General Rules

70.3.1 - General Rules (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) • The plan must meet the access to services requirement by establishing signed contracts or agreements with a sufficient number and range of providers that meet the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. • The plan must operate a network of direct-contracting providers (also known as network providers) for all categories of Part A and Part B services. • This access method is required for a plan that establishes payment rates for all categories of Part A and Part B services that are less than the rates paid under Original Medicare. • As discussed in sections 30.3 and 30.4 of this chapter, beginning in plan year 2011, non-employer PFFS plans located in network areas and all employer/union sponsored PFFS plans must meet the access to services requirement by operating as full network plans. • The plan must also cover out-of-network Part A and Part B services furnished by providers who do not have a signed contract or agreement with the plan, if the provider agrees to accept the plan’s terms and conditions of payment and becomes a deemed provider as described in 42 CFR 422.216(f) and section 40.2 of this chapter.