Do Medicare Advantage PFFS plans have problems with doctors? Is there any balance billing on Coventry plans?

Question

I am looking at PFFS plans from various insurance companies. They seem to have flexible coverage and allow freedom of choice.
My question is a two-parter:

1) Are HMO and PPO Medicare Advantage plans better than PFFS plans or PFFS are better for consumers?

2) Is there a balance billing for any of the following plans:

- Coventry Freedom
- Humana
- Aetna
- Today's Options
- Secure Horizons

Your expertise would be welcome.

Answer 1

There is an excellent reference on the medicare website that will answer alot if not all of your questions.

http://www.medicare.gov/Publications/Pubs/pdf/10144.pdf

The answers to your questions cannot be answered in a generic way as the answers are based on YOUR health and financial needs. You need to evaluate your health needs, what providers you currently use are on the plans (if you wish to continue to use them) and what you are able to afford in premiums, co-pays and out of pocket costs incurred as these are all important decisions.

Edit:Spock is partially correct. With a PFFS, your doctor has a choice whether or not to agree to the payments and provisions for coverage if you are treated. If he chooses not to agree, your out of pocket is greatly increased.

Answer 2

With a PFFS plan you need to make sure the doctor will accept Medicare and the plans payments and terms every time you visit them. This is known as a "deemed" provider and means the provider accepts assignment. "Accepting assignment" means they agree to the payment that Medicare will allow. This is the amount the insurance company will pay. If the provider does not accept assignment they can balance bill, or charge up to 15% more than Medicare will allow. You will be responsible for those excess charges. This usually happens with specialists in places such as the Mayo Clinic. There is balance billing with all your listed companies.

With a PPO and HMO you do not have balance billing if you stay within the network. An HMO does not allow you to go outside the network so you have less freedom of choice. The PPO does allow you to go outside the network. If you do go outside the network your cost sharing will be higher plus the provider can balance bill.

Which plan is better depends upon you. If your doctors are in the network the PPO and HMO plans are very good for keeping the cost down. If you want the freedom to go to the Mayo Clinic you'll need a PPO or PFFS, since the Mayo is not in any Medicare HMO networks.

In general, you have more restrictions and lower overall costs with an HMO and less restrictions and higher overall costs with a PFFS. The PPO is in the middle.

Answer 3

1) PFFS plans have had a good deal of problems. Many providers are still unfamiliar with these plans and refuse to see patients on them. Also, many plans leave huge gaps in what is included under the out of pocket maximum, so hospitals will refuse these patients rather than be stuck with the bad debt for unpaid co-payments. With copayments this high and huge gaps in coverage you may be better off to buy a supplement and avoid the headaches.

PPO plans are great but they often charge much more when you go out of network and sometimes the out of pocket maximum can be double out of network.

Some good options to consider are an open access HMO (no referrals required to specialistst within the plan) or an HMO with a POS option. as these plans allow you realize savings by using in network doctors while providing the flexibility to use doctors that are not in the network as well. Usually, plans charge more out of network, but some POS plans are designed to allow in and out of network coverage at the same price.

Answer 4

virtually all PFFS plans result in the patient being responsible for a co-payment for everything. you can't get something for nothing.

the something you get with a PFFS plan is any doctor without gatekeeper controls. That gives the insurance company about zero bargaining leverage with the physicians, so you get to pay the balance.

Answer 5

Today's Options does not allow balance billing.