§890.114. Surprise billing and transparency.
5 C.F.R. § 890.114
A carrier must comply with requirements described in 26 CFR 54.9816-3, 54.9816-6A, 54.9816-6, 54.9816-8, 54.9816-9, 54.9817-2; 29 CFR 2590.716-3 through 2590.716-6, 2590.716-6A, 2590.716-8, 2590.717-1, 2590.717-2, 2590.722, 2590.725-1 through 2590.725-4; and 45 CFR 149.30, 149.100, 149.110 through 149.140, 149.310, 149.510 through 530, and 149.710 through 149.740 in the same manner as such provisions apply to a group health plan or health insurance issuer offering group or individual health insurance coverage, subject to 5 U.S.C. 8902(m)(1), and the provisions of the carrier's contract. For purposes of application of such sections, all carriers are deemed to offer health benefits in the large group market.
For purposes of the provisions referenced in paragraph (a) of this section— Group health plan or plan shall mean a “health benefits plan” defined at 5 U.S.C. 8901(6), which is a Federal governmental plan offered pursuant to 5 U.S.C. chapter 89.
Health insurance issuer or issuer shall include a carrier defined at 5 U.S.C. 8901(7). Where the carrier for a health benefits plan is a voluntary association, an association of organizations or entities, or is otherwise comprised of multiple entities, each entity is responsible for compliance in the same manner as such sections apply to group health plans and issuers. If and to the extent an entity offering a health benefits plan under 5 U.S.C. chapter 89 is licensed under state law and is properly considered an issuer as defined at section 2791 of the Public Health Service Act, the entity is considered a carrier to the extent of its FEHB health benefits plan contractual and regulatory compliance.
Participant, beneficiary, or enrollee shall include an “enrollee” or “covered individual” as defined by 5 CFR 890.101, as appropriate.
When a complaint challenges a carrier's action or inaction with respect to the surprise billing provisions, OPM will coordinate with the Departments of Health and Human Services, Labor, and the Treasury to resolve the complaint.
In addition to notification to the Department per 26 CFR 54.9816-8T(b)(2)(iii), 29 CFR 2590.716-8(b)(2)(iii), and 45 CFR 149.510(b)(2)(iii), a carrier must notify the Director of its initiation of the Federal IDR process, or its receipt of written notice that a provider, facility, or provider of air ambulance services has initiated the Federal IDR process, upon sending or receiving such notice.
The Director will coordinate with the Departments in resolving matters under 26 CFR 54.9816-8T(c)(4)(vii)(A)(1), 29 CFR 2590.716-8(c)(4)(vii)(A)(1), or 45 CFR 149.510(c)(4)(vii)(A)(1) where fraud or material misrepresentation are presented, and matters involving 26 CFR 54.9816-8T(c)(4)(vii)(A)(2), 29 CFR 2590.716-8(c)(4)(vii)(A)(2), and 45 CFR 149.510(c)(4)(vii)(A)(2). The Director will coordinate with the Departments in oversight of reports submitted by certified IDR entities with respect to carriers pursuant to 26 CFR 54.9816-8T(f), 29 CFR 2590.716-8(f), or 45 CFR 149.510(f).
[Reserved]
The Director will coordinate with the Departments in oversight of prescription drug and health care spending with respect to FEHB carriers pursuant to 45 CFR 149.710 through 149.740.
Notes, amendments, and revision history
Amendments
[86 FR 36947, July 13, 2021, as amended at 86 FR 56092, Oct. 7, 2021; 86 FR 66696, Nov. 23, 2021; 91 FR 34046, June 4, 2026]
Authority
Authority: 5 U.S.C. 8913. Sec. 890.102 also issued under sections 11202(f), 11232(e), and 11246(b) of Pub. L. 105-33, 111 Stat. 251. Sec. 890.111 also issued under 36 U.S.C. 5522. Sec. 890.112 also issued under 2 U.S.C. 2051. Sec. 890.113 also issued under section 1110 of Pub. L. 116-92, 133 Stat. 1198 (5 U.S.C. 8702 note). Sec. 890.301 also issued under 26 U.S.C. 9801. Sec. 890.302(b) also issued under 42 U.S.C. 300gg-14. Sec. 890.803 also issued under 50 U.S.C. 3516 (formerly 50 U.S.C. 403p); 22 U.S.C. 4069c and 4069c-1. Subpart L also issued under section 599C of Pub. L. 101-513, 104 Stat. 2064 (5 U.S.C. 5561 note). Subpart M also issued under 10 U.S.C. 1108; 25 U.S.C. 1647b. Subpart P also issued under 5 U.S.C. 8903c.
Source
Source: 33 FR 12510, Sept. 4, 1968, unless otherwise noted.
Amendments
[86 FR 36947, July 13, 2021, as amended at 86 FR 56092, Oct. 7, 2021; 86 FR 66696, Nov. 23, 2021; 91 FR 34046, June 4, 2026]