US · guidance
CMS Pub. 100-16, ch. 4, § 110.5.1
- Access through Non-contracted Providers
Situations may arise where an MA plan cannot establish contracts with providers that
meet Medicare access requirements in portions of an RPPO’s defined service area. In
such cases, RPPOs may meet Medicare access requirements by demonstrating to CMS’
satisfaction that there is adequate access to all plan-covered services through
arrangements other than through contracted provider (42 CFR §422.112(a)(1)(ii)).
Enrollees who receive plan-covered services in non-network areas of an RPPO must be
covered at in-network cost-sharing levels for the enrollee.
History
(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
2894243db8a14c1d7f6f51ab3730b9de80f037395fbf35d748287ab3a407f46d
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