CMS Pub. 100-16, ch. mc86c16a, § 30.3.1

Non-employer PFFS plans that are operating in a network area (as defined in section

1852(d)(5)(B) of the Act) must meet the access to services requirements through signed

contracts with providers. These plans must establish signed contracts or agreements with

a sufficient number and range of health care providers in their service area for all

categories of Part A and Part B services in accordance with the access standards

described in 1851(d)(1) of the Act and section 30.2 of this chapter.

Non-employer PFFS plans operating in network areas will not be allowed to meet the

access to services requirement by establishing payment rates that are not less than the

rates that apply under Original Medicare for a particular category of provider and having

providers deemed to be contracted under the plan as provided under 42 CFR 422.216(f)

and described in section 40.2 of this chapter. Consequently, these plans must operate as

full network PFFS plans, instead of non-network or partial network plans.

While a non-employer PFFS plan operating in a network area must meet the access to

services requirement by establishing signed contracts or agreements with providers and

operate as a full network plan, providers who do not have a signed contract or agreement

with the plan may continue to furnish out-of-network Part A and Part B services to

members of the plan by agreeing to accept the PFFS plan’s terms and conditions of

payment and becoming a deemed provider as described in 42 CFR 422.216(f) and section

40.2 of this chapter. However, the plan may establish higher cost sharing requirements

for members who obtain covered services from deemed providers instead of plan network

providers.

CMS annually determines the location of the network areas for non-employer PFFS

plans, which can be downloaded from the following CMS website:

http://www.cms.hhs.gov/PrivateFeeforServicePlans/.