US · guidance
CMS Pub. 100-16, ch. mc86c16a, § 10
Introduction
42 CFR 422.4(a)(3)
A Medicare Advantage private fee-for-service (PFFS) plan is an MA plan that:
• Pays providers of services at a payment rate determined by the plan on a fee-for-service basis without placing the provider at financial risk;
• Does not vary the payment rates for a provider based on the utilization of that
provider's services, except under the following two circumstances (refer to section
60 of this chapter):
o A PFFS plan may vary the payment rates for a provider based on the
specialty of the provider, the location of the provider, or other factors
related to the provider that are not related to utilization and do not violate
the provider antidiscrimination rules under 42 CFR 422.205.
o A PFFS plan may also increase the payment rates for a provider based on
increased utilization of specified preventive or screening services.
• Does not restrict members' choices among providers that are lawfully authorized
to provide services and agree to accept the plan's terms and conditions of
payment; and
• May not require prior notification (refer to section 90.3 of this chapter).
History
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
6cef5061ce3f0feb88f1bc560c366a985e085c436b46ae0220b5f4b18e4270eb
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.