CMS Pub. 100-16, ch. mc86c16a, § 80.1

and Non-Contracting Providers under PFFS Plans

(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)

42 CFR 422.100(b)(2)

Non-contracting providers are required to accept as payment in full from a PFFS plan

(including any member cost sharing) the amount they would have received under

Original Medicare for a covered service (including any balance billing permitted under

Original Medicare). While a non-contracting physician can only collect the plan-allowed

cost sharing from a PFFS plan member, the difference that the plan must pay the provider

varies depending on whether the provider is a participating or non-participating physician

under Original Medicare. If a deemed provider collects more from an enrollee than is

allowed under the PFFS plans terms and conditions of payment the PFFS plan must

reimburse the member for their overpayment and seek the money the plan is still owed

from the provider. In the event the provider is non-cooperative the PFFS plan must

report the provider to CMS and advise their plan member to not return to that provider

until the provider has agreed to accept the plans terms and conditions of payment.

PFFS plans that are required to pay deemed physicians at least the Original Medicare

payment rates must also take into account whether a physician is participating or non-participating under Original Medicare in order to determine the total amount due to the

deemed physician.

The total amount due to the physician is as follows:

• Participating, deemed or non-contracting physicians: The physician is required to

accept the fee schedule amount, including any plan-allowed member cost sharing,

as payment in full.

• Non-participating, deemed or non-contracting physicians: The physician can

charge an additional amount, up to the limiting charge, above the non-participating physician fee schedule amount. The limiting charge is defined as the

maximum amount that non-participating physicians can charge above the non-participating physician fee schedule, which is 15%. The PFFS plan member is

only required to pay the plan-allowed cost sharing. However, the PFFS plan must

pay the provider the difference between the non-participating physician fee

schedule amount (including any additional amount up to the limiting charge) and

the member cost sharing.