2011 MIPPA Provisions: Certain PFFS Plans Must Have Networks of Contracted Providers

2011 MIPPA Provisions: Certain PFFS Plans Must Have Networks of Contracted Providers

Starting in January 2011, all non-employer sponsored Medicare Advantage Private Fee-For-Service (PFFS) plans in counties with at least 2 HMOs and/or local PPOs must have a network of contracted providers for their enrollees to use. This change is in accordance with the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The provision will help beneficiaries who currently have the burden of finding providers who will accept their PFFS plan’s terms of payment. Some beneficiaries have enrolled in PFFS plans without understanding this, only to find out their doctor didn’t accept their PFFS plan’s payment terms and hence needed a new provider.

Based on the 2011 plan market data, however, this new rule only applies to one out of 58 counties in the state, Shasta County. PFFS plans are leaving most urban counties and will only be available in rural ones in 2011, with the exception of Merced, Mendocino and Napa counties.

See the Centers for Medicare and Medicaid Services (CMS) 2011 Medicare Advantage and Part D plan charts for a list of plans, their premiums and some coverage details. Also use the Medicare Plan Finder tool on Medicare.gov to search specific information on 2011 plans available in your area.

Also starting in January 2011, all employer-sponsored PFFS plans must have a network of contracted providers for their enrollees in EACH county of operation, regardless of the number of HMOS or PPOs in a given county.

For more information on MIPPA, see our article Updates on Provisions Now Effective from Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.