General Requirements

30.3.1 - General Requirements (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) Non-employer PFFS plans that are operating in a network area (as defined in section 1852(d)(5)(B) of the Act) must meet the access to services requirements through signed contracts with providers. These plans must establish signed contracts or agreements with a sufficient number and range of health care providers in their service area for all categories of Part A and Part B services in accordance with the access standards described in 1851(d)(1) of the Act and section 30.2 of this chapter. Non-employer PFFS plans operating in network areas will not be allowed to meet the access to services requirement by establishing payment rates that are not less than the rates that apply under Original Medicare for a particular category of provider and having providers deemed to be contracted under the plan as provided under 42 CFR 422.216(f) and described in section 40.2 of this chapter. Consequently, these plans must operate as full network PFFS plans, instead of non-network or partial network plans. While a non-employer PFFS plan operating in a network area must meet the access to services requirement by establishing signed contracts or agreements with providers and operate as a full network plan, providers who do not have a signed contract or agreement with the plan may continue to furnish out-of-network Part A and Part B services to members of the plan by agreeing to accept the PFFS plan’s terms and conditions of payment and becoming a deemed provider as described in 42 CFR 422.216(f) and section 40.2 of this chapter. However, the plan may establish higher cost sharing requirements for members who obtain covered services from deemed providers instead of plan network providers. CMS annually determines the location of the network areas for non-employer PFFS plans, which can be downloaded from the following CMS website: http://www.cms.hhs.gov/PrivateFeeforServicePlans/.