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PFFS Plan Network Requirements

Guidance for Private Fee-for-Service Plan network requirements.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: February 11, 2020

As provided under the Medicare Improvements for Patients and Providers Act of 2008(MIPPA), beginning in 2011, non-employer PFFS plans operating in network areas must establish contracts with a sufficient number of providers across service categories in order to operate. Network areas are those in which at least two network-based plans are operating with enrollment for a given plan year. Similarly, employer/union sponsored PFFS plans are required to establish contracts with a sufficient number of providers across service categories in their services areas.

In the Annual Rate Announcement, released each April, CMS publishes a list of network areas applicable two contract years in the future, using January 1 enrollment data for the current year. For example, in the first year this provision was implemented, we used January 1, 2009 enrollment data for the network areas analysis in the CY 2010 payment notice for network areas applicable in CY 2011.

Click below, in the "Downloads" section, on “PFFS_Network_Counties” to see the network areas for Non-employer PFFS Plans for contract year 2026; for comparison purposes, network areas for 2011 - 2025 are also presented.
  

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.