Title 5, Part 890 — Federal Employees Health Benefits Program

Definitions; time computations.

Coverage.

Correction of errors.

Initial decision and reconsideration on enrollment.

Filing claims for payment or service.

Carrier entitlement to pursue subrogation and reimbursement recoveries.

Court review.

Will OPM waive requirements for continued coverage during retirement?

Exclusion of certain periods of eligibility when determining continued coverage during retirement.

Enrollment reconciliation.

Continuation of eligibility for former Federal employees of the Civilian Marksmanship Program.

Continuation of coverage for certain Senate Restaurants employees.

Designation of FEHB Program services as emergency services under the Antideficiency Act.

Surprise billing and transparency.

Special provisions for Postal Service employees, Postal Service annuitants, and their eligible family members.

Minimum standards for health benefits plans.

Minimum standards for health benefits carriers.

Application for approval of, and proposal of amendments to, health benefit plans.

Withdrawal of approval of health benefits plans or carriers.

Nonrenewal of contracts of health benefits plans.

Opportunities for employees to enroll or change enrollment; effective dates.

Coverage of family members.

Continuation of enrollment.

Termination of enrollment.

Reinstatement of enrollment after military service.

When can annuitants or survivor annuitants change enrollment or reenroll and what are the effective dates?

Waiver or suspension of annuity or compensation.

Disenrollment and removal from enrollment.

Temporary extension of coverage and conversion.

Government contributions.

Withholdings, contributions, LWOP, premiums, and direct premium payment.

Reserves.

Disposition of contingency reserves upon reorganization or merger of plans.

Recurring premium payments to carriers.

Coverage.

Opportunity to change enrollment.

Effective date.

[Reserved]

Persons confined on effective date.

Introduction.

Definition.

Who may enroll.

Coverage.

Application time limitations.

When can former spouses change enrollment or reenroll and what are the effective dates?

When do enrollments terminate, cancel or suspend?

Employing office responsibilities.

Purpose.

Definition.

Covered services.

Determination of FEHB benefit payment.

Limits on inpatient hospital and physician charges.

Retired enrolled individuals coinsurance payments.

Effective dates.

Notification of HHS.

End-of-year settlements.

Provider information.

Scope and purpose.

Use of terminology.

Definitions.

Bases for mandatory debarments.

Time limits for OPM to initiate mandatory debarments.

Notice of proposed mandatory debarment.

Minimum length of mandatory debarments.

Mandatory debarment for longer than the minimum length.

Contesting proposed mandatory debarments.

Debarring official's decision of contest.

Bases for permissive debarments.

Time limits for OPM to initiate permissive debarments.

Deciding whether to propose a permissive debarment.

Notice of proposed permissive debarment.

Minimum and maximum length of permissive debarments.

Aggravating and mitigating factors used to determine the length of permissive debarments.

Determining length of debarment based on revocation or suspension of a provider's professional licensure.

Determining length of debarment for an entity owned or controlled by a sanctioned provider.

Determining length of debarment based on ownership or control of a sanctioned entity.

Determining length of debarment based on false, wrongful, or deceptive claims.

Determining length of debarment based on failure to furnish information needed to resolve claims.

Contesting proposed permissive debarments.

Information considered in deciding a contest.

Standard and burden of proof for deciding contests.

Cases where additional fact-finding is not required.

Procedures if a fact-finding proceeding is not required.

Cases where an additional fact-finding proceeding is required.

Conducting a fact-finding proceeding.

Deciding a contest after a fact-finding proceeding.

Effect of a suspension.

Grounds for suspension.

Length of suspension.

Notice of suspension.

Counting a period of suspension as part of a subsequent debarment.

Provider contests of suspensions.

Information considered in deciding a contest.

Cases where additional fact-finding is not required.

Deciding a contest without additional fact-finding.

Cases where additional fact-finding is required.

Conducting a fact-finding proceeding.

Deciding a contest after a fact-finding proceeding.

Effective dates of debarments.

Effect of debarment on a provider.

Entities notified of OPM-issued debarments and suspensions.

Informing persons covered by FEHBP about debarment or suspension of their provider.

Effect of debarment or suspension on payments for services furnished in emergency situations.

Special rules for institutional providers.

Waiver of debarment for a provider that is the sole source of health care services in a community.

Claims for non-emergency items or services furnished by a debarred or suspended provider.

Exception to a provider's debarment for an individual enrollee.

Applying for reinstatement when period of debarment expires.

Reinstatements without application.

Table of procedures and effective dates for reinstatements.

Agencies and entities to be notified of reinstatements.

Contesting a denial of reinstatement.

Purpose and scope of civil monetary penalties and assessments.

Bases for penalties and assessments.

Deciding whether to impose penalties and assessments.

Maximum amounts of penalties and assessments.

Determining the amounts of penalties and assessments to be imposed on a provider.

Deciding whether to suspend or debar a provider in a case that also involves penalties and assessments.

Notice of proposed penalties and assessments.

Provider contests of proposed penalties and assessments.

Effect of not contesting proposed penalties and assessments.

Information the debarring official must consider in deciding a provider's contest of proposed penalties and assessments.

Deciding contests of proposed penalties and assessments.

Further appeal rights after final decision to impose penalties and assessments.

Collecting penalties and assessments.

Purpose.

Definitions.

Eligibility.

Notification by agency.

Initial election of temporary continuation of coverage; application time limitations and effective dates.

Coverage.

Length of temporary continuation of coverage.

Opportunities to change enrollment; effective dates.

Premium payments.

Termination of enrollment or coverage.

Employing office responsibilities.

Denial of continuation of coverage due to involuntary separation for gross misconduct.

The administrative charge.

Purpose.

Definitions.

Coverage.

Effective date of coverage.

Change in type of enrollment.

Cancellation of coverage.

Termination of coverage.

Premiums.

Responsibilities of the U.S. Department of State.

Reconsideration and appeal rights.

Purpose.

Duration.

Eligibility.

Enrollment.

Termination and cancellation.

Government premium contributions.

Data collection.

Carrier participation.

Purpose.

Definitions and deemed references.

Tribal employer purchase of FEHB requires current deposit of premium payment and timely payment of administrative fee.

Tribal employer election and agreement to purchase FEHB.

Tribal employees eligible for enrollment.

Correction of enrollment errors.

Enrollment process; effective dates.

Change in enrollment type, plan, or option.

Cancellation of coverage or decreases in enrollment.

Termination of enrollment and 31-day temporary extension of coverage; and conversion to individual policy.

Temporary Continuation of Coverage (TCC).

Non-pay status, insufficient pay, or change to ineligible position.

Premiums and administrative fee.

Responsibilities of the tribal employer.

Reconsideration of enrollment and eligibility decisions and appeal rights.

Filing claims for payment or service and court review.

No continuation of FEHB enrollment into retirement from employment with a tribal employer.

No continuation of FEHB enrollment in compensationer status past 365 days.

Purpose.

Definitions and deemed references.

Eligibility for the Postal Service Health Benefits Program.

Medicare enrollment requirement for certain Postal Service annuitants and eligible family members.

Enrollment in the initial contract year.

Opportunities to enroll, change enrollment, or reenroll; effective dates.

Initial decision and reconsideration.

Disenrollment, removal, termination, cancellation, and suspension.

Temporary extension of coverage, conversion, or temporary continuation of coverage.

Minimum standards for PSHB Program plans and Carriers.

Withdrawal of approval of health benefits plan or carrier.

Information sharing.

Postal Service contract year beginning date, Medicare late enrollment penalty, calculations for the Postal Service Retiree Health Benefits Fund, and clarification of statutory terms.

Other administrative provisions.

Crediting separate reserves for PSHB.

Medicare Part D.