PFFS Plan Network Requirements

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 on “Network Areas for Non-employer PFFS Plans” to see the network areas for contract years 2011, 2012, and 2013.

Network areas for 2013 are in the download below. For comparison purposes, you may also download network areas for 2011 and 2012.