General Rules

70.1 – General Rules (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) A PFFS plan can operate as one of three plan types depending on how the plan meets the access to services requirement. Specifically, a PFFS plan can operate as a non-network, full network, or a partial network PFFS plan depending on the method the plan uses to meet the access to services requirement described in section 30.1 of this chapter. As discussed in section 60 of this chapter, a PFFS plan may vary the payment rates for a provider based on the specialty of the provider, the location of the provider, or other factors related to the provider that are not related to utilization. This flexibility allows PFFS plans to establish provider-specific payment rates that are different from the payment rates in their terms and conditions of payment for deemed providers, through signed contracts or agreements with providers. Below we describe the access to services rules under each of the three types of PFFS plans, including their payment rules for deemed and direct-contracting providers and cost sharing rules for members. Under each plan type, the plan must pay non-contracting providers, as defined in section 40.3 of this chapter, furnishing covered services an amount that the provider would have received under Original Medicare (including balance billing permitted under Original Medicare). Also, refer to section 80.1 of this chapter. Providers may only collect the plan-allowed cost sharing from PFFS members, including any balance billing amounts permitted under the plan, and may not otherwise charge or bill members.