by such plan for a health service or supply, be made, to the maximum extent practicable, on a checks-presented basis (as defined under regulations of the Department of the Treasury). (b) Portions of the contributions made by enrollees and the Government shall be regularly set aside in the Fund as follows:(1) A percentage, not to exceed 1 percent of all contributions, determined by the Office to be reasonably adequate to pay the administrative expenses made available by subsection (a) of this section. (2) In fiscal year 2026, $66,000,000, to be derived from all contributions, and to remain available until the end of fiscal year 2035, for the Director of the Office to carry out subsections (c) through (f) of the FEHB Protection Act of 2025. (3) For each health benefits plan, a percentage, not to exceed 3 percent of the contributions toward the plan, determined by the Office to be reasonably adequate to provide a contingency reserve. The Office, from time to time and in amounts it considers appropriate, may transfer unused funds for administrative expenses to the contingency reserves of the plans then under contract with the Office. When funds are so transferred, each contingency reserve shall be credited in proportion to the total amount of the subscription charges paid and accrued to the plan for the contract term immediately before the contract term in which the transfer is made. The income derived from dividends, rate adjustments, or other refunds made by a plan shall be credited to its contingency reserve. The contingency reserves may be used to defray increases in future rates, or may be applied to reduce the contributions of enrollees and the Government to, or to increase the benefits provided by, the plan from which the reserves are derived, as the Office from time to time shall determine. (c) The Secretary of the Treasury may invest and reinvest any of the money in the Fund in interest-bearing obligations of the United States, and may sell these obligations for the purposes of the Fund. The interest on and the proceeds from the sale of these obligations become a part of the Fund. (d) When the assets, liabilities, and membership of employee organizations sponsoring or underwriting plans approved under section 8903(3) or 8903a of this title are merged, the assets (including contingency reserves) and liabilities of the plans sponsored or underwritten by the merged organizations shall be transferred at the beginning of the contract term next following the date of the merger to the plan sponsored or underwritten by the successor organization. Each employee, annuitant, former spouse, or person having continued coverage under section 8905a of this title affected by a merger shall be transferred to the plan sponsored or underwritten by the successor organization unless he enrolls in another plan under this chapter. If the successor organization is an organization described in section 8901(8)(B) of this title, any employee, annuitant, former spouse, or person having continued coverage under section 8905a of this title so transferred may not remain enrolled in the plan after the end of the contract term in which the merger occurs unless that individual is a full member of such organization (as determined under section 8903a(d) of this title). (e)(1) Except as provided by subsection (d) of this section, when a plan described by section 8903(3) or (4) or 8903a of this title is discontinued under this chapter, the contingency reserve of that plan shall be credited to the contingency reserves of the plans continuing under this chapter for the contract term following that in which termination occurs, each reserve to be credited in proportion to the amount of the subscription charges paid and accrued to the plan for the year of termination. (2) Any crediting required under paragraph (1) pursuant to the discontinuation of any plan under this chapter shall be completed by the end of the second contract year beginning after such plan is so discontinued. (3) The Office shall prescribe regulations in accordance with which this subsection shall be applied in the case of any plan which is discontinued before being credited with the full amount to which it would otherwise be entitled based on the discontinuation of any other plan. (f)(1) No tax, fee, or other monetary payment may be imposed, directly or indirectly, on a carrier or an underwriting or plan administration subcontractor of an approved health benefits plan by any State, the District of Columbia, or the Commonwealth of Puerto Rico, or by any political subdivision or other governmental authority thereof, with respect to any payment made from the Fund. (2) Paragraph (1) shall not be construed to exempt any carrier or underwriting or plan administration subcontractor of an approved health benefits plan from the imposition, payment, or collection of a tax, fee, or other monetary payment on the net income or profit accruing to or realized by such carrier or underwriting or plan administration subcontractor from business conducted under this chapter, if that tax, fee, or payment is applicable to a broad range of business activity. (g) The fund described in subsection (a) is available to pay costs that the Office incurs for activities associated with implementation of the demonstration project under section 1108 of title 10.

5 U.S.C. § 8909a Postal Service Retiree Health Benefits Fund

(a) There is in the Treasury of the United States a Postal Service Retiree Health Benefits Fund which is administered by the Office of Personnel Management. (b) The Fund is available without fiscal year limitation for payments required under section 8906(g)(2)(A). (c) The Secretary of the Treasury shall immediately invest, in interest-bearing securities of the United States such currently available portions of the Fund as are not immediately required for payments from the Fund. Such investments shall be made in the same manner as investments for the Civil Service Retirement and Disability Fund under section 8348. (d)(1) Not later than June 30, 2026, and by June 30 of each succeeding year, the Office shall compute, for the most recently concluded fiscal year, the amount (if any) that Government contributions required to be paid from the Fund under section 8906(g)(2)(A) exceeded the estimated net claims costs under the enrollment of the individuals described in section 8906(g)(2)(A). (2) Not later than September 30 of each year in which the Office makes a computation under paragraph (1), the United States Postal Service shall pay into the Fund the amount (if any) of the excess computed under such paragraph. (e) Any computation required under section 3654(b) of title 39 shall be based on—(1) the net present value of the future net claims costs with respect to—(A) current annuitants of the United States Postal Service as of the end of the fiscal year ending on September 30 of the relevant reporting year; and (B) current employees of the United States Postal Service who would, as of September 30 of that year—(i) be eligible to become annuitants pursuant to section 8901(3)(A)(i) or (ii); and (ii) if they were retired as of that date, meet the criteria for coverage of annuitants under section 8905(b); (2) economic and actuarial methods and assumptions consistent with the methods and assumptions used in determining the Postal surplus or supplemental liability under section 8348(h); and (3) any other methods and assumptions, including a health care cost trend rate, that the Director of the Office determines to be appropriate. (f) After consultation with the United States Postal Service, the Office shall promulgate any regulations the Office determines necessary under this subsection. (g) For purposes of this section, the term “estimated net claims costs” shall mean the difference between—(1) the sum of—(A) the estimated costs incurred by a carrier in providing health services to, paying for health services provided to, or reimbursing expenses for health services provided to, annuitants of the United States Postal Service and any other persons covered under the enrollment of such annuitants; and (B) an amount of indirect expenses reasonably allocable to the provision, payment, or reimbursement described in subparagraph (A), as determined by the Office; and (2) the amount withheld from the annuity of or paid by annuitants of the United States Postal Service under section 8906.

5 U.S.C. § 8910 Studies, reports, and audits

(a) The Office of Personnel Management shall make a continuing study of the operation and administration of this chapter, including surveys and reports on health benefits plans available to employees and on the experience of the plans. (b) Each contract entered into under section 8902 of this title shall contain provisions requiring carriers to—(1) furnish such reasonable reports as the Office determines to be necessary to enable it to carry out its functions under this chapter; and (2) permit the Office and representatives of the Government Accountability Office to examine records of the carriers as may be necessary to carry out the purposes of this chapter. (c) Each Government agency shall keep such records, make such certifications, and furnish the Office with such information and reports as may be necessary to enable the Office to carry out its functions under this chapter. (d) The Office, in consultation with the Department of Health and Human Services, shall develop and implement a system through which the carrier for an approved health benefits plan described by section 8903 or 8903a will be able to identify those annuitants or other individuals covered by such plan who are entitled to benefits under part A or B of title XVIII of the Social Security Act in order to ensure that payments under coordination of benefits with Medicare do not exceed the statutory maximums which physicians may charge Medicare enrollees.

5 U.S.C. § 8911 Advisory committee

The Director of the Office of Personnel Management shall appoint a committee composed of five members, who serve without pay, to advise the Office regarding matters of concern to employees under this chapter. Each member of the committee shall be an employee enrolled under this chapter or an elected official of an employee organization.

5 U.S.C. § 8912 Jurisdiction of courts

The district courts of the United States have original jurisdiction, concurrent with the United States Court of Federal Claims, of a civil action or claim against the United States founded on this chapter.

5 U.S.C. § 8913 Regulations

(a) The Office of Personnel Management may prescribe regulations necessary to carry out this chapter. (b) The regulations of the Office may prescribe the time at which and the manner and conditions under which an employee is eligible to enroll in an approved health benefits plan described by section 8903 or 8903a of this title. The regulations may exclude an employee on the basis of the nature and type of his employment or conditions pertaining to it, such as short-term appointment, seasonal or intermittent employment, and employment of like nature. The Office may not exclude—(1) an employee or group of employees solely on the basis of the hazardous nature of employment; (2) a teacher in the employ of the Board of Education of the District of Columbia, whose pay is fixed by section 1501 of title 31, District of Columbia Code, on the basis of the fact that the teacher is serving under a temporary appointment if the teacher has been so employed by the Board for a period or periods totaling not less than two school years; (3) an employee who is occupying a position on a part-time career employment basis (as defined in section 3401(2) of this title); or (4) an employee who is employed on a temporary basis and is eligible under section 8906a(a). (c) The regulations of the Office shall provide for the beginning and ending dates of coverage of employees, annuitants, members of their families, and former spouses under health benefits plans. The regulations may permit the coverage to continue, exclusive of the temporary extension of coverage described by section 8902(g) of this title, until the end of the pay period in which an employee is separated from the service, or until the end of the month in which an annuitant or former spouse ceases to be entitled to annuity, and in case of the death of an employee or annuitant, may permit a temporary extension of the coverage of members of his family for not to exceed 90 days. (d) The Secretary of Agriculture shall prescribe regulations to effect the application and operation of this chapter to an individual named by section 8901(1)(H) of this title.

5 U.S.C. § 8914 Effect of other statutes

Any provision of law outside of this chapter which provides coverage or any other benefit under this chapter to any individuals who (based on their being employed by an entity other than the Government) would not otherwise be eligible for any such coverage or benefit shall not apply with respect to any individual appointed, transferred, or otherwise commencing that type of employment on or after October 1, 1988.