CMS Pub. 100-16, ch. 9, § 40.2

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).