Medicare Managed Care 
Chapter 16a  Private Fee-for-Service (PFFS) Plans 
 
 
Table of Contents 
(Rev. 99, Issued: 05-27-11) 
 
Transmittals for Chapter 16a 
 
10  Introduction 
20  General Requirements 
30  Access to Services 
30.1 - General Requirements 
30.2 - Access Standards for Full and Partial Network Plans 
30.3 - Requirement for Certain Non-Employer PFFS Plans to Use Contract 
Providers 
30.3.1 - General Requirements 
30.3.2 - Methodology Used to Identify the Location of Network Areas 
30.3.3  Operational Impact on Non-Employer PFFS Plans 
30.4 - Requirement for All Employer/Union Sponsored PFFS Plans to Use 
Contract Providers 
30.4.1  General Requirements 
30.4.2  Operational Impact on Employer PFFS Plans 
40 - Provider Types: Direct-Contracting, Deemed-Contracting, and Non-Contracting 
40.1  Direct-Contracting Providers 
40.2  Deemed-Contracting Providers 
40.3  Non-Contracting Providers 
50  PFFS Terms and Conditions of Payment for Deemed Providers 
50.1  General Requirements 
50.2 - Model Terms and Conditions of Payment 
50.3 - Process for Submission and Review of Terms and Conditions of Payment 
50.4 - Mid-year Changes to Terms and Conditions of Payment 
50.5 - Availability of the Terms and Conditions of Payment 
50.6 - Terms and Conditions of Payment Identification System 
60 - Variations in Payment Rates to Providers 
70  PFFS Payment Rules for Providers and Cost Sharing Rules for Members 
70.1  General Rules 
70.2  Non-Network PFFS Plan Rules 
70.2.1 - General Rules 
  70.2.2 - Payment Rules for Deemed Providers 
70.2.3 - Payment Rules for Direct-Contracting Providers 
70.2.4 - Cost Sharing Rules for Members 
70.2.5 - Review of Provider Networks 
70.3  Full Network PFFS Plan Rules 
70.3.1 - General Rules 
70.3.2 - Payment Rules for Direct-Contracting Providers 
70.3.3 - Payment Rules for Deemed Providers 
70.3.4 - Cost Sharing Rules for Members 
70.3.5 - Review of Provider Networks 
70.4  Partial Network PFFS Plan Rules 
70.4.1 - General Rules 
70.4.2 - Payment Rules for Direct-Contracting Providers 
70.4.3 - Payment Rules for Deemed Providers 
70.4.4 - Cost Sharing Rules for Members 
70.4.5 - Review of Provider Networks 
80 - Balance Billing Rules 
80.1  Original Medicare Balance Billing Rules that Apply to Deemed and Non-
Contracting Providers under PFFS Plans 
80.2 - Additional Balance Billing Rules Allowed under PFFS Plans for Deemed 
and Direct-Contracting Providers 
80.2.1 - Advance Notice for Hospital Services 
90  Prohibition on Prior Authorization, Prior Notification, and Referrals 
90.1  General Requirements 
90.2  Prior Authorization 
90.3  Prior Notification 
90.4  Referrals 
100 - Written Advance Organization Determinations 
110 - Prompt Payment Requirements 
120  Timing Filing Requirement 
130  Provider Payment Dispute Resolution Process 
130.1  Process for Resolving Provider Payment Disputes through the PFFS Plan 
130.2 - Process for Resolving Provider Payment Disputes through the Payment 
Dispute Resolution Contractor 
140 - Requirement for PFFS Plans to Provide an Explanation of Benefits to Members 
150 - Requirement for PFFS Plans to have a Quality Improvement Program 
150.1  General Requirements 
150.2  Quality Data Collection and Reporting Requirements 
160  PFFS Crosswalk Options 
  160.1 - Non-Network PFFS Plan Transitioning to a Partial Network PFFS Plan 
160.2 - Some Counties of a Non-Network PFFS Plan Transitioning to a Partial 
Network PFFS Plan 
160.3 - Non-Network PFFS Plan Transitioning to a Full Network PFFS Plan 
160.4 - Some Counties of a Non-Network PFFS Plan Transitioning to a Full 
Network PFFS Plan 
160.5 - Partial Network PFFS Plan Transitioning to a Full Network PFFS Plan 
160.6 - Some Counties of a Partial Network PFFS Plan Transitioning to a Full 
Network PFFS Plan 
 
  10  Introduction  
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
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): 
 
  A PFFS plan may vary the payment rates for a provider based on the 
o
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.  
 
  A PFFS plan may also increase the payment rates for a provider based on 
o
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). 
 
20  General Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
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 plans 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. 
 
30  Access to Services 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.114 
 
30.1 - General Requirements 
(Rev.99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.114(a)(1) and (2) 
 
An MA organization that offers a PFFS plan must provide sufficient access to health care 
services by demonstrating to CMS that it has a sufficient number and range of providers 
willing to furnish services under the plan.  CMS will find that an MA organization meets 
this access to services requirement if, with respect to a particular category of health care 
providers, the PFFS plan has 
(1) Payment rates that are not less than the rates that apply under Original 
Medicare for the provider in question.  (These plans are called non-network PFFS 
plans.  Refer to section 70.2 of this chapter.); OR 
(2) Signed contracts or agreements with a sufficient number and range of 
providers to meet the access standards described in section 1852(d)(1) of the Act.  
(These plans are called full network PFFS plans.  Refer to sections 30.2 and 70.3 
of this chapter.); OR 
(3) A combination of (1) and (2).  (These plans are called partial network PFFS 
plans.  Refer to sections 30.2 and 70.4 of this chapter.) 
 
Non-employer PFFS plans offered in network areas and all employer/union sponsored 
PFFS plans must meet the access to services requirement for all categories of Part A and 
Part B health care providers by establishing signed contracts or agreements with a 
sufficient number and range of providers to meet the access standards described in 
  section 1852(d)(1) of the Act and section 30.2 of this chapter.  Consequently, these plans 
must operate as full network PFFS plans.  Refer to sections 30.3 and 30.4 of this chapter 
for more information about these requirements. 
 
30.2  Access Standards for Full and Partial Network Plans 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.114(a)(2)(ii)(A)  
 
As discussed in section 30.1 of this chapter, a PFFS plan can meet the access to services 
requirement with respect to a particular category of health care providers by establishing 
signed contracts or agreements with a sufficient number and range of providers to meet 
the access standards described in section 1852(d)(1) of the Act.  Section 1852(d)(1) of the 
Act describes the requirements that MA organizations offering a coordinated care plan 
(CCP) must meet when selecting providers to furnish benefits covered under the plan.  
The access standards for CCPs are described in 42 CFR 422.112(a) and section 110.1 of 
Chapter 4 of this manual. 
 
Full and partial (only for the categories of providers for which the plan is using a network 
of providers with signed contracts or agreements with the plan) network PFFS plans are 
required to meet the same access standards as CCPs.  Providers with signed contracts or 
agreements with the plan are also known as direct-contracting providers or network 
providers.  CMS reviewers follow the same procedure when reviewing the Health Service 
Delivery (HSD) Tables for initial and service area expansion applications for coordinated 
care, PFFS, and network MSA plans in order to determine whether an MA organizations 
proposed network meets the access standards.  Full and partial network plans must submit 
information about their proposed provider networks to CMS.  CMS reviews that 
information as part of the application approval process to ensure that timely, accessible, 
and appropriate care is provided. 
 
30.3 - Requirement for Certain Non-Employer PFFS Plans to Use 
Contract Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.114(a)(3)  
 
30.3.1 - General Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
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 plans 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/. 
 
30.3.2 - Methodology Used to Identify the Location of Network Areas 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
Network area is defined, for a given plan year, as the area that the Secretary identifies 
(in the announcement of the risk and other factors to be used in adjusting MA capitation 
rates for each MA payment area (also known as the Rate Announcement) for the 
previous plan year) as having at least 2 network-based plans (as defined in section 
1852(d)(5)(C) of the Act) with enrollment as of the first day of the year in which the 
announcement is made. 
 
For purposes of this requirement, CMS interprets having a network-based plan with 
enrollment to mean having a network-based plan in an area that is generally open to 
enrollment.  Thus, an area that has only one network-based plan that is generally open to 
enrollment, along with other limited enrollment network-based plans, such as a plan 
limited to members of an employer group or special needs population, would not meet 
this test.  Therefore, employer/union sponsored group health plans and special needs 
plans (SNPs), which are not generally open to enrollment, are not considered network-
based plans. 
 
CMS also interprets the phrase having at least 2 network-based plans to mean that there 
are at least 2 plans (i.e. plan benefit packages (PBPs) each of which meets the definition 
of a network-based plan and that are offered by the same MAO or by different MAOs.  
 
Additionally, CMS interprets the phrase with enrollment to mean that a network-based 
plan is required to have at least one beneficiary enrolled in the plan in order to be counted 
  for purposes of identifying the location of network areas.  Therefore, if a plan has no 
members, it would not be counted as a network-based plan. 
 
Network-based plan is defined as: (1) an MA plan that is a coordinated care plan as 
described in section 1851(a)(2)(A)(i) of the Act, excluding non-network regional PPOs 
(RPPOs); (2) a network-based MSA plan; or (3) a section 1876 cost plan. 
 
The types of coordinated care plans that meet the definition of a network-based plan are 
HMOs, PSOs, local PPOs, and certain RPPOs (refer to section 30 of Chapter 1 of this 
manual).  An RPPO meets the definition of a network-based plan in only the portions of 
its service area where the RPPO meets access standards solely by establishing signed 
contracts or agreements with providers in accordance with section 110.1 of Chapter 4 of 
this manual, and therefore, is operating as a network RPPO.  42 CFR 422.112(a)(1)(ii) 
permits RPPOs to meet access standards, upon CMS approval, using methods other than 
written agreements with providers (that is, the plan may allow members to see non-
contracting providers at in-network cost sharing in areas where the plan has not 
established a network of direct-contracting providers).  An RPPO that meets access 
standards in portions of its service area under the authority of 42 CFR 422.112(a)(1)(ii), 
rather than signed contracts, does not meet the definition of a network-based plan.  These 
plans operate as non-network RPPOs. 
 
For purposes of identifying the location of network areas for a given plan year, CMS will 
annually determine whether at least 2 network-based plans with enrollment exist in each 
of the counties in the United States, including its 5 territories and the District of 
Columbia.  In some cases, network areas consist of partial counties and are identified by 
zip codes.  Refer to the annual Advance Notice and the Rate Announcement for more 
information about the specific methodology used to identify the location of network areas 
for each plan year. 
 
30.3.3  Operational Impact on Non-Employer PFFS Plans 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
An existing PFFS plan may, in a subsequent contract year, have some counties (or partial 
counties) in its current service area that meet the definition of a network area and other 
counties (or partial counties) that do not.  In order to preserve benefit uniformity under an 
MA plan, CMS will not permit an MA organization offering a PFFS plan to operate a 
mixed model where some counties (or partial counties) in the plans service area are 
considered network areas and other counties (or partial counties) that are non-network 
areas (where there are no network-based plan options or only one other network-based 
plan).  In other words, a PFFS plan must be either a network based plan, a non-network 
plan, or a partial network plan. 
 
PFFS Plans Operating in Both Network and Non-Network Areas.  Current MA 
organizations offering PFFS plans with service areas spanning both network and non-
network areas must complete the initial application process in order to bring the network 
portions of their service area into compliance with the access to services requirement.  
  These organizations will be issued a new contract (H) number through the application 
process to encompass the network portions of the service area.  If the application is 
approved, the organization will be authorized to move the affected members to the new 
contract number.  The current contract will continue to operate in the non-network areas. 
 
PFFS Plans Operating in Network Areas.  Current MA organizations offering PFFS plans 
whose service area lies solely in network areas must complete the initial application 
process in order to qualify to offer their PFFS plan to current and new members as a 
network PFFS plan.  These organizations may NOT purport to meet the access to services 
requirement by moving their enrollees into aHealth Maintenance Organization (HMO) or 
Preferred Provider Organization (PPO) as it is not permissible to move affected members 
from the PFFS plan into other types of MA plans.  The organizations that fail to complete 
the initial application process will be non-renewed or have their service area reduced and 
the affected members will be disenrolled to Original Medicare. 
 
PFFS plans operating in network areas must meet the access to services requirement for 
all categories of Part A and Part B health care providers by establishing signed contracts 
or agreements with a sufficient number and range of providers to meet the access 
standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. 
Consequently, these plans must operate as full network PFFS plans.  These PFFS plans 
may not use alternate methods to meet the access to services requirement in network 
areas.  Specifically, these plans may not operate as non-network or partial network PFFS 
plans.  If an MA organization is not able to establish a network of direct-contracting 
providers that CMS determines to be adequate in a network area, then it may not offer a 
PFFS plan in that area. 
 
Current MA organizations offering PFFS plans that need to file an initial application to 
enable them to transition some or all of their plans to full network plans must first file a 
Notice of Intent to Apply (NOIA).  CMS will not accept NOIAs and applications for non-
network PFFS plans for those counties (or partial counties) determined to be network 
areas for a given plan year. 
 
PFFS Plans Operating in Non-Network Areas.  PFFS plans whose service areas lie solely 
in non-network areas can continue to operate as non-network plans, where the plan meets 
the access to services requirement by establishing payment rates that are not less than the 
rates that apply under Original Medicare (refer to section 70.2 of this chapter) 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.  PFFS plans in non-network areas may also 
choose to operate as full network plans (refer to section 70.3 of this chapter) or partial 
network plans (refer to section 70.4 of this chapter).  No new application is required. 
 
A network based PFFS plan must meet the access to services requirement by establishing 
signed contracts or agreements with a sufficient number and range of providers to furnish 
Part A and B services.  However, 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 those members of the plan who seek care with them by agreeing to accept the 
  PFFS plans terms and conditions of payment and becoming a deemed providers 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 plans network providers. Please note that all providers are 
still subject to balance billing limitations. 
 
30.4 - Requirement for All Employer/Union Sponsored PFFS Plans to 
Use Contract Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.114(a)(4)  
 
30.4.1  General Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
All employer/union sponsored PFFS plans that have waivers under section 1857(i) of the 
Act must meet the access to services requirement by establishing signed contracts or 
agreements with a sufficient number and range of health care providers in their service 
area for Medicare Part A and Part B services in accordance with Medicare access and 
availability to health care services standards.  Consequently, these plans must operate as 
full network PFFS plans, instead of non-network or partial network plans.  Although 
CMS does not review the HSD tables for employer/union sponsored plans, these PFFS 
plans must ensure that their provider networks meet the access standards described in 
section 1852(d)(1) of the Act and section 30.2 of this chapter. 
 
While (as described above) an employer/union sponsored PFFS plan must meet the 
access to services requirement by establishing signed contracts or agreements with 
providers and operating 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 plans 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 PFFS plan may establish 
higher cost sharing requirements for members who obtain covered services from deemed 
providers instead of plans network providers.  Please note that all providers are still 
subject to balance billing limitations. 
 
30.4.2  Operational Impact on Employer PFFS Plans  
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
In order to offer new employer/union sponsored PFFS plans, organizations must first file 
a notice of intent to apply (NOIA) and then complete the application for a new Medicare 
Advantage contract.  Employer-only PFFS plans must be network based. 
 
Employer/union sponsored PFFS plans that operate on a non-calendar year schedule must 
complete the initial application process on the same timeline as other MA applicants and 
pursuant to the same requirements as indicated in the initial application and related 
  materials. Organizations are not required to offer the approved network-based PFFS 
products, however, until the beginning of the organizations applicable plan year.  For 
example, if an organizations 2011 plan year begins on July 1, 2011, then the 
organization must offer the network-based plan as of that date. 
 
40 - Provider Types: Direct-Contracting, Deemed-Contracting, and 
Non-Contracting 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216 
 
There are three types of providers that may furnish services to members of PFFS plans: 
direct-contracting, deemed-contracting, and non-contracting providers.  Each is described 
in more detail sections 40.1, 40.2, and 40.3 of this chapter. 
 
40.1  Direct-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
A provider is a direct-contracting provider if the provider has a signed contract or 
agreement with a PFFS plan to deliver covered services to the plans members.  These 
providers are also known as network providers.  Direct-contracting providers have 
already agreed to see members of the plan. 
 
  Full network PFFS plans must establish direct-contracting providers for all 
categories of Part A and Part B services in accordance with the access standards 
described in section 1852(d)(1) of the Act and section 30.2 of this chapter. 
 
  Partial network PFFS plans may have direct-contracting providers for one or more 
categories of Part A or Part B services in accordance with the access standards 
described in section 1852(d)(1) of the Act and section 30.2 of this chapter. 
 
  Non-network PFFS plans generally do not have direct-contracting providers.  
However, non-network plans may establish signed contracts or agreements with 
some providers without meeting the access standards described in section 
1852(d)(1) of the Act and section 30.2 of this chapter. 
 
The payment rules for direct-contracting providers under the three types of PFFS plans 
are discussed in section 70 of this chapter. 
 
40.2  Deemed-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216(f)  
 
Members of PFFS plans can receive health care services from any provider in the United 
States, if (1) the provider agrees to accept the plans 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.  If all of the deeming conditions described 
below are met, then the provider is deemed to have agreed to accept the PFFS plans 
terms and conditions of payment for a member specific to the visit. 
 
A provider that furnishes health care services to a PFFS plan member, except for 
emergency services, and does not have a signed contract or agreement with the plan is 
deemed to have a contract with the PFFS plan if the following conditions are met: 
 
  The provider is aware in advance of furnishing health care services that the 
individual receiving the services is enrolled in a PFFS plan; 
 
  The provider has reasonable access to the plans terms and conditions of payment 
in advance of furnishing services (refer to section 50 of this chapter for more 
information on the PFFS terms and conditions of payment); and 
 
  The provider furnishes services that are covered by the plan. 
 
These providers are considered deemed-contracting providers (or deemed providers). 
 
A provider is aware in advance of an individuals enrollment in a PFFS plan, if a notice 
of enrollment for the individual was obtained from: 
 
  The individual (e.g., presentation of an enrollment card or other document 
attesting to enrollment in a PFFS plan); 
 
  CMS; 
 
  A Medicare intermediary, carrier or MAC; or  
 
  The MA organization itself. 
 
A provider has reasonable access to the plans terms and conditions of payment if the 
plan makes the terms and conditions accessible through: 
 
  The postal service; 
 
  Electronic mail; 
 
  Fax; 
 
  Telephone; or 
 
  The plans website. 
 
  Announcements in newspapers, journals, magazines, radio, or television are not 
considered reasonable methods for allowing access to the terms and conditions of 
payment. 
 
It is the providers responsibility to call the PFFS plan or visit the plans website to obtain 
the plans terms and conditions of payment.  The provider doesnt have to actually read 
the terms and conditions of payment; instead, if the provider had the opportunity to read 
them and treats the member, the law deems the provider to have agreed to accept the 
plans terms and conditions of payment for that specific visit. 
 
A deemed provider can decide whether or not to accept the PFFS plans terms and 
conditions of payment each time the provider sees one of the plans members.  However, 
the provider cannot change his or her mind about accepting the terms and conditions of 
payment after providing services to the member.  A decision to treat one plan member 
does not obligate the provider to treat other members of the same PFFS plan, nor does it 
obligate the provider to accept the same member for treatment at a subsequent visit. 
 
A provider is not required to agree to accept a PFFS plans terms and conditions of 
payment or agree to treat a PFFS plan member.  If a provider does not agree to accept the 
plans terms and conditions of payment or refuses to treat the member, then the member 
will need to find another provider that will accept the plans terms and conditions of 
payment.  PFFS plans should assist members to locate another provider in the members 
area who will accept the plans terms and conditions of payment. For example, if there 
are providers in the area that the PFFS plan knows have accepted its terms and conditions 
of payment it should identify those providers to its members who are seeking a provider 
willing to be deemed as possible sources of care. 
 
A provider that decides not to accept the plans terms and conditions of payment should 
not provide services to a member, except in emergencies.  If the provider nonetheless 
furnishes non-emergency services, then the provider will become a deemed provider 
under the plan for that specific visit and be subject to the plans terms and conditions 
whether the provider agrees to them or not. 
 
If a member needs emergency care, then it is covered whether a provider agrees to accept 
the plans terms and conditions of payment or not.  Refer to section 40.3 of this chapter. 
 
Example:  If a PFFS plan member shows a provider an enrollment card identifying him 
or her as a member of a PFFS plan and the provider furnishes non-emergency services to 
that member, then the provider will be considered a deemed provider.  Therefore, it is the 
providers responsibility to obtain and review the terms and conditions of payment before 
providing services, except in the case of emergency services. 
 
Members of full network and partial network (for categories of services for which 
network providers are available) PFFS plans can receive out-of-network Part A and Part 
B services from any provider who does not have a signed contract with the plan, as long 
as the provider agrees to accept the PFFS plans terms and conditions of payment and 
  meets the deeming conditions described above.  Note that a PFFS plan may establish 
higher cost sharing amounts for members who receive covered services from deemed 
(out-of-network) providers instead of network providers. 
 
Members of partial network PFFS plans (for categories of services for which network 
providers are NOT available) can receive Part A and Part B services from any provider 
who does not have a signed contract with the plan, as long the provider agrees to accept 
the PFFS plans terms and conditions of payment and meets the deeming conditions 
described above. 
 
Non-network PFFS plans generally operate using deemed providers for all categories of 
Part A and Part B services. 
 
The payment rules for deemed providers under the three types of PFFS plans are 
discussed in section 70 of this chapter. 
 
40.3  Non-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
A provider is a non-contracting provider if the provider is not a direct-contracting 
provider or a deemed provider.  Generally, these providers furnish emergency services to 
PFFS plan members. 
 
The following examples illustrate when a provider is considered non-contracting: 
 
Example 1: A provider who provides care in an emergency to an unconscious 
individual is a non-contracting provider, if the provider did not know prior to 
furnishing services that the individual is a member of a PFFS plan. 
 
Example 2: A provider who, prior to furnishing services, did not have reasonable 
access to the PFFS plans terms and conditions of payment, is also considered 
non-contracting. 
 
The payment rules for non-contracting providers under the three types of PFFS plans are 
discussed in sections 70 and 80.1 of this chapter.  The rules for services furnished by non-
contracting providers are also described in section 20.7 of Chapter 4 of this manual. 
 
50  PFFS Terms and Conditions of Payment for Deemed Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216 
 
50.1  General Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  MA organizations offering full, partial, or non-network PFFS plans are required to make 
information on each PFFS plans payment rates and provider requirements available to 
deemed providers that furnish services to their members.  A PFFS plans terms and 
conditions of payment is the primary means for deemed providers to obtain necessary 
information regarding a PFFS plans payment rates for covered items and services and 
provider requirements in order to allow the providers to make a confident decision as to 
whether or not they will agree to accept the terms and conditions of payment. 
 
All full, partial, and non-network PFFS plans, including employer/union sponsored PFFS 
plans, are required to implement the terms and conditions of payment for their deemed 
providers effective January 1 of the applicable contract year.  Employer/union sponsored 
PFFS plans that operate on a non-calendar year schedule are expected to implement the 
terms and conditions of payment effective the beginning of the plans applicable contract 
year. 
 
The terms and conditions of payment establish the payment rates for plan-covered items 
and services that apply to deemed providers and the rules that deemed providers must 
follow in order to be paid by the PFFS plan for furnishing services to its members.  PFFS 
plans must ensure that providers furnishing services to plan members are paid accurately 
and timely according to the terms and conditions of payment.  At a minimum, PFFS plans 
are expected to include the following components in their term and conditions of 
payment: 
 
  An explanation of the deeming process (refer to section 40.2 of this chapter); 
 
  Provider qualifications and requirements (i.e., the provider is State-licensed and in 
compliance with other applicable State or Federal requirements, and the provider 
is eligible to provide services under Original Medicare); 
 
  Explanation of provider payment rates (i.e., the amounts the plan will pay 
providers for  covered items and services, the amounts providers are permitted to 
collect from members, balance billing rules, and hold harmless requirements); 
 
  Provider billing requirements, including prompt payment requirements; 
 
  Description of rules for maintaining medical records and allowing audits; 
 
  How a provider can get an advance organization determination; 
 
  Description of the plans provider payment dispute resolution process; 
 
  Description of member and provider rights for filing appeals and grievances; and  
 
  Plan contact information. 
 
  Each component should contain sufficient information and instructions on how to obtain 
additional information if necessary. 
 
50.2 - Model Terms and Conditions of Payment 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
CMS annually issues a model terms and conditions of payment for PFFS plans for each 
contract year.  CMS expects all full, partial, and non-network PFFS plans, including 
employer/union sponsored PFFS plans, to implement the model terms and conditions of 
payment for their deemed providers effective January 1 of the applicable contract year.  
Employer/union sponsored PFFS plans that operate on a non-calendar year schedule are 
expected to implement the model terms and conditions of payment effective the 
beginning of the plans applicable contract year. 
 
The model terms and conditions of payment provide a uniform format and content, which 
is of particular benefit to providers treating members of different PFFS plans.  Use of the 
model also expedites review by CMS Regional Offices (ROs).  Refer to section 50.3 of 
this chapter for more information.  The model terms and conditions of payment are 
posted on the CMS website at http://www.cms.hhs.gov/PrivateFeeforServicePlans/. 
 
50.3 - Process for Submission and Review of Terms and Conditions of 
Payment 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
All terms and conditions of payment must be reviewed and approved by the appropriate 
CMS RO account manager prior to use by PFFS plans.  Plans must update their terms and 
conditions of payment annually to reflect changes in their plan benefit packages.  The 
updated terms and conditions of payment must be submitted to the plans RO account 
manager for review and approval.  Plans may not use a terms and conditions of payment 
without prior approval by CMS.  Similarly, plans may not change the contents of the 
terms and conditions of payment during the year without CMS approval. 
 
PFFS plans should submit their terms and conditions of payment to their RO account 
manager via email.  Although the terms and conditions of payment do not meet the 
definition of marketing material, as defined in section 20 of Chapter 3 of this manual, 
CMS will follow the standard 10-day review process described in section 90.5 of Chapter 
3 of this manual for the review and approval of the terms and conditions of payment 
when a plan uses the model provided by CMS. The 10-day period begins on the date on 
which the terms and conditions of payment are received by the RO account manager. 
 
50.4 - Mid-year Changes to Terms and Conditions of Payment  
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
During the course of the year, it may be necessary for PFFS plans to update their terms 
and conditions of payment, for example, to reflect accurate payment rates for certain 
provider types, reflect changes to CMS policy (e.g., changes in coverage policy), or to 
  correct errors.  Accordingly, PFFS plans will be permitted to update their terms and 
conditions of payment under limited circumstances, subject to CMS review and approval. 
 
Once CMS has approved mid-year changes to a PFFS plans terms and conditions of 
payment, the plan must notify providers of the changes at least 30 days before the 
effective date of the updated terms and conditions of payment.  However, in some cases, 
if the terms and conditions contain payment or other errors that could negatively impact 
beneficiaries or providers, changes can be made effective immediately at CMS direction.  
Notification of changes to the terms and conditions must be effected by prominently 
noting the plan changes in the updated terms and conditions and by sending the updated 
terms and conditions of payment to providers who previously furnished services to plan 
members by electronic or direct mail. 
 
50.5 - Availability of the Terms and Conditions of Payment 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
PFFS plans are required to make their terms and conditions of payment easily accessible 
to providers in the United States.  CMS considers a provider to have reasonable access to 
a plans terms and conditions of payment if the plan makes this information easily 
accessible through the postal service, electronic mail, fax, telephone, or the plans 
website.  PFFS plans should post the terms and conditions of payment on their website in 
a way that requires minimal navigation from the plans main webpage. 
 
50.6 - Terms and Conditions of Payment Identification System 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
All terms and conditions of payment are required to have a unique identifier.  PFFS plans 
are required to place on all CMS-approved terms and conditions of payment a unique 
identifier in order to allow CMS to track these documents in the marketplace, address 
provider inquiries and/or complaints, and allow immediate recognition of the documents 
as approved items. 
 
PFFS plans will be required to follow a specific format for the identifier similar to the 
format established for marketing materials in Chapter 3 of this manual.  The identifier 
must: (1) begin with the organizations contract number; (2) be followed by an 
underscore; (3) be followed by the three-character plan number; (4) be followed by an 
underscore; (5) be followed by a unique material-ID number (numbers or letters chosen 
at the discretion of the organization); and (6) be followed by a place-holder for the CMS 
approval date (the date when the plan is notified by CMS that the terms and conditions of 
payment have been approved).  MA organizations that will use the same CMS approved 
terms and conditions of payment for multiple PFFS plans do not need to include the plan 
number in the identifier.  PFFS plans must ensure that the identifier is prominently 
displayed on their terms and conditions of payment on the front page in the lower left- or 
lower right-hand corner of the document. 
 
 
  60 - Variations in Payment Rates to Providers  
(Rev.99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.4(a)(3)(ii) and 42 CFR 422.216(a)   
 
A PFFS plan cannot not vary the payment rates for a provider based on the utilization of 
that provider's services, except under the following two circumstances: 
 
  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; and  
 
  A PFFS plan may also increase the payment rates for a provider based on 
increased utilization of specified preventive or screening services. 
 
All three types of PFFS plans (full, partial, and non-network plans) are still required to 
establish uniform payment rates in their terms and conditions of payment for deemed 
providers of all categories of Part A and Part B services and are required to pay these 
deemed providers at least the Original Medicare rates or higher.  However, plans also 
have the flexibility to establish through signed contracts or agreements with specific 
providers payment rates that are different than the rates listed in the terms and conditions 
that would otherwise apply, as long as the variations in payment rates are not based on 
utilization (as described above).  As noted in section 40.1 of this chapter, providers with 
signed contracts or agreements with a PFFS plan are considered direct-contracting 
providers. 
 
PFFS plans may vary payment rates for their direct-contracting providers as long as the 
rates are not based on utilization, with the payment rates being effective according to the 
terms of the contract or agreement between the plan and the provider.  However, PFFS 
plans must continue to establish uniform payment rates for deemed providers in their 
terms and conditions of payment.  As noted in section 40.2 of this chapter, all deemed 
providers have the right to decide, on a patient-by-patient and visit-by-visit basis, whether 
to treat plan members unless the provider becomes a direct-contracting provider by 
entering into a signed contract or agreement with the plan to see plan members over a 
certain period of time. 
 
Example 1:  PFFS plans may utilize the flexibility to establish provider-specific payment 
rates to encourage participation by providers who otherwise would not have agreed to 
accept the payment rates listed in the terms and conditions of payment.  For example, a 
PFFS plan that lists a payment rate of 100% of Original Medicare for cardiology services 
in the terms and conditions of payment that apply to deemed providers can establish a 
higher provider-specific payment rate (e.g., 110% of Original Medicare) through a signed 
contract or agreement to encourage a provider in a rural area to provide these services. 
 
  Example 2:  A PFFS plan that intends to increase payment rates to a provider based on 
increased utilization of specified preventive or screening services may establish the rates 
in its signed contracts or agreements with direct-contracting providers and/or in the terms 
and conditions of payment for deemed providers.  The plan may also choose to apply this 
policy on a provider-by-provider basis. 
 
PFFS plans must maintain a record of all provider-specific payment rates that they 
negotiate with direct-contracting providers along with the final rates paid.  PFFS plans 
must also have the capacity to report this information to CMS or to an independent entity 
contracted by CMS upon request. 
 
Section 70 of this chapter discusses the payment rules for direct-contracting and deemed 
providers in each of the three types of PFFS plans. 
 
70  PFFS Payment Rules for Providers and Cost Sharing Rules for 
Members 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.114 and 422.216 
 
70.1  General Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
A PFFS plan can operate as one of three plan types depending on how the plan meets the 
access to services requirement.  Specifically, a PFFS plan can operate as a non-network, 
full network, or a partial network PFFS plan depending on the method the plan uses to 
meet the access to services requirement described in section 30.1 of this chapter. 
 
As discussed in section 60 of this chapter, 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.  This flexibility allows 
PFFS plans to establish provider-specific payment rates that are different from the 
payment rates in their terms and conditions of payment for deemed providers, through 
signed contracts or agreements with providers. 
 
Below we describe the access to services rules under each of the three types of PFFS 
plans, including their payment rules for deemed and direct-contracting providers and cost 
sharing rules for members. 
 
Under each plan type, the plan must pay non-contracting providers, as defined in section 
40.3 of this chapter, furnishing covered services an amount that the provider would have 
received under Original Medicare (including balance billing permitted under Original 
Medicare).  Also, refer to section 80.1 of this chapter. 
 
  Providers may only collect the plan-allowed cost sharing from PFFS members, including 
any balance billing amounts permitted under the plan, and may not otherwise charge or 
bill members. 
 
70.2  Non-Network PFFS Plan Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
70.2.1 - General Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan must meet the access to services requirement by paying all providers at 
least the Original Medicare rates or higher for all categories of Part A and Part B 
services. 
 
  The plan must operate using deemed providers for all categories of Part A and 
Part B services, if the deeming conditions described in 42 CFR 422.216(f) and 
section 40.2 of this chapter are met. 
 
  The plan may have some direct-contracting providers.  The plan may establish 
signed contracts or agreements with some providers without meeting the access 
standards described in section 1852(d)(1) of the Act and section 30.2 of this 
chapter. 
 
70.2.2 - Payment Rules for Deemed Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan must pay all deemed providers at least the Original Medicare rates or 
higher.  Specifically, the total payment rates for these providers (plan and member 
portions) must be at least the amounts they would have received as participating 
or non-participating physicians, as applicable, under Original Medicare for 
Medicare-covered services, including balance billing up to the limiting charge for 
non-participating physicians.  Refer to section 80.1 of this chapter. 
 
  The plan must establish the payment rates for deemed providers in its terms and 
conditions of payment and cannot vary the rates for deemed providers within a 
particular category of Part A or Part B service. 
 
70.2.3 - Payment Rules for Direct-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan may establish payment rates for direct-contracting providers that are 
different than the rates established in the terms and conditions of payment for 
deemed providers. 
 
    Since the plan meets the access to services requirement by paying all providers at 
least the Original Medicare rates or higher, direct-contracting providers must also 
be paid at least the Original Medicare rates or higher. 
 
  The payment rates for direct-contracting providers must be established in the 
signed contract or agreement between the plan and the provider. 
 
  The payment rates can be provider-specific, and public disclosure of the rates is 
not required. 
 
70.2.4 - Cost Sharing Rules for Members 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
The plan cannot vary a members actual out-of-pocket costs (regardless of whether 
copayment or coinsurance applies) with respect to a particular category of Part A or Part 
B service, regardless of whether the provider is a deemed or direct-contracting provider.   
 
70.2.5 - Review of Provider Networks 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
A plan that has some direct-contracting providers is not required to meet the access 
standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. 
 
The plan must disclose information about its direct-contracting providers to CMS upon 
request. 
 
70.3  Full Network PFFS Plan Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
70.3.1 - General Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan must meet the access to services requirement by establishing signed 
contracts or agreements with a sufficient number and range of providers that meet 
the access standards described in section 1852(d)(1) of the Act and section 30.2 of 
this chapter. 
 
  The plan must operate a network of direct-contracting providers (also known as 
network providers) for all categories of Part A and Part B services. 
 
  This access method is required for a plan that establishes payment rates for all 
categories of Part A and Part B services that are less than the rates paid under 
Original Medicare. 
 
    As discussed in sections 30.3 and 30.4 of this chapter, beginning in plan year 
2011, non-employer PFFS plans located in network areas and all employer/union 
sponsored PFFS plans must meet the access to services requirement by operating 
as full network plans. 
 
  The plan must also cover out-of-network Part A and Part B services furnished by 
providers who do not have a signed contract or agreement with the plan, if the 
provider agrees to accept the plans terms and conditions of payment and becomes 
a deemed provider as described in 42 CFR 422.216(f) and section 40.2 of this 
chapter. 
 
70.3.2 - Payment Rules for Direct-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan may establish payment rates for direct-contracting providers that are 
different than the rates established in the terms and conditions of payment for 
deemed providers.  The plan may also vary the payment rates among the direct-
contracting providers within a particular category of Part A or Part B service. 
 
  The payment rates for direct-contracting providers may be higher, lower, or equal 
to the Original Medicare rates. 
 
  The payment rates for direct-contracting providers must be established in the 
signed contract or agreement between the plan and the provider. 
 
  The payment rates can be provider-specific, and public disclosure of the rates is 
not required. 
 
70.3.3 - Payment Rules for Deemed Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan must pay all deemed providers at least the Original Medicare rates or 
higher.  Specifically, the total payment rates for these providers (plan and member 
portions) must be at least the amounts they would have received as participating 
or non-participating physicians, as applicable, under Original Medicare for 
Medicare-covered services, including balance billing up to the limiting charge for 
non-participating physicians.  Refer to section 80.1 of this chapter. 
 
  The plan must establish the payment rates for deemed providers in its terms and 
conditions of payment and cannot vary the rates for deemed providers within a 
particular category of Part A or Part B service. 
 
70.3.4 - Cost Sharing Rules for Members 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
    The plan cannot vary a members actual out-of-pocket costs (regardless of 
whether copayment or coinsurance applies) with respect to a particular category 
of Part A or Part B service for direct-contracting providers. 
 
  The plan cannot vary a members actual out-of-pocket costs (regardless of 
whether copayment or coinsurance applies) with respect to a particular category 
of Part A or Part B service for deemed providers. 
 
  The members actual out-of-pocket costs (regardless of whether copayment or 
coinsurance applies) with respect to a particular category of Part A or Part B 
service may be higher when the member receives out-of-network services from a 
deemed provider instead of in-network services from a direct-contracting 
provider. 
 
70.3.5  Review of Provider Networks 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
Review of all direct-contracting provider networks is required in accordance with section 
30.2 of this chapter. 
 
70.4  Partial Network PFFS Plan Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
70.4.1 - General Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  The plan must meet the access to services requirement using a combination of the 
methods used by full network and non-network PFFS plans. 
 
  The plan must operate a network of direct-contracting providers for one or more 
categories of Part A and Part B services that meets the access standards described 
in section 1852(d)(1) of the Act and section 30.2 of this chapter.  
 
  For the categories of Part A and Part B services for which the plan uses direct-
contracting providers, the plan must also cover out-of-network services furnished 
by providers who do not have a signed contract or agreement with the plan, if the 
provider agrees to accept the plans terms and conditions of payment and becomes 
a deemed provider as described in 42 CFR 422.216(f) and section 40.2 of this 
chapter. 
 
  The plan must pay all providers for the other categories of Part A and Part B 
services (i.e., those categories for which direct-contracting providers are not used) 
at least the Original Medicare rates or higher.  The plan must operate using 
deemed providers for these categories of services; however, the plan may have 
some direct-contracting providers.  The plan may establish signed contracts or 
  agreements with some providers without meeting the access standards described 
in section 1852(d)(1) of the Act and section 30.2 of this chapter. 
 
70.4.2 - Payment Rules for Direct-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
The payment rules that apply under full network PFFS plans also apply to partial network 
plans.  Refer to section 70.3.2 of this chapter. 
 
70.4.3 - Payment Rules for Deemed Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
The payment rules that apply under non-network and full network PFFS plans also apply 
for partial network plans.  Refer to sections 70.2.2 and 70.3.3 of this chapter. 
 
70.4.4 - Cost Sharing Rules for Members 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
The member cost sharing rules that apply under full network PFFS plans also apply to 
partial network plans.  Refer to section 70.3.4 of this chapter. 
 
70.4.5 - Review of Provider Networks 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
Review of all direct-contracting provider networks is required in accordance with section 
30.2 of this chapter. 
 
80 - Balance Billing Rules 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
80.1  Original Medicare Balance Billing Rules that Apply to Deemed 
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. 
 
80.2 - Additional Balance Billing Rules Allowed under PFFS Plans for 
Deemed and Direct-Contracting Providers 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216(b)(1)(ii) 
 
In addition to the Original Medicare balance billing rules described in section 80.1, there 
is a special rule that permits a PFFS plan to allow deemed and direct-contracting 
providers to charge the member up to 15% of the PFFS plans total payment rate for a 
service, in addition to the plan-allowed member cost sharing. However, this special PFFS 
balance billing is only permitted if it is explicitly stated in the plans terms and conditions 
of payment for deemed providers or in the signed contract or agreement between the plan 
and the direct-contracting providers. Providers are not permitted to balance bill a member 
who is also enrolled in a State Medicaid program, and as a result, the member is held 
harmless from Medicare cost sharing. 
 
If a PFFS plan prohibits this special balance billing, then the deemed or direct-contracting 
providers may only collect the plan-allowed cost sharing from the member and may not 
otherwise charge or bill members. 
 
 
  80.2.1 - Advance Notice for Hospital Services 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216(d)(2) 
 
PFFS plans must require a deemed or direct-contracting hospital that intends to impose 
balance billing to provide members, before furnishing any hospital services for which the 
balance billing amount could be greater than $500, with the following: 
 
(1) A notice that balance billing is permitted for those services; 
 
(2) A good faith estimate of the likely amount of balance billing based on the 
members presenting condition; and  
 
(3) The amount of any deductible, coinsurance, and copayment that may be due in 
addition to the balance billing amount. 
 
The PFFS plan must include these requirements in its terms and conditions of payment 
for deemed hospitals or in the signed contract or agreement between the plan and the 
direct-contracting hospital. 
 
90  Prohibition on Prior Authorization, Prior Notification, and 
Referrals 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.4(a)(3) 
 
90.1  General Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
PFFS plans are prohibited from restricting a members access to services by requiring 
prior authorization, prior notification, or referrals as a condition of coverage when 
medically necessary, plan-covered services are furnished to members.  However, 
members and providers have the right to request a written advance organization 
determination from the plan, in accordance with Subpart M of Part 422, before a member 
receives a service in order to confirm that the service is medically necessary and will be 
covered by the plan.  Refer to section 100 of this chapter for information on advance 
organization determinations.  The requirements described below apply to all three types 
(full, partial, and non-network) of PFFS plans. 
 
90.2  Prior Authorization 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
PFFS plans can perform retrospective review of claims for the purpose of verifying 
medical necessity and that the service furnished is a covered service.  However, PFFS 
plans may not require members or providers to obtain prior authorization from the plan as 
  a condition of coverage.  Prior authorization occurs when a plan requires its members or 
their providers to seek approval from the plan before the member receives a service from 
the provider as a condition of coverage. However, as described below both enrollees and 
providers are entitled to request and receive an advance determination of coverage if they 
want to ensure that a particular service will be covered by the PFFS plan as described 
below under section 100. 
 
90.3  Prior Notification 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
Under prior notification, a plan reduces its standard cost sharing levels when the provider 
from whom a member is receiving plan-covered services voluntarily notifies the plan 
prior to furnishing those services, or the member voluntarily notifies the plan prior to 
receiving plan-covered services from a provider.  PFFS plans may not require members 
or providers to prior notify the plan as a condition of coverage nor can PFFS plans 
establish voluntary prior notification rules. 
 
90.4  Referrals 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
PFFS plans may not require members to obtain referrals in order to receive medically 
necessary, plan-covered services.  If a member receives a medically necessary, plan-
covered service from a qualified provider, without a referral or prior authorization from 
the plan, the PFFS plan must pay for the service. 
 
100 - Written Advance Organization Determinations 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216(e) 
If a member of a full, partial, or non-network PFFS plan sees a deemed provider who 
agrees to accept the plans terms and conditions of payment, then the member and the 
provider have the right to request a written advance organization determination (also 
known as an advance coverage determination) from the plan before the member receives 
a service from the deemed provider.  This allows the member and the provider to confirm 
that the service is medically necessary and a covered service, and therefore, will be paid 
for by the plan.  The PFFS plan must make advance organization determinations in 
accordance with Subpart M of Part 422 and Chapter 13 of this manual. 
 
In the absence of an advance organization determination, a PFFS plan can retroactively 
deny payment for a service furnished to a member only if the plan determines that the 
service was not covered by the plan or was not medically necessary.  However, members 
and providers have the right to dispute the plans decision by exercising member appeals 
rights.  Refer to Chapter 13 of this manual for more information. 
 
PFFS plans should take an active role to educate their members and providers about their 
right to request a written advance organization determination from the plan before a 
  member receives a service in order to confirm that the service is medically necessary and 
will be covered by the plan.  PFFS plans should clearly explain the process for requesting 
an initial organization determination in member materials and respond to requests from 
members and providers on a timely basis as described in subpart M section 422.568 and 
422.572.  PFFS plans should also encourage members and providers to request advance 
organization determinations prior to receiving costly services. 
 
110 - Prompt Payment Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.520 
 
MA organizations offering PFFS plans must establish prompt payment requirements for 
deemed providers in their terms and conditions of payment.  At a minimum: 
 
  The MA organization must pay 95 percent of the clean claims within 30 days of 
receipt, if they are submitted by or on behalf of a member of a PFFS plan; and  
 
  The MA organization must pay interest on clean claims that are not paid within 30 
days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B) of the Act. 
 
A clean claim includes the minimum information necessary to adjudicate a claim, not to 
exceed the information required by Original Medicare.  PFFS plans will process all non-
clean claims from deemed providers and notify providers of the determination within 60 
days of receiving such claims. 
 
MA organizations offering PFFS plans are also required to include a prompt payment 
provision in the signed contracts or agreements with their direct-contracting providers, 
the terms of which are developed and agreed to by both the MA organization and the 
relevant provider.  The MA organization is obligated to pay direct-contracting providers 
under the terms of the contract between the MA organization and the provider. 
 
120  Timely Filing Requirement 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
For services furnished on or after January 1, 2010, deemed and non-contracting providers 
furnishing services to PFFS plan members must submit a claim to the plan for an Original 
Medicare-covered service within the same time frame the provider would have to submit 
under Original Medicare, which is within 1 calendar year after the date of service 
The rules for submitting timely claims under Original Medicare can be found at 
https://www.cms.gov/MLNMattersArticles/downloads/MM6960.pdf. 
 
130  Provider Payment Dispute Resolution Process 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  130.1  Process for Resolving Provider Payment Disputes through the 
PFFS Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
Under its contract with CMS, PFFS plans are required to have a process in place to 
resolve provider payment disputes. 
 
A PFFS plan is required to ensure that deemed providers are being paid according to its 
terms and conditions of payment.  If a deemed provider believes that the payment amount 
the provider received from the PFFS plan is less than the amount indicated in the plans 
terms and conditions of payment, then the provider has the right to dispute the payment 
amount following the plans provider payment dispute resolution process. 
 
The provider payment dispute resolution process must be explained in the PFFS plans 
terms and conditions of payment.  In its description of the provider payment dispute 
resolution process, the PFFS plan must describe how a provider can file a dispute with 
the plan and the appropriate documentation that the provider should submit to the plan to 
demonstrate that the plan paid the provider less than required under the PFFS plans 
terms and conditions of payment. 
 
The following guidelines identify some optimal features of a provider payment dispute 
resolution process, which CMS encourages all PFFS plans to implement.  PFFS plans 
that follow the model features of the provider payment dispute process will meet CMS 
requirements.  CMS considers an effective provider payment dispute process a critical 
part of a PFFS plan since it will encourage provider participation in the plan. 
 
Model Features of a Provider Payment Dispute Process: 
 
1. The PFFS plan has a system for receiving provider payment disputes (e.g., dedicated 
phone line, e-mail address) and establishes a specific and reasonable timeline for 
resolution/adjudication of disputes. (CMS recommends 30 days from the time the 
provider payment dispute is first received by the plan.) 
 
2. The PFFS plan maintains a record of provider payment disputes and documents its 
final decisions regarding provider payment disputes.  The PFFS plan has the capacity to 
report this information to CMS upon request - including documentation of any corrective 
actions taken to prevent future payment errors. 
 
3. If the PFFS plan finds for the provider (i.e., it agrees that it initially underpaid the 
provider), in addition to paying the provider the additional amount due in a timely 
manner, the plan should correct its payment system going forward, and identify similar 
claims for that contract year to ensure that it has paid them correctly. 
 
4. The PFFS plan informs the provider in writing of its decision in cases where a provider 
payment dispute is denied by the plan. 
 
  CMS has provided language in its model terms and conditions of payment to describe a 
PFFS plans provider payment dispute resolution process.  Refer to section 50.2 of this 
chapter. 
 
As discussed in section 110 of this chapter, PFFS plans must pay clean claims from 
deemed providers within 30 days.  When reviewing a provider payment dispute process, 
CMS will review the PFFS plans terms and conditions of payment and the rate at which 
it rejects provider claims from the clean-claim process.  Specifically, the plans terms and 
conditions of payment must furnish clear instructions telling providers how to bill the 
plan for services furnished to its members.  CMS will pay particular attention to PFFS 
plans that reject a large percentage of claims because they are not clean (i.e., claims not 
paid because they were not billed according to plan instructions).  CMS will determine 
what constitutes a large number of rejected claims based on comparisons with the 
average rejection rate of other PFFS plans.  CMS will also review the terms and 
conditions of payment to ensure that it clearly informs providers how they can appeal to 
the plan if the provider believes the amount paid by the plan is less than what is described 
in its terms and conditions of payment.  In its review, CMS will pay particular attention 
to how the plan documents its process and if it appropriately responds to provider appeals 
in a timely manner. 
 
130.2 - Process for Resolving Provider Payment Disputes through the 
Payment Dispute Resolution Contractor 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
After completing the PFFS plans provider payment dispute resolution process, if a 
deemed provider still believes that the plan has reached an incorrect decision regarding 
payment on a claim, the provider may file an additional request for review with an 
independent review organization contracted by CMS.  To file this additional request for 
review of a payment dispute with the independent review organization, the provider may 
contact the Payment Dispute Resolution Contractor (PDRC) directly.  Information on 
filing a dispute with the PDRC is available on the CMS website at  
https://www.cms.gov/HealthPlansGenInfo/18_ProviderPaymentDisputeResolution.asp. 
 
The deemed provider must first complete the PFFS plans provider payment dispute 
resolution process before requesting a review by the independent review organization. 
 
Both deemed and non-contracting providers furnishing services to PFFS members may 
file payment disputes with the PDRC. 
 
The provider payment dispute process cannot be used to challenge payment denials by 
organizations that result in zero payment being made to the non-contracted provider. 
Instead, these matters must be processed as appeals under 42 CFR Subpart M.  In 
addition, the payment dispute process may not be used to resolve payment disputes 
between contracted network providers and organizations covered by this process. 
However, in cases where the plan makes a payment but the provider disputes the amount 
of the payment the provider may utilize the provider payment dispute process. 
   
140 - Requirement for PFFS Plans to Provide an Explanation of 
Benefits to Members 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.216(d)(1) 
 
MA organizations offering PFFS plans must provide plan members, for each claim filed 
by the member or the provider that furnished the service, with an appropriate explanation 
of benefits.  The explanation of benefits must include a clear statement of the member's 
liability for deductibles, coinsurance, copayment, and balance billing. 
 
150 - Requirement for PFFS Plans to have a Quality Improvement 
Program 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.152 
 
150.1  General Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.152(a) 
 
MA organizations offering PFFS plans must meet the requirement that MA plans have an 
ongoing quality improvement program.  As part of its ongoing quality improvement 
program, a PFFS must: 
 
  Have chronic care improvement programs; 
 
  Conduct quality improvement projects on an annual basis; and  
 
  Encourage its providers to participate in CMS and HHS quality improvement 
initiatives.  PFFS plans are required to meet this requirement only for their direct-
contracting providers (i.e., providers who have a signed contract with the plan). 
 
In order to implement the quality improvement program requirements, MA organizations 
should follow guidance in Chapter 5 of this manual and seek assistance from State 
Quality Improvement Organizations as well as CMS. 
 
150.2  Quality Data Collection and Reporting Requirements 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
42 CFR 422.152(h) 
 
PFFS plans must provide for the collection, analysis, and reporting of data that permits 
  the measurement of health outcomes and other indices of quality.  The quality data 
collection and reporting requirements for PFFS plans cannot exceed the data collection 
and reporting requirements established for local PPO plans under 42 CFR 422.152(e).  
Refer to Chapter 5 of this manual more information. 
 
160  PFFS Crosswalk Options 
(Rev.99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
CMS has established specific rules that MA organizations must follow in order for CMS 
to allow non-network and partial network PFFS plans to transition to partial or full 
network PFFS plans.  These rules are described below.  Contract year-specific deadlines 
and processes associated with plan crosswalks are articulated in greater detail in the 
annual call letter and other CMS guidance. 
 
160.1 - Non-Network PFFS Plan Transitioning to a Partial Network 
PFFS Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
An MA organization with a PFFS non-network contract may consolidate one or more 
current non-network PFFS PBPs into a new or renewal partial network PFFS plan benefit 
package (PBP) under a separate contract held by the same legal entity. 
 
Current members of a PFFS non-network plan or plans being consolidated into a new or 
renewal PFFS partial network plan will not be required to take any enrollment action, and 
the organization will not submit enrollment transactions to MARx for those current 
members, although it may need to submit updated 4Rx data to CMS for the current 
members affected by the consolidation.  New members must complete enrollment 
requests, and the MA organization will submit enrollment transactions to MARx for 
those new members.  Current members of the consolidated PFFS partial network plan 
must receive a standard annual notice of change (ANOC). 
 
160.2 - Some Counties of a Non-Network PFFS Plan Transitioning to a 
Partial Network PFFS Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
An MA organization with a PFFS non-network contract may consolidate some counties 
in the service area of a current non-network PFFS PBP into a single new or renewal 
partial network PFFS PBP under a separate contract held by the same legal entity.  
Current members in the remaining counties in the current years non-network PFFS PBP 
may remain in the current non-network PBP provided the MA organization follows the 
rules for a renewal plan with a SAR described in section 140.6 of Chapter 4 of this 
manual. 
 
The MA organization must submit enrollment transactions to MARx for current members 
in the counties affected by the SAR who will be transitioned to a new or renewing partial 
network PBP under a separate contract held by the same legal entity.  New members must 
  complete enrollment requests, and the MA organization will submit enrollment 
transactions to MARx for those new members as usual.  Current members transitioned to 
the PFFS partial network plan must receive a standard ANOC. 
 
160.3 - Non-Network PFFS Plan Transitioning to a Full Network PFFS 
Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
An MA organization with a PFFS non-network contract may consolidate one or more 
current entire non-network PFFS PBPs into a new or renewal full network PFFS PBP 
under a separate contract held by the same legal entity. 
 
Current members of a PFFS non-network plan or plans being consolidated into a new or 
renewal PFFS full network plan will not be required to take any enrollment action, and 
the organization will not submit enrollment transactions to MARx for those current 
members, although it may need to submit updated 4Rx data to CMS for the current 
members affected by the consolidation.  New members must complete enrollment 
requests, and the MA organization will submit enrollment transactions to MARx for 
those new members.  Current members of the consolidated PFFS full network plan must 
receive a standard ANOC. 
 
160.4 - Some Counties of a Non-Network PFFS Plan Transitioning to a 
Full Network PFFS Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
An MA organization with a PFFS non-network contract may consolidate some counties 
in the service area of a current non-network PFFS PBP into a single new or renewal full 
network PFFS PBP under a separate contract held by the same legal entity.  Current 
members in the remaining counties in the current year non-network PFFS PBP may 
remain in subsequent years non-network PBP provided the MA organization follows the 
rules for a renewal plan with a SAR described in section 140.6 of Chapter 4 of this 
manual. 
 
The MA organization must submit enrollment transactions to MARx for current members 
in the counties affected by the SAR who will be transitioned to a new or renewing full 
network PBP under a separate contract held by the same legal entity.  New members must 
complete enrollment requests, and the MA organization will submit enrollment 
transactions to MARx for those new members.  Current members transitioned to the 
PFFS full network plan must receive a standard ANOC. 
 
160.5 - Partial Network PFFS Plan Transitioning to a Full Network 
PFFS Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
  An MA organization with a PFFS partial network contract may consolidate one or more 
current partial network PFFS PBPs into a new or renewal full network PFFS PBP under a 
separate contract held by the same legal entity. 
 
Current members of a PFFS partial network plan or plans being consolidated into a new 
or renewal PFFS full network plan will not be required to take any enrollment action, and 
the organization will not submit enrollment transactions to MARx for those current 
members. New members must complete enrollment requests, and the MA organization 
will submit enrollment transactions to MARx for those new members.  Current members 
of the consolidated PFFS full network plan must receive a standard ANOC. 
 
160.6 - Some Counties of a Partial Network PFFS Plan Transitioning to 
a Full Network PFFS Plan 
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) 
 
An MA organization with a PFFS partial network contract may consolidate some 
counties in the service area of a current partial network PFFS PBP into a single new or 
renewal full network PFFS PBP under a separate contract held by the same legal entity.  
Current members in the remaining counties in the current years partial network PFFS 
PBP may remain in the subsequent years partial network PBP provided the MA 
organization follows the rules for a renewal plan with a SAR described in section 140.6 
of Chapter 4 of this manual. 
 
The MA organization must submit enrollment transactions to MARx for current members 
in the counties affected by the SAR who will be transitioned to a new or renewing full 
network PBP under a separate contract held by the same legal entity.  New members must 
complete enrollment requests, and the MA organization will submit enrollment 
transactions to MARx for those new members.  Current members transitioned to the 
PFFS full network plan must receive a standard ANOC. 
  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R99MCM 05/27/2011  Initial Issuance of Chapter  05/27/2011 N/A