Medicare Private Fee-for-Service PlansGetting older can involve developing more complicated health conditions resulting in frequent trips to see different medical professionals.   While some care may be routine, often it will also include seeing specialists and undergoing different tests. For Medicare recipients, this can mean not having many options regarding providers and being required to cover co-pays and other out-of-pocket expenses.  The good news is that Medicare does offer recipients an option which can help improve the situation.

Medicare Advantage Plans

Medicare recipients typically have some available coverage for hospital, medical care, and prescription drugs.  However, this does not cover co-insurance, co-pays, and deductibles. Medicare Advantage Plans, also known as Medicare Part C, allow recipients to purchase managed care plans to supplement these expenses.  However, like HMOs some Medicare Advantage Plans limit provider choices to specific networks and regions or can charge more for you see a care professional outside of the specified network.

Private Fee-for-Service Plan (PFFS) 

Medicare Advantage also offers Private-Fee-for-Service Plans (PFFS) which are purchased through private insurance companies.  PFFS plans are not the same as Medicare or Medigap. Instead, the PFFS policy determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.  Unlike Medicare, there is not a specific cap on how much you can be charged for out-of-pocket expenses.  The idea behind the plans is that by having a negotiated rather than set rate the focus can be on the quality of services rather than quantity.

Advantages of PFFS Plans

Under PFFS plans you can choose any Medicare-approved doctor or hospital as long as that provider accepts the plan’s payment terms.  While providers can stop taking the plan at any time, in an emergency, doctors, hospitals, and other providers must treat you even if they do not accept the PFFS plan.  PFFS plans can also offer some coverage which is not available under Medicare such as partial payment for dental and vision care.

Plan Limitations

Ultimately, the flexibility and freedom which PFFS plans offer come with increased out-of-pocket costs. There is also the potential for expenses to be higher than initially stated under the plan.  This is because PFFS providers can “balance bill” which allows them to charge up to 15 percent above the plan payment amount for their services. These plans also vary regarding provider costs and where services are offered.   PFFS plan recipients cannot buy a Medigap policy in addition to a PFFS, so it is essential to evaluate both options carefully before making a selection.

Before enrolling in a PFFS or any other Medicare Advantage plan, you should think about the co-payments, monthly premium, and your budget.  Our office has attorneys and regularly works with local experts who are knowledgeable about Medicare and Medicare Advantage plans and can help you understand your options and make informed decisions. Please contact us online or by phone if we may be of assistance.

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