Offering of 800-series Network Private Fee-For-Service (PFFS) Plans

40.2 - Offering of 800-series Network Private Fee-For-Service (PFFS) Plans Exclusive to Employers (Rev. 111, 05-03-13, Effective: 05-03-13, Implementation: 05-03-13) In 2006, CMS granted a waiver of the “nexus” test (that requires that an MAO offering an 800- series EGWP also offer an individual market MA plan under the same contract) for non-network private-fee-for service plans (PFFS) effective CY 2008. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) prohibits non-network employer PFFS plans beginning in CY 2011; therefore, this waiver is no longer available. Section 162(a)(2) of MIPPA amended section 1852(d) of the Act by adding a new requirement for employer/union-sponsored PFFS plans. For plan year 2011 and subsequent plan years, MIPPA requires that all employer/union- sponsored PFFS plans under section 1857(i) of the Act meet the access standards described in section 1852(d)(4) of the Act only through entering into written contracts or agreements in accordance with section 1852(d)(4)(B) of the Act, and not, in whole or in part, through establishing payment rates meeting the requirements under section 1852(d)(4)(A) of the Act. 42 CFR 422.114(a)(4) describes this requirement. Further detail on requirements related to PFFS plans can be found in Medicare Managed Care Manual Chapter 16a (Private Fee-for-Service (PFFS) Plans).