General Requirements

30.4.1 – General Requirements (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) All employer/union sponsored PFFS plans that have waivers under section 1857(i) of the Act must meet the access to services requirement by establishing signed contracts or agreements with a sufficient number and range of health care providers in their service area for Medicare Part A and Part B services in accordance with Medicare access and availability to health care services standards. Consequently, these plans must operate as full network PFFS plans, instead of non-network or partial network plans. Although CMS does not review the HSD tables for employer/union sponsored plans, these PFFS plans must ensure that their provider networks meet the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. While (as described above) an employer/union sponsored PFFS plan must meet the access to services requirement by establishing signed contracts or agreements with providers and operating 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 PFFS plan may establish higher cost sharing requirements for members who obtain covered services from deemed providers instead of plan’s network providers. Please note that all providers are still subject to balance billing limitations.