FEHB LAW (5 U.S.C. 8904(B)),
I retired at age 65 from fed govt. I have FEHB blue cross/blue shield (BCBS) and Medicare Plan A only. The following info is for those who are unaware (I only found out about because it was written on my recent Explanation of Benefits (EOB) for claims made to my BCBS ins:
"Under FEHB LAW (5 U.S.C. 8904(B)), when services are provided by Medicare Participating Provider, they are required to base their payment on Medicare Fee Schedule Amount or the providers charge, whichever is less. This law applies to services provided to fed retirees and annuitants who are 65 or older AND who are not enrolled in Medicare Plan B. Because the FEHB law is applied to these services, the No Surprises Act and its independent dispute resolution (IDR) are not applicable even if they otherwise would be. You are not responsible for any amounts for covered services over the Medicare Fee Schedule amount."
Keep in mind that 90% of today's doctors do opt to be a Medicare Participating Provider (except maybe doctors like psychiatrists or cosmetic surgeons). I think most of them participate because its guaranteed payment I'm when the file claim with ins company, even if the amount is way less than their submitted claim. They probably figure it's better than not getting paid at all due to a lot of folks being un-insured.
Anyway, just to give you an idea of how this whole thing worked out for me, I recently had a small surgical procedure performed at a Medstar surgical center. The surgeon initially showed an estimated billing of $8K but submitted a claim to BCBS for $1281 because this doctor was a Medicare Participating Provider. But he only received $476. Yep its shown on my EOB. Also the surgical center (non-hospital center) where the procedure was performed filed a very high claim for the use of their facility, however due to that FEHB law, they were paid a lower amount. I still had to make a co-payment of $200 for use of surgical center (according to BCBS plan). Additionally, there were other claims filed from other surgical team members, such as lab technician and anesthesiologist, but yet again because of that FEHB law specific to Medicare Participating Providers that provide services to federal retirees 65 and older, I didn't have to pay another dime to the others. So bottomline? Entire total of claims filed for that one hour surgical procedure (a small lipoma removal) was at least $10k but I only came out of pocket with a copayment for use of surgical facility. Keep in mind I do not have Medicare Plan B, however that FEHB law 5 USC 8904(B) operates like I do.