Under the new Medicare Advantage Program, insurance companies can offer a way to receive Medicare benefits known as a Private Fee for Service Plan or PFFS. A Medicare private fee-for-service (PFFS) plan arranges care for Medicare-eligible beneficiaries enrolled in the PFFS.
A Private Fee For Service Plan is NOT a Medicare Supplement
A Medicare Supplement gives you access to any Doctor, any hospital, any provider in the Medicare Program.
A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan.
With Private Fee for Service a doctor or hospital is NOT required to agree to accept the plan’s terms and conditions, and may choose not to treat you,
If a doctor or hospital does not agree to accept the payment terms and conditions of the Fee For Service, they may choose not to provide health care services to you, except in emergencies.
Most Medicare Private Fee-For-Service Plans don’t have a network of participating providers for you to get covered services.
You must find doctors, hospitals, and other types of providers willing to accept the plan’s payment terms.
Before enrolling in a Medicare Private Fee-for-Service Plan, be sure you have found providers willing to accept the Medicare Private Fee-for-Service Plan’s terms.
So what is a Private Fee For Service Plan?
Private Fee for Service, sometimes referred to as “Privatized” Medicare, is a plan offered by a private insurance company having a yearly contract with Medicare to provide beneficiaries with all of their Medicare benefits plus any additional benefits the company may decide to provide.
Services covered by the plan usually require a co-payment, and in some cases, members of these plans must also pay a percentage of the Medicare-approved amount, at times up to 35 percent.
People who join these plans must be on Medicare Parts A and B. They can see any provider who also receives payment for Medicare covered services and who agrees to accept payment from the PFFS plan.
PFFS plans can require beneficiaries to notify them before they are admitted to a hospital or skilled nursing facility for a planned stay.
Failure to comply with a plan’s requirement for prior approval for certain services can result in a higher co-payment.
Doctors and Hospitals and other providers do not bill Medicare for services. Instead, they must bill the PFFS plan.
Some private fee-for-service patients have been denied services by physicians who previously accepted their traditional Medicare
If your provider agrees to the plan’s terms and conditions of payment.
The provider must follow the plan’s terms and conditions for payment, and bill the plan for the services they provide for you. However, the provider can decide at every visit whether or not to accept the plan and agree to treat you.
If your provider doesn’t agree to the plan’s terms and conditions of payment
The provider shouldn’t provide services to you except for emergencies,
and you will need to find another provider that will accept the plan.
Patients must inform their doctors and any other providers from which they receive medical services about the plan’s payment structure.
To do this, beneficiaries can get forms from the plan to give to their providers that explain coverage and billing procedures.
What can I do if my Medicare Private Fee-for-Service Plan
won’t pay for a service I think is medically necessary?
If your plan won’t pay for, or doesn’t allow, a service that you think should be covered, you can file an appeal.
If you have Medicare, you have certain guaranteed rights.
One of these is the right to a fair process to appeal decisions about healthcare payment of services.
An appeal is a kind of complaint you make if your Medicare Private Fee-for-Service Plan refuses to pay for a service item, or prescription drug that you got and think should be covered, your Medicare Private Fee-for-Service Plan has told you in advance that it won’t cover a service item, or prescription drug you think should be covered, you disagree with the amount that you have to pay for a service or item you got.
The appeal rights listed above apply to benefits generally covered by Medicare and extra plan benefits provided by your Medicare Private Fee-for-Service Plan.
If you decide to file an appeal, ask your doctor, health care provider, or supplier for any information that may help your case.
For more details concerning Private Fee For Service Plans visit:
http://www.medicare.gov/Publications/Pubs/pdf/10144.pdf
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