§8903 — Title 5 Government Organization and Employees | U.S. Code

Summary

OPM can approve or contract for four kinds of health plans for federal employees, annuitants, and certain family members. One Government-wide plan may be run by affiliates in many States and must offer at least two levels of benefits for regular enrollees and at least two levels for Postal Service enrollees; under it a carrier usually pays providers under contract, and in some cases may pay the enrollee. One other Government-wide plan must offer two benefit levels and pays carriers amounts that do not exceed actual expenses for the benefit types listed in section 8904(2). OPM can also approve employee-organization plans that are run or sponsored by employee organizations and are only open to members and their families (see section 8901(8)(A)), and three kinds of prepaid plans: group-practice plans (at least three physicians in a shared center, covering needed specialties), individual-practice plans (individual doctors accept plan payments as full payment, including hospital, office, home, diagnostic, and preventive services, and must be offered by organizations with prior successful experience), and mixed plans that combine group and individual models.

Title 5, §8903

Government Organization and Employees — Source: USLM XML via OLRC

The Office of Personnel Management may contract for or approve the following health benefits plans:

(1)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)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 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)(A)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 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 which are a combination of the type of plans described in subparagraph (A) and the type of plans described in subparagraph (B).

Notes & Related Subsidiaries

Historical and Revision Notes

DerivationU.S. CodeRevised Statutes andStatutes at Large 5 U.S.C. 3003.Sept. 28, 1959, Pub. L. 86–382, § 4, 73 Stat. 711. July 8, 1963, Pub. L. 88–59, § 1(b), 77 Stat. 77. Standard changes are made to conform with the definitions applicable and the style of this title as outlined in the preface to the report.

Editorial Notes

Amendments

2022—Par. (1). Pub. L. 117–108 substituted “at least 2 levels of benefits for enrollees under this chapter generally and at least 2 levels of benefits for enrollees under the Postal Service Health Benefits Program established under section 8903c” for “two levels of benefits”. 1998—Par. (1). Pub. L. 105–266 substituted “plan, which may be underwritten by participating affiliates licensed in any number of States,” for “plan,”. 1988—Par. (1). Pub. L. 100–654 substituted “former spouses, or persons having continued coverage under section 8905a of this title,” for “or former spouses,” and “former spouse, or person having continued coverage under section 8905a of this title.” for “or former spouse.” 1986—Par. (4)(A). Pub. L. 99–251, § 102, amended second sentence generally, substituting “at least 3 physicians” for “physicians representing at least three major medical specialties” and inserted “and who represent 1 or more medical specialties appropriate and necessary for the population proposed to be served by the plan”. Par. (4)(C). Pub. L. 99–251, § 111, added subpar. (C). 1985—Par. (3). Pub. L. 99–53 inserted “described in section 8901(8)(A) of this title” after “employee organizations”. 1984—Par. (1). Pub. L. 98–615, § 3(3), substituted “employees, annuitants, members of their families, or former spouses” for “employees or annuitants, or members of their families” and “employee, annuitant, family member, or former spouse” for “employee or annuitant or member of his family”. 1978—Pub. L. 95–454 substituted “Office of Personnel Management” and “Office” for “Civil Service Commission” and “Commission”, respectively, wherever appearing.

Statutory Notes and Related Subsidiaries

Effective Date

of 1988 AmendmentAmendment by Pub. L. 100–654 applicable with respect to any calendar year beginning, and contracts entered into or renewed for any calendar year beginning, after end of 9-month period beginning Nov. 14, 1988, and with respect to any qualifying event occurring on or after first day of first calendar year beginning after end of such 9-month period, see section 203 of Pub. L. 100–654, set out as a note under section 8902 of this title.

Effective Date

of 1984 AmendmentAmendment by Pub. L. 98–615 effective May 7, 1985, with enumerated exceptions, and applicable to any individual who is married to an employee or annuitant on or after that date, see section 4(a)(2) of Pub. L. 98–615, as amended, set out as a note under section 8341 of this title.

Effective Date

of 1978 AmendmentAmendment by Pub. L. 95–454 effective 90 days after Oct. 13, 1978, see section 907 of Pub. L. 95–454, set out as a note under section 1101 of this title.

§8903 Health benefits plans

Summary

Title 5, §8903

Notes & Related Subsidiaries

Historical and Revision Notes

Editorial Notes

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Effective Date

Effective Date

Citations & Metadata