CMS Pub. 100-16, ch. mc86c16a, § 20

An MA organization that offers a PFFS plan must meet all applicable requirements for

MA organizations as required by the Social Security Act (the Act) and the Code of

Federal Regulations (CFR). This chapter is generally limited to the requirements

specifically for PFFS plans as set forth in Part C of Title XVIII of the Act and Part 422 of

Chapter 42 of the CFR.

Guidance on requirements that apply to all MA organizations, including organizations

offering PFFS plans, may be found in other chapters of this manual, notably Chapter 1

(General Provisions), Chapter 2 (Enrollment and Disenrollment), Chapter 3 (Marketing),

Chapter 4 (Benefits and Beneficiary Protections), Chapter 5 (Quality Improvement

Program), and Chapter 13 (Beneficiary Grievances, Organization Determinations, and

Appeals). Furthermore, PFFS plans that choose to provide qualified Part D prescription

drug coverage must abide by applicable requirements of Part D of Title XVIII of the Act

and Part 423 of Chapter 42 of the CFR. Guidance on Part D requirements may be found

in the Medicare Prescription Drug Benefit Manual (Publication 100-18) located at

http://www.cms.gov/Manuals/IOM/.

Unless specified in Chapter 9 of this manual or waived by CMS under employer/union

plan waiver authority, employer/union sponsored PFFS plans are also required to meet

the requirements described in this chapter.

The requirements that all MA organizations offering a PFFS plan must meet include, but

are not limited to:

• Providing members with all medically necessary Original Medicare (Part A and

Part B) covered items and services as described in section 10.2 of Chapter 4 of

this manual. A PFFS plan may offer mandatory or optional supplemental benefits

as well. In addition, a PFFS plan can choose to offer qualified Part D prescription

drug coverage (as defined at 42 CFR 423.100 and section 20.1 of Chapter 5 of the

Prescription Drug Benefit Manual).

This obligation to provide coverage applies to all PFFS plan types and provider

types that can furnish services under a PFFS plan, as described in section 70 of

this chapter.

• Allowing members to use any provider, such as a physician, health professional,

hospital, or other Medicare provider in the United States if (1) the provider agrees

to accept the plan’s terms and conditions of payment before providing services to

the member, and (2) the provider is eligible to provide services under Medicare

Part A and Part B.

• Meeting the requirement for access to services described in section 30.1 of this

chapter.

• Paying deemed-contracting providers of all categories of Part A and Part B

services at least the Original Medicare rates or higher. Specifically, including

plan allowed cost sharing paid by the enrollee, PFFS plans must pay these

providers at least the amounts they would have received as participating or non-participating physicians, as applicable, under Original Medicare for Medicare-covered services. Refer to sections 40.2, 70, and 80.1 of this chapter for more

information.

• Establishing and disclosing a terms and conditions of payment for deemed-contracting providers. The terms and conditions of payment must be submitted to

CMS and approved on an annual basis. Refer to section 50 of this chapter.

• Not requiring prior authorization, prior notification, or referral as a condition of

coverage when medically necessary, plan-covered services are furnished to

members. Refer to section 90 of this chapter.

• Abiding by the prompt payment requirements. Refer to section 110 of this

chapter.

• Meeting the quality improvement program requirements described in section 150

of this chapter and Chapter 5 of this manual.

• Complying with all applicable MA beneficiary grievances, organization

determinations, and appeals requirements described in Chapter 13 of this manual.

PFFS plans may, but are not required to, provide Part D coverage. As described in

section 10.5 of Chapter 4 of this manual, enrollees in a PFFS plan that does not elect to

include Part D coverage may enroll in a stand-alone prescription drug plan (PDP) for

their Part D coverage.