Insurance Agent Forum

[midwestbroker]

I learned something new today about how PFFS plans are accepted by providers.

While they do not need to be contracted, they are deemed to accepting the payment terms.

Example: This plan will pay 100% of the Medicare allowable rate for test A,B, and C. However, test D is paid out at 90% of the Medicare allowable amount

That is why some doctors are not taking PFFS plans.

But, most of the time it is an education issue, and in that case I will fax them a copy of the provider info that the carriers put out.

But the MA plan, by law, can not pay less than original medicare. So if original medicare would have paid 80% for that Test D, the MA plan has to pay 80% or more. That is a requirement for any MA plan to get their valuable medicare contract. There really is no reason for any doctor to turn down a MA plan--they will get paid at least as good, usually better and much faster with the MA carrier.
Med supps are a different story though.

[midwestbroker]

I thought that they could negotiate prices to providers, as long as the providers accepted the terms and conditions.

I know that on the member side they can be paying more then they would've on Medicare. Example: Humana's Kansas City PPO is a 75/25 split for out-of-network doctor visits.

Maybe with PPOs but I only work with PFFS plans...PPOs and HMOs are different and yes they can negotiate with providers because they have actual provider contracts. With PFFS plans a provider is deemed if they simply bill the PFFS carrier.

[midwestbroker]

K. I think I am understanding it all now.

Thanks!

[Cenla Agent]

My understanding is that PFFS will pay the providers the same as Medicare will. However there is may to be closer scrutiny of certain items like Home Health Care to make sure that services not covered by Medicare (like housekeeping, etc.) aren't being billed. Thus you will occasionally hear that MA "doesn't cover home health". It does, but only what Medicare is supposed to cover and nothing more.

[Cenla Agent]

Originally Posted by midwestbroker

I thought that they could negotiate prices to providers, as long as the providers accepted the terms and conditions.

I know that on the member side they can be paying more then they would've on Medicare. Example: Humana's Kansas City PPO is a 75/25 split for out-of-network doctor visits.

For the LA/MS Regional PPO non-network is 70/30, but several of the most common benefits this year have a copay that is not much more than the in-network copay, but with the member having to meet a $500 deductible.

The rule for MA in general (regardless of the type of plan) is that on average it has to be as good or better than Original Medicare. Humana appears to try to be at least as good as Medicare on nearly every benefit. But some other MA plans, particularly PFFS, will be quite good on doctor and hospital copays but will slam the members at 45-50% for DME and prosthetic devices, for example. I've also seen a plan (Pyramid I think) that makes the member pay 15% for home health whereas they pay 0 with Original Medicare.