CMS Pub. 100-16, ch. 4, § 110.4

PPOs must furnish all services in-network and out-of-network, but may charge higher

cost-sharing for plan covered services obtained out-of-network. The following rules

apply to PPO coverage outside the service area:

• The out-of-network requirement for PPOs applies to the entire United States and its

territories. For example, a PPO with a service area in Puerto Rico must cover all

plan benefits furnished to its enrollees on the mainland. An MAO wishing to furnish

all plan-covered services outside its service area but only in certain geographic

locations should offer an HMOPOS plan;

• PPO plans must provide reimbursement for all plan-covered medically necessary

services received from non-contracted providers without prior authorization

requirements. However, both enrollees and providers have the right to request a prior

written advance determination of coverage from the plan prior to receiving/providing

services;

• PPO plans offering an optional supplemental benefit must offer the same benefit in-network and out-of-network;

• PPO plans that cap the dollar value of supplemental benefits must use the same cap

for both in-network and out-of-network benefits; and

• PPO plans are prohibited from establishing prior notification rules under which an

enrollee is charged lower cost-sharing when either the enrollee or the provider

notifies the plan before a service is furnished.