Federal Employees Health Benefits Program: Debarment

OFFICE OF PERSONNEL MANAGEMENT

5 CFR Part 890

RIN 3206-AG03

Federal Employees Health Benefits Program: Debarment

AGENCY: Office of Personnel Management.

ACTION: Interim regulations with request for comments.

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SUMMARY: The Office of Personnel Management (OPM) is issuing interim

regulations to incorporate into regulations the statutory requirement

that carriers in the Federal Employees Health Benefits (FEHB) Program

may not deny claims for services or supplies due to the debarment of

the providers who supplied them if the claimants could not have known

that the provider was debarred. The purpose of these regulations is to

comply with the provision of law that requires OPM to prescribe

regulations on this issue.

DATES: These interim regulations are effective June 9, 1994. Comments

must be received on or before July 11, 1994.

ADDRESSES: Written comments may be sent to Lucretia F. Myers, Assistant

Director for Insurance Programs, Retirement and Insurance Group, Office

of Personnel Management, P.O. Box 57, Washington, DC 20044, or

delivered to OPM, room 3415, 1900 E Street NW., Washington, DC.

FOR FURTHER INFORMATION CONTACT:

Margaret Sears (202) 606-0191.

SUPPLEMENTARY INFORMATION: On October 30, 1989, OPM published interim

regulations in the Federal Register (54 FR 43939) implementing title I

of Public Law 100-654, which allowed OPM to exclude from further

participation in the FEHB Program any health care provider (1)

convicted of fraud or various other cited examples of unethical

professional conduct, or (2) determined by OPM to have committed

various cited offenses against the FEHB Program.

Public Law 100-654 contained a provision requiring OPM to prescribe

regulations allowing payment of claims for service or supplies

furnished by debarred providers if the claimant could not reasonably

have known of the debarment. This issue was inadvertently not addressed

by the regulations published October 30, 1989. Therefore, in compliance

with the requirements of 5 U.S.C. 8902a(i) OPM is now issuing these

interim regulations.

Under these interim regulations, carriers cannot deny claims based

on debarment if there was no reasonably way the claimant could have

known that the provider was debarred. When an individual who has not

previously been notified of a provider's debarment, submits a claim for

services or supplies furnished by a debarred provider, the carrier must

(1) honor the claim under the terms of its contract with OPM, and (2)

inform the individual about the debarment of the provider and the

minimum period of time remaining under the terms of the debarment.

In practical terms, this generally means that the first claim(s) an

enrollee submits for services or supplies received after a provider has

been debarred, but before the enrollee has been informed of the

debarment, is (are) paid to the same extent it (they) would have been

paid had the provider not been debarred. The carrier must, at the same

time, inform the enrollee concerning the debarment. The carrier will

deny any subsequent claims for service or supplies furnished during the

period the provider is debarred.

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

rulemaking because this regulation primarily affects Federal employees

and annuitants and merely incorporates statutory requirements into

regulation.

Regulatory Flexibility Act

I certify that these regulations will not have a significant

economic impact on a substantial number of small entities because it

primarily affects Federal employees and annuitants.

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, Reporting

and recordkeeping requirements, Retirement.

U.S. Office of Personnel Management.

Lorraine A. Green,

Deputy 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.

2. In subpart J, a new Sec. 890.1006 is added to read as follows:

Sec. 890.1006 Payment of claims for service or supplies furnished by

debarred providers.

Health plans may not deny claims for services or supplies based on

debarment of the provider under this subpart if the claimant did not

know or could not reasonably be expected to have known of the

debarment. In any such instance, the carrier involved must 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.

[FR Doc. 94-11164 Filed 5-9-94; 8:45 am]

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