Are you considering getting a Medicare Advantage plan? Private Fee for Service (PFFS) Medicare Advantage plans might be an option for you. These plans are sold by private insurance companies and offer coverage that is at least as comprehensive as Original Medicare.
What are the Basics of the PFFS Plan?
With the PFFS plan, the insurance company decides in advance what they will pay for certain services and procedures, and what you will need to pay out of pocket. This could include annual deductibles, coinsurance (a percentage of the fee), or a flat copayment.
One of the benefits of a PFFS plan is that you can see any healthcare provider who accepts your insurance plan’s payment rates and agrees to treat you. You don’t need a referral from your primary care doctor to see a specialist either. However, keep in mind that not all healthcare providers will accept your plan – even if they do accept Medicare.
This means that some providers may decide on a case-by-case basis whether they will accept your plan or not. You may have to ask your providers if they’ll take your plan before every visit. Alternatively, some plans have networks of providers who have agreed to always accept your plan’s rates and treat you, even if you’re a new patient. Seeing a network doctor relieves you from having to ask every time and guarantees you’ll be seen for follow-up visits.
It’s important to note that in case of an emergency, all hospitals and medical providers must treat you, even if they do not accept your plan.
Some PFFS plans may also offer prescription drug coverage, but if you enroll in a plan without prescription coverage, you can sign up for a standalone Medicare Part D prescription drug plan.
Also, you will need to pay an extra premium for the Medicare Advantage plan, in addition to your regular Medicare Part B premium. The rates for premiums, deductibles, copays, and coinsurance are set by the insurance company offering the plan, which means they can differ between plans.
PFFS Medicare Advantage plans may be a good option for those who want more flexibility in choosing healthcare providers. Just be sure to do your research and understand the plan’s limitations and out-of-pocket costs.
What is the Meaning of Balance Billing with the PFFS Plan?
Plan Balance Billing is a term used to describe the difference between what a healthcare provider charges for a particular service and what the PFFS plan is willing to pay for that service. In other words, it refers to the amount that the healthcare provider may charge you above and beyond what your PFFS plan covers. With a PFFS plan, healthcare providers are not required to accept the plan’s payment as payment in full. This means that they may bill you for the difference between their standard charges and what your PFFS plan covers. It is important to note that not all healthcare providers will accept PFFS plans, and those that do may vary in their billing practices. Medical providers may be permitted to charge you up to 15% on top of the initial cost of the medical procedure.
How PFFS Plan Differs from other Medicare Advantage Options?
PFFS (Private Fee-for-Service) plans differ from other Medicare Advantage plans in several key ways. Firstly, PFFS plans do not typically have a network of healthcare providers. Instead, they contract with any Medicare-approved healthcare provider that accepts the payment terms of the plan. In contrast, other Medicare Advantage plans usually have a network of providers that patients must use in order to receive in-network benefits.
Secondly, with PFFS plans, the insurance company determines the rates it will pay your healthcare provider and how much you will pay for a covered health service. This is different from other Medicare Advantage plans, where Medicare sets these rates.
Thirdly, PFFS plans may not include prescription drug coverage. In this case, patients have the option to add a Medicare Part D plan. However, this option is not available for HMO or PPO plans that do not include Part D coverage. Fourthly, if a medically necessary service is not covered by a PFFS plan, patients have the option to request an advance coverage decision which is a determination about whether will your plan cover the service or not.
Lastly, with PFFS plans, patients may need to confirm before each visit whether a healthcare provider will cover the service under the plan. Other Medicare Advantage plans usually have more defined rules around what services are covered and which providers are in-network.
Overall, it’s important to consider the unique features of PFFS plans before choosing a Medicare Advantage plan that is right for you.
What if I no Longer Want PFFS Plan?
If you no longer want your Medicare Advantage PFFS plan, you have a few options:
- Switch to another Medicare Advantage plan: You can switch to a different Medicare Advantage plan during the Annual Enrollment Period (AEP) from October 15 to December 7 each year.
- Switch to Original Medicare: You can disenroll from your Medicare Advantage plan and switch back to Original Medicare during the Annual Enrollment Period (AEP) or the Medicare Advantage Open Enrollment Period (OEP) from January 1 to March 31 each year.
- Enroll in a Medicare Supplement plan: If you switch back to your Original Medicare, you may also want to enroll in a Medicare Supplement plan to help cover some of the out-of-pocket costs that Original Medicare doesn’t cover.
It’s important to note that if you disenroll from your Medicare Advantage plan, you may not be able to enroll in another Medicare Advantage plan until the next Annual Enrollment Period. So, it’s important to carefully consider your options and make the best decision for your healthcare needs.
- PFFS Medicare Advantage plans offer comprehensive coverage but have limitations and out-of-pocket costs that vary between plans.
- PFFS plans allow you to see any healthcare provider who accepts your insurance plan’s payment rates and agrees to treat you, but not all providers will accept your plan.
- Balance billing refers to the difference between what a healthcare provider charges for a service and what the PFFS plan is willing to pay. Medical providers may be permitted to charge you up to 15% on top of the initial cost of the medical procedure.
- PFFS plans differ from other Medicare Advantage plans in terms of healthcare provider networks, rate setting, prescription drug coverage, and coverage decisions.
- If you no longer want your PFFS plan, you can switch to another Medicare Advantage plan, switch to Original Medicare, or enroll in a Medicare Supplement plan.
- If you disenroll from your Medicare Advantage plan, you may not be able to enroll in another Medicare Advantage plan until the next Annual Enrollment Period.