Medicare Managed Care Manual (Pub. 100-16), Ch. 16a § 50.4
Mid-year Changes to Terms and Conditions of Payment
50.4 - Mid-year Changes to Terms and Conditions of Payment
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
During the course of the year, it may be necessary for PFFS plans to update their terms
and conditions of payment, for example, to reflect accurate payment rates for certain
provider types, reflect changes to CMS policy (e.g., changes in coverage policy), or to
correct errors. Accordingly, PFFS plans will be permitted to update their terms and
conditions of payment under limited circumstances, subject to CMS review and approval.
Once CMS has approved mid-year changes to a PFFS plan’s terms and conditions of
payment, the plan must notify providers of the changes at least 30 days before the
effective date of the updated terms and conditions of payment. However, in some cases,
if the terms and conditions contain payment or other errors that could negatively impact
beneficiaries or providers, changes can be made effective immediately at CMS’ direction.
Notification of changes to the terms and conditions must be effected by prominently
noting the plan changes in the updated terms and conditions and by sending the updated
terms and conditions of payment to providers who previously furnished services to plan
members by electronic or direct mail.