[Code of Federal Regulations]
[Title 5, Volume 2]
[Revised as of January 1, 2005]
From the U.S. Government Printing Office via GPO Access
[CITE: 5CFR890.904]

[Page 483]
 
                    TITLE 5--ADMINISTRATIVE PERSONNEL
 
          CHAPTER I--OFFICE OF PERSONNEL MANAGEMENT (CONTINUED)
 
PART 890_FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM--Table of Contents
 
 Subpart I_Limit on Inpatient Hospital Charges, Physician Charges, and 
                          FEHB Benefit Payments
 
Sec. 890.904  Determination of FEHB benefit payment.

    (a) The FEHB plan's benefit payment for inpatient hospital services 
under this subpart is the amount calculated by the FEHB plan, using 
information and instructions provided by the Department of Health and 
Human Services (HHS) and guidelines specified by OPM, as equivalent to 
the Medicare Part A payment under the DRG-based PPS (this is, the amount 
payable before the Medicare deductible, coinsurance and lifetime limits 
are applied), reduced by any FEHB plan deductible, coinsurance, 
copayment, or preadmission certification penalty that is the 
responsibility of the retired enrolled individual.
    (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.

[58 FR 38663, July 20, 1993, as amended at 60 FR 26668, May 18, 1995]