[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR422.114]



[Page 1003]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

             Subpart C_Benefits and Beneficiary Protections

 

Sec. 422.114  Access to services under an MA private fee-for-service plan.



    (a) Sufficient access. (1) An MA organization that offers an MA 

private fee-for-service plan must demonstrate to CMS that it has 

sufficient number and range of providers willing to furnish services 

under the plan.

    (2) CMS finds that an MA organization meets the requirement in 

paragraph (a)(1) of this section if, with respect to a particular 

category of health care providers, the MA organization has--

    (i) Payment rates that are not less than the rates that apply under 

original Medicare for the provider in question;

    (ii) Contracts or agreements with a sufficient number and range of 

providers to furnish the services covered under the MA private fee-for-

service plan; or

    (iii) A combination of paragraphs (a)(2)(i) and (a)(2)(ii) of this 

section.

    (b) Freedom of choice. MA fee-for-service plans must permit 

enrollees to obtain services from any entity that is authorized to 

provide services under Medicare Part A and Part B and agrees to provide 

services under the terms of the plan.

    (c) Contracted network. Private fee-for-service plans that meet 

network adequacy requirements for a category of health care professional 

or provider by meeting the requirements in paragraph (a)(2)(ii) of this 

section may provide for a higher beneficiary copayment in the case of 

health care professionals or providers of that same category who do not 

have contracts or agreements to provide covered services under the terms 

of the plan.



[63 FR 35077, June 26, 1998, as amended at 70 FR 4723, Jan. 28, 2005]