General Rules

70.4.1 - 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 using a combination of the methods used by full network and non-network PFFS plans. • The plan must operate a network of direct-contracting providers for one or more categories of Part A and Part B services that meets the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. • For the categories of Part A and Part B services for which the plan uses direct- contracting providers, the plan must also cover out-of-network 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. • The plan must pay all providers for the other categories of Part A and Part B services (i.e., those categories for which direct-contracting providers are not used) at least the Original Medicare rates or higher. The plan must operate using deemed providers for these categories of services; however, the plan may have some direct-contracting providers. The plan may establish signed contracts or agreements with some providers without meeting the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter.