A Reader Comments On Open Enrollment and PFFS Medicare
When I wrote last week regarding the Medicare Open Enrollment period, that time of year when Medicare recipients can sign up for or change their Medicare “D” prescription drug coverage or their Medicare Advantage health insurance plans, I was not expecting a response from a reader regarding Private Fee For Service (PFFS) Medicare. Still, that is what I received and the response only confirms for me the difficulties with PFFS plans.
Readers might remember that I have written on PFFS Medicare, a type of Medicare Advantage plan, several times. On July 7, 2008, I devoted an entire column to the subject. See “With PFFS Americans May Pay More For Less Medicare” at www.collitonlaw.com/08/070708.htm. In my column two weeks ago regarding the effect of the 2008 Presidential election, I also discussed PFFS stating that, with the election of the new President, while PFFS plans will remain, I expect them to be marketed less aggressively. See “Election Is Over – What Does the Future Hold?” http://collitonlaw.com/08/081108.htm.
With permission from the reader who sent me this communication by e-mail, I am including here his practical experiences with PFFS. While I cannot confirm this specific experience, it is consistent with information received from other sources.
“Your column in the Daily Local has always provided useful and timely info. Todays (11/17) was no exception as I’m in the process of changing healthcare insurance for both my wife and myself. You mentioned PFFS plans in today’s column but didn’t go into detail. I think your readers need to be cautioned about these plans.
My wife and I are both on a PFFS, <Naming the Plan>. It always worked great until this year when just about all the hospitals in this area (eastern Chester County) began refusing to accept the plan. All hospitals in the Mainline Healthcare group (Paoli, Bryn Mawr, Lankenau, Riddle) and all hospitals in the Keystone Crozer group (Crozer, Delaware County Memorial, Taylor). And they can do this.
As you probably are aware, unlike the other Medicare Advantage plans, PFFS plans can be refused by providers on an individual basis. They can accept it Monday, refuse it Tuesday, and accept it again on Wednesday. What I don’t understand is why Medicare allows this loophole. <Naming the Plan> is receiving approximately $900 a month from Medicare, $70 a month from me and $1700 a year from my employer to provide coverage, and hospitals in the area no longer accept the plan. Our doctors seem to still accept it but if they want to admit you for an non-emergency procedure there is nowhere to go.
This situation seems to benefit no one but the insurance company. Over $13k a year, ($26k for both of us) ,coming in and little chance of anything going out. . . I would have thought that a plan approved by Medicare should be accepted by any provider that accepts Medicare. But not so. Providers that accept Medicare are not required to accept Medicare approved PFFS plans. Just thought you should know.”
Readers might question the reason why hospitals or doctors might refuse to accept PFFS.
One answer is in my July 7, 2008 column cited above. PFFS insurance plans do not have to pay Medicare standard rates to providers including physicians and hospitals. If the provider cannot get even the Medicare approved rate, it may no longer be cost effective to provide the service. The laws establishing PFFS also allow providers to refuse it. Even basic Medicare has lately been less generous in its coverage. Less than basic Medicare can be toxic.
If a reader has a PFFS plan and is unhappy with it, this is the time during Open Enrollment when she can obtain a type of Medicare Advantage plan that is not PFFS or she may just decide to purchase a Medicare Supplement or Medigap which is generally more expensive but more generally accepted and will cover the gaps in Medicare coverage.
If a reader has a PFFS plan and has not had to use its coverage for hospitalizations, doctor visits or procedures, this is the time during Open Enrollment to explore whether the coverage will be available if needed at local hospitals or with local physicians. She should ask the providers.
The reader should scrutinize everything that the company sends regarding plans and ask questions. This may be followed by telephone calls and letters or e-mails to confirm. Health insurance is an important enough matter to spend some time.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.