(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 Approval of a plan may be withdrawn only after notice and opportunity for hearing to the carrier concerned without regard to subchapter II of chapter 5 and chapter 7 of this title.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) 1 of title XIII of the Public Health Service Act (42 U.S.C. 300c–9(d)).
(m)(1) The terms of any contract under this chapter which relate to the nature, provision, or extent of coverage or benefits (including payments with respect to benefits) shall supersede and preempt any State or local law, or any regulation issued thereunder, which relates to health insurance or plans.
(2)(A) Notwithstanding the provisions of paragraph (1) of this subsection, if a contract under this chapter provides for the provision of, the payment for, or the reimbursement of the cost of health services for the care and treatment of any particular health condition, the carrier shall provide, pay, or reimburse up to the limits of its contract for any such health service properly provided by any person licensed under State law to provide such service if such service is provided to an individual covered by such contract in a State where 25 percent or more of the population is located in primary medical care manpower shortage areas designated pursuant to section 332 of the Public Health Service Act (42 U.S.C. 254e).
(B) The provisions of subparagraph (A) shall not apply to contracts entered into providing prepayment plans described in section 8903(4) of this title.
(n) A contract for a plan described by section 8903(1), (2), or (3), or section 8903a, shall require the carrier—
(1) to implement hospitalization-cost-containment measures, such as measures—
(A) for verifying the medical necessity of any proposed treatment or surgery;
(B) for determining the feasibility or appropriateness of providing services on an outpatient rather than on an inpatient basis;
(C) for determining the appropriate length of stay (through concurrent review or otherwise) in cases involving inpatient care; and
(D) involving case management, if the circumstances so warrant; and
(2) to establish incentives to encourage compliance with measures under paragraph (1).
(o) A contract may not be made or a plan approved which includes coverage for any benefit, item, or service for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.
(Pub. L. 89–554, Sept. 6, 1966, 80 Stat. 601; Pub. L. 93–246, §3, Jan. 31, 1974, 88 Stat. 4; Pub. L. 93–363, §1, July 30, 1974, 88 Stat. 398; Pub. L. 94–183, §2(43), Dec. 31, 1975, 89 Stat. 1059; Pub. L. 94–460, title I, §110(b), Oct. 8, 1976, 90 Stat. 1952; Pub. L. 95–368, §1, Sept. 17, 1978, 92 Stat. 606; Pub. L. 95–454, title IX, §906(a)(2), (3), Oct. 13, 1978, 92 Stat. 1224; Pub. L. 96–179, §3, Jan. 2, 1980, 93 Stat. 1299; Pub. L. 98–615, §3(2), Nov. 8, 1984, 98 Stat. 3203; Pub. L. 99–53, §2(a), June 17, 1985, 99 Stat. 94; Pub. L. 99–251, title I, §§105(b), 106(a)(3), Feb. 27, 1986, 100 Stat. 15, 16; Pub. L. 100–202, §101(m) [title VI, §626], Dec. 22, 1987, 101 Stat. 1329–390, 1329–430; Pub. L. 100–654, title II, §§201(b), 202(a), Nov. 14, 1988, 102 Stat. 3845; Pub. L. 101–508, title VII, §7002(a), Nov. 5, 1990, 104 Stat. 1388–329; Pub. L. 101–509, title IV, §1, Nov. 5, 1990, 104 Stat. 1421; Pub. L. 102–393, title V, §537(a), (b), Oct. 6, 1992, 106 Stat. 1765; Pub. L. 105–12, §9(g), Apr. 30, 1997, 111 Stat. 27; Pub. L. 105–266, §§3(c), 8, Oct. 19, 1998, 112 Stat. 2366, 2370; Pub. L. 111–350, §5(a)(15), Jan. 4, 2011, 124 Stat. 3842.)
| Derivation | U.S. Code | Revised Statutes and Statutes at Large |
|---|---|---|
| 5 U.S.C. 3005. | Sept. 28, 1959, Pub. L. 86–382, §6, 73 Stat. 712. | |
| Mar. 17, 1964, Pub. L. 88–284, §1(7)–(9), 78 Stat. 165. |
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Last modified: October 26, 2015