As we advance in age, we are often faced with new medical challenges and the need for specialized treatment. Under Medicare, this can mean receiving care from new doctors and incurring a great deal of out-of-pocket expenses.  Fortunately, having some freedom of choice as to your provider and sense of how much you will have to pay is possible under Medicare.

As a recipient of Medicare, you have the option of purchasing coverage for expenses such as co-payments, co-insurance, and deductibles through Medicare Advantage Plans.  Some Medicare Advantage Plans include managed care plans which limit choices of doctor to specific networks or charge more for you see a doctor outside of the specified network.  Medicare Advantage also offers a Private Fee-for-Service Plan (PFFS).

A PFFS plan determines how much it will pay doctors, other healthcare providers, and hospitals, and how much you must pay when you get care.  Unlike Medicare, there is no limit under a PFFS plan on how much you can be charged for co-payments, co-insurance, and deductibles. The theory behind this plan is that you are afforded more freedom to choose a provider and the providers at an insurance negotiated rate which is supposed encourage quality of services rather than quantity.

Generally, these plans provide greater flexibility and choice as you may select any Medicare-approved doctor or hospital as long as that provider accepts the plan’s payment terms.  Providers can stop accepting the plan at any time, and plan coverage can vary greatly by region. However, in an emergency, doctors, hospitals, and other providers must treat you even if they don’t accept the PFFS plan.  While there can be coverage under PFFS plans which is not offered by Medicare such as vision and dental care but patients will usually have to pay some of the costs. You cannot be sold a Medigap policy if you have a PFFS plan, so it is important to evaluate both options before making a selection. PFFS plans may let providers “balance bill” which means they can charge up to 15 percent above the plan’s payment amount for services.

The bottom line is that while PFFS plans may offer more flexibility in your choice of provider and services but you will most likely be more out out-of-pocket for this freedom.  Plans vary greatly regarding what you will be paying and where the providers are willing to accept the plan so it is important to consider this option given what your needs may be and what is offered where you live.   As always, before you enroll in a PFFS plan or any other Medicare Advantage plan you should consider the monthly premium, co-payments, and the cost of extra benefits to make sure the plan fits your budget and meets your needs. Our office has attorneys and other sources who are knowledgeable about Medicare and can help you understand your choices and make informed decisions.  Please contact us if we may be of assistance at 517-548-7400 or online.

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