[Federal Register Volume 60, Number 96 (Thursday, May 18, 1995)]
[Rules and Regulations]
[Pages 26667-26668]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-12169]
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Rules and Regulations
Federal Register
________________________________________________________________________
This section of the FEDERAL REGISTER contains regulatory documents
having general applicability and legal effect, most of which are keyed
to and codified in the Code of Federal Regulations, which is published
under 50 titles pursuant to 44 U.S.C. 1510.
The Code of Federal Regulations is sold by the Superintendent of Documents.
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Federal Register / Vol. 60, No. 96 / Thursday, May 18, 1995 / Rules
and Regulations
[[Page 26667]]
OFFICE OF PERSONNEL MANAGEMENT
5 CFR Part 890
RIN 3206-AG31
Federal Employees Health Benefits Program: Limitation on
Physician Charges and FEHB Program Payments
AGENCY: Office of Personnel Management.
ACTION: Interim regulation with request for comments.
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SUMMARY: The Office of Personnel Management (OPM) is issuing an interim
regulation that amends current Federal Employee Health Benefits (FEHB)
Program regulations to require that the charges and FEHB fee-for-
service plans' benefit payments for certain physician services
furnished to retired enrolled individuals do not exceed the limits on
charges and payments established under the Medicare fee schedule for
physician services. The regulation authorizes the FEHB plans, under the
oversight of OPM, to notify the Secretary of Health and Human Services
(HHS) of a Medicare participating hospital, physician or supplier who
knowingly and willfully fails to accept, on a repeated basis, the
Medicare rate as payment in full from an FEHB plan. The regulation also
authorizes the FEHB plans, under the oversight of OPM, to notify the
Secretary of HHS of a Medicare nonparticipating physician or supplier
who knowingly and willfully charges, on a repeated basis, more than the
Medicare limiting charge amount (115 percent of the Medicare
Nonparticipating Physician Fee Schedule amount).
DATES: This interim regulation is effective May 18, 1995. Comments must
be received on or before July 17, 1995.
ADDRESSES: Send written comments to Lucretia F. Myers, Assistant
Director for Insurance Programs, Retirement and Insurance Group, Office
of Personnel Management, 1900 E Street, NW., Washington, DC 20415; or
FAX to (202) 606-0633.
FOR FURTHER INFORMATION CONTACT:
Robert G. Iadicicco (202) 606-0004.
SUPPLEMENTARY INFORMATION: Section 11003 of the Omnibus Budget
Reconciliation Act (OBRA) of 1993, Pub. L. 103-66, amended the FEHB law
to limit the charges and FEHB fee-for-service plans' benefit payments
for certain physician services (as defined in section 1848(j) of the
Social Security Act) received by retired enrolled individuals.
The OBRA of 1993 provision is related to section 7002(f) of OBRA of
1990, Pub. L. 101-508. The OBRA of 1990 provision limited the charges
and FEHB fee-for-service plans' benefit payments for certain inpatient
hospital services received by retired enrolled individuals. OPM
implemented the OBRA of 1990 provision by issuing interim and final
regulations in the March 27, 1992, and July 20, 1993, issues of the
Federal Register (57 FR 10609 and 58 FR 38661). This interim regulation
amends the previous regulations.
The interim regulation expands the definition of a retired enrolled
individual to include individuals who are not enrolled in Medicare part
B.
The interim regulation specifies the physician services covered by
the limitation on charges and benefit payments.
The interim regulation establishes how FEHB fee-for-service plans
will determine benefit payments for physician services covered by the
limitation. The plans will base their payment on the lower of the
actual charge of the provider or the amount determined to be equivalent
to the Medicare part B payment under the Medicare Participating
Physician Fee Schedule for Medicare participating physicians and the
Medicare Nonparticipating Physician Fee Schedule for Medicare
nonparticipating physicians. Retired enrolled individuals' coinsurance
payments will be based on the same amount.
The interim regulation specifies the limits on what providers can
collect for both inpatient hospital services and physician services.
OPM has not required fee-for-service plans with an insufficient
number of affected enrollees to apply the limits on physician services.
We made this determination in keeping with OBRA of 1993's primary
objective of reducing expenses.
The interim regulation authorizes the FEHB plans, under the
oversight of OPM, to notify the Secretary of Health and Human Services
(HHS) or the Secretary's designee when a medical provider knowingly and
willfully collects, on a repeated basis, more than the applicable
limits for inpatient hospital services or physician services. OPM
strongly encourages and supports the efforts of FEHB plans to inform
retired enrolled individuals and medical providers of the limits on
charges and benefit payments, monitor compliance with the limits, and,
if necessary, report repeat violators to the Secretary of HHS, or the
Secretary's designee.
Waiver of Notice of Proposed Rulemaking
Pursuant to section 553(b)(3)(B) of title 5 of the U.S. Code, I
find that good cause exists for waiving the general notice of proposed
rulemaking and making this regulation effective upon publication. The
notice is being waived because the limitation on FEHB plans' benefit
payments and providers' charges enacted by Pub. L. 103-66 addressed in
this regulation was effective with respect to the contract year
beginning on January 1, 1995.
Regulatory Flexibility Act
I certify that these regulations will not have a significant
economic impact on a substantial number of small entities because they
primarily affect the health care coverage of Federal annuitants and
former spouses.
E.O. 12866, Regulatory Review
This rule has been reviewed by OMB in accordance with E.O. 12866.
List of Subjects in 5 CFR Part 890
Administrative practice and procedure, Government employees, Health
facilities, Health insurance, Health professions, Hostages, Iraq,
Kuwait, Lebanon, Reporting and recordkeeping requirements, Retirement.
[[Page 26668]] Office of Personnel Management.
James B. King,
Director.
Accordingly, OPM is amending 5 CFR part 890 as follows:
PART 890--FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
1. The authority citation for part 890 continues to read as
follows:
Authority: 5 U.S.C. 8913; Sec. 890.803 also issued under 50
U.S.C. 403p, 22 U.S.C. 4069c and 4069c-1; subpart L also issued
under sec. 599C of Pub. L. 101-513, 104 Stat. 2064, as amended.
2. The heading of subpart I is revised to read as follows:
Subpart I--Limit on Inpatient Hospital Charges, Physician Charges,
and FEHB Benefit Payments
3. Section 890.901 is revised to read as follows:
Sec. 890.901 Purpose.
This subpart identifies the individuals whose charges and FEHB
benefit payments for inpatient hospital services and/or physician
services may be limited and sets forth the circumstances of the limit.
4. Section 890.902 is amended by revising paragraphs (c) and (d) to
read as follows:
Sec. 890.902 Definition.
* * * * *
(c) Is age 65 or older or becomes age 65 while receiving inpatient
hospital services or physician services; and
(d) Is not covered by Medicare part A and/or part B.
5. Section 890.903 is revised to read as follows:
Sec. 890.903 Covered services.
(a) The limitation on the charges and FEHB benefit payments for
inpatient hospital services apply to inpatient hospital services which
are:
(1) Covered under both Medicare part A and the retired enrolled
individual's FEHB plan; and
(2) Supplied to a retired enrolled individual who does not have
Medicare part A; and
(3) Provided by hospital providers who have in force participation
agreements with the Secretary of Health and Human Services (HHS)
consistent with sections 1814(a) and 1866 of the Social Security Act,
and receive Medicare part A payments in accordance with the diagnosis
related group (DRG) based prospective payment system (PPS).
(b) The limitation on the charges and FEHB benefit payments for
physician services apply to physician services, (as defined in section
1848(j) of the Social Security Act), which are:
(1) Covered under both Medicare part B and the retired enrolled
individual's FEHB plan; and
(2) Supplied to a retired enrolled individual who does not have
Medicare part B.
6. Section 890.904 is amended by designating the current paragraph
as paragraph (a), amending newly designated paragraph (a) by adding the
words ``for inpatient hospital services'' after the words ``FEHB plan's
benefit payment'', and by adding paragraph (b) to read as follows:
Sec. 890.904 Determination of FEHB benefit payment.
* * * * *
(b) The FEHB plan's benefit payment for physician services under
this subpart is determined by taking the lower of the following
amounts:
(1) The amount determined by the FEHB plan, which is equivalent to
the Medicare part B payment under the Medicare Participating Physician
Fee Schedule for Medicare participating physicians and the Medicare
Nonparticipating Physician Fee Schedule for Medicare nonparticipating
physicians (the amount payable before the Medicare deductible and
coinsurance are applied); or
(2) The actual billed charges; and
(3) Reducing the lower amount by any FEHB plan deductible,
coinsurance, or copayment that is the responsibility of the retired
enrolled individual.
7. Section 890.905 is revised to read as follows:
Sec. 890.905 Limits on inpatient hospital and physician charges.
(a) Hospitals may not collect from FEHB plans and retired enrolled
individuals for inpatient hospital services more than the amount
determined to be equivalent to the Medicare part A payment under the
DRG-based PPS.
(b) Medicare participating providers may not collect for FEHB plans
and retired enrolled individuals for physician services more than the
amount determined to be equivalent to the Medicare part B payment under
the Medicare Participating Physician Fee Schedule.
(c) Medicare nonparticipating providers may not collect from FEHB
plans and retired enrolled individuals for physician services more than
the amount to be equivalent to the Medicare limiting charge amount.
8. Section 890.906 is redesignated as Sec. 890.909 and a new
Sec. 890.906 is added to read as follows:
Sec. 890.906 Retired enrolled individuals coinsurance payments.
(a) A retired enrolled individual's coinsurance responsibility for
inpatient hospital services is calculated in accordance with the plan's
contractual benefit structure and is based on the amount determined to
be equivalent to the Medicare part A payment under the DRG-based PPS.
(b) A retired enrolled individual's coinsurance responsibility for
physician services is calculated in accordance with the plan's
contractual benefit structure and is based on the lower of the actual
charges or the amount determined to be equivalent to the Medicare part
B payment under the Medicare Participating Physician Fee Schedule for
Medicare participating physicians and the Medicare Nonparticipating
Physician Fee Schedule for Medicare nonparticipating physicians.
9. Section 890.907 is redesignated as Sec. 890.910 and a new
Sec. 890.907 is added to read as follows:
Sec. 890.907 Effective dates.
(a) The limitation specified in this subpart applies to inpatient
hospital admissions commencing on or after January 1, 1992.
(b) The limitation specified in this subpart applies to physician
services supplied on or after January 1, 1995.
10. Section 890.908 is added to read as follows:
Sec. 890.908 Notification of HHS.
An FEHB plan, under the oversight of OPM, will notify the Secretary
of HHS, or the Secretary's designee, if the plan finds that:
(a) A hospital knowingly and willfully collects, on a repeated
basis, more than the amount determined to be equivalent to the Medicare
part A payment under the DRG-based PPS.
(b) A Medicare participating physician or supplier knowingly and
willfully collects, on a repeated basis, more than the amount
determined to be equivalent to the Medicare part B payment under the
Medicare Participating Physician Fee Schedule.
(c) A Medicare nonparticipating physician or supplier knowingly and
willfully charges, on a repeated basis, more than the amount determined
to be equivalent to the Medicare limiting charge amount.
[FR Doc. 95-12169 Filed 5-17-95; 8:45 am]
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