Original Medicare Balance Billing Rules that Apply to Deemed

80.1 – Original Medicare Balance Billing Rules that Apply to Deemed and Non-Contracting Providers under PFFS Plans (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 42 CFR 422.100(b)(2) Non-contracting providers are required to accept as payment in full from a PFFS plan (including any member cost sharing) the amount they would have received under Original Medicare for a covered service (including any balance billing permitted under Original Medicare). While a non-contracting physician can only collect the plan-allowed cost sharing from a PFFS plan member, the difference that the plan must pay the provider varies depending on whether the provider is a participating or non-participating physician under Original Medicare. If a deemed provider collects more from an enrollee than is allowed under the PFFS plans terms and conditions of payment the PFFS plan must reimburse the member for their overpayment and seek the money the plan is still owed from the provider. In the event the provider is non-cooperative the PFFS plan must report the provider to CMS and advise their plan member to not return to that provider until the provider has agreed to accept the plans terms and conditions of payment. PFFS plans that are required to pay deemed physicians at least the Original Medicare payment rates must also take into account whether a physician is participating or non- participating under Original Medicare in order to determine the total amount due to the deemed physician. The total amount due to the physician is as follows: • Participating, deemed or non-contracting physicians: The physician is required to accept the fee schedule amount, including any plan-allowed member cost sharing, as payment in full. • Non-participating, deemed or non-contracting physicians: The physician can charge an additional amount, up to the limiting charge, above the non- participating physician fee schedule amount. The limiting charge is defined as the maximum amount that non-participating physicians can charge above the non- participating physician fee schedule, which is 15%. The PFFS plan member is only required to pay the plan-allowed cost sharing. However, the PFFS plan must pay the provider the difference between the non-participating physician fee schedule amount (including any additional amount up to the limiting charge) and the member cost sharing.