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§ 890.903 - Covered services.

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The limitation on the charges and FEHB benefit payments for inpatient hospital services apply to inpatient hospital services which are:

Covered under both Medicare part A and the retired enrolled individual's FEHB plan; and

Supplied to a retired enrolled individual who does not have Medicare part A; and

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).

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:

Covered under both Medicare part B and the retired enrolled individual's FEHB plan; and

Supplied to a retired enrolled individual who does not have Medicare part B.

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§ 890.902 - Definition.
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§ 890.904 - Determination of FEHB benefit payment.