PFFS versus PPO

[Winter_123]

MA virgin here.

If I look at the MA's being offered in my state I see, for example, a Secure Horizons PPO plan and then I see a Today's Option PFFS plan, etc.
There are differences on deductibles, copay, moop, drug copays etc. as you might expect.

What I am trying to understand is this: Assume just for the sake of argument that a PFFS and a PPO plan are equal in premium cost, be that zero or whatever, and that all of the other deductible, copay, factors are basically equal. Is it a given that a PFFS plan would be better in this instance or is it more complicated than that in the real world. Obviously with a PPO plan you are in a network and with a PFFS plan you can go anywhere. So PFFS would seem better, assuming premiums are equal and other features are tolerably close. But that also assumes that if they go to a doctor of choice within a PFFS plan that that doctor is going to accept the whole MA gig doesn't it? And if they are not part of a network how do they know that?

To put the question another way, cost aside, are there scenarios where a PFFS plan may not work as well as a PPO plan or there may be surprises of some sort?

Thanks,

Winter

 

[GreenSky]

Until recently I thought that the PFFS plans were the best thing that has happened to Seniors since Medicare. However, my thinking has been changed.

Since a doctor can change his mind on a daily basis about PFFS, it may not be the way to go. All the new training even points out that the doctor might see your neighbor, but not you. Great selling point!

With a PPO, there is no issue. If the doc is in network, you get to see that doc. Sure, there IS a network, but PPOs tend to have pretty large networks.

PFFS was designed for rural folks who have no access to any other Medicare Advantage plan. In metro areas, if there is a PPO, it may be the better way to go.

Of course, a Med Supp is best if the person can afford the premiums.

Rick

 

[Guest]

Thanks, Rick. Informative as always. But you left a few things unanswered:

Since a doctor can change his mind on a daily basis about PFFS, it may not be the way to go. All the new training even points out that the doctor might see your neighbor, but not you. Great selling point!

Really? Isn't there a reg that says if a provider takes Medicare they have to take everyone without cherry-picking? Wouldn't this apply to PFFS? (Not arguing, just asking.)

With a PPO, there is no issue. If the doc is in network, you get to see that doc. Sure, there IS a network, but PPOs tend to have pretty large networks.

Out of curiosity... do docs get paid more for joining a Medicare (MA) network? If they are in the network for a large carrier's IFP PPO, can they opt out of the MA network? Are there 2 different networks? What is incentive for doctor to be part of a MA network when he can get lots of patients by just taking regular Medicare?

PFFS was designed for rural folks who have no access to any other Medicare Advantage plan. In metro areas, if there is a PPO, it may be the better way to go.

Why? Choice? How should a senior evaluate joining a network MA or a PFFS plan?

Of course, a Med Supp is best if the person can afford the premiums.

Except for 3-months before and 3 months after your 65th b-day, OR if your previous Med sup carrier drops out, what other times are med sups NOT underwritten? Is there some kind of OE for them as well? I remember something about a "birthday rule"... perhaps just in CA?

Thanks Rick. No one knows this %$#@ like you (and Dave, maybe Frank and a few others.)

Al

 

[Cenla Agent]

IMO a PPO is more complicated than PFFS (and arguably more complicated than an HMO) especially for those seniors who have never had any kind of PPO in the past. When I started in 2005 I thought the opposite. But if you sell a PFFS right, they know they have to check with every provider to ensure acceptance. But with a PPO there's a tendency sometimes not to do that. Also keep in mind that if the provider doesn't take the PFFS most likely they won't treat them at all. Not so with a PPO, they will just be charged the out of network rates. Probably the biggest problem to watch out for is referrals. Their PCP may be in network, but what about the specialist to which they are referred? How about the hospital where their PCP sends them for outpatient tests? There are some smaller towns for example where practically every doctor is in the PPO network but not the hospital. Some doctors and offices will be more conscientious about referring their patients to network PPO providers than others. I have always emphasized to my clients their need to independently confirm that the provider is in network, but I would imagine the tendency is to go along with whatever their doctor suggests. There is also the real possibility of confusion on the part of the provider. With Humana this may be a bigger problem than with some other carriers. I think Secure Horizons is strictly a brand for seniors and so may be less likely to be confused with something else. But when a member calls up a doctor and says "do you take Humana," (i.e. are they in the PPO network) they have to be very explicit about what particular plan they have or they are likely to get a yes when the answer may very well be no. For example here in LA many state employees are on Humana, and practically every provider is in that network. But that's not the case for the Choice PPO, which is a smaller network. Other providers may confuse the PPO for the PFFS if they are not familiar with both plans. So with Humana at least, they need to specify that they have Gold Plus (HMO), Choice PPO, or Gold Choice (PFFS) to get an accurate answer. It may not be as complicated with other plans that have different branding or that don't have so many different MA's that they offer.

By contrast, with an HMO it is very cut and dried. Either the provider is in network or not, and the PCP coordinates all care, except for Louisiana, where Humana has self referral to a network specialist. Obviously I'm not saying an HMO is for everyone, just that for some it may actually be simpler (not to mention much cheaper), and in some metros the network is pretty good. But where an HMO is available usually a PPO isn't even on the table (PPO is much higher in LA, don't know about other states) unless you're dealing with someone who has problems with the geographic restrictions of an HMO.

 

[retread]

Cenla's remarks:

Probably the biggest problem to watch out for is referrals. Their PCP may be in network, but what about the specialist to which they are referred? How about the hospital where their PCP sends them for outpatient tests? There are some smaller towns for example where practically every doctor is in the PPO network but not the hospital. Some doctors and offices will be more conscientious about referring their patients to network PPO providers than others. I have always emphasized to my clients their need to independently confirm that the provider is in network, but I would imagine the tendency is to go along with whatever their doctor suggests.

--------
TRUE!! I have been in both HMOs and PPOs for many years under my employer's group health insurance. Most recently (the last 15 years or so) I have been in a PPO. More than once, I have been surprised with a bill from a specialist that was larger than expected, and found out he was an "out of network" doctor referred by the "in-network" doctor. I have since learned to inquire beforehand, but for those who are not PPO-savvy, there are some lessons to learn. When this happens, who ya gonna think will get the blame?

 

[policy doctor]

I had a client call me becaue her Coventry PFFS card was refused by her imaging center. She was referred there by her dr for her mammogram X-ray.

I did a 3-way call to Coventry claims, and was assured they would handle it.

All the providers get paid the same amount of money as Orig Medicare would pay. Plus they usually get paid within 2 weeks by the MA company. So really they have an incentive to accept the MA.

Now the copays, which they get on the day of service, or they bill the client, come in quicker than waiting the traditional insurance way...which can take up to 2-3 months for payment.

Since most doctors taking Medicare patients accept assignment, I don't understand why they would be selective and not take patient B, but treat patient A, even if both have the same MA plan. I can understand why they don't participate in all plans, because of the additional paperwork.

I beleive that ins companies will be more aggressive in their contact and marketing this year to medical providers and these will become non-issues.





The copay

 

[senior-advisor-indiana]

Al,
Just because a Dr. accepts medicare doesn't mean they wil accept PFFS plans. What Rick is saying is that the Dr. can accept the plan's payments on a case by case basis and a client by client basis. You could see the doc today for a cold and he could refuse you the next day for a broken arm(or whatever). HIghly unlikely that that would happen but that is what you have to tell the prospect.

 

[Cenla Agent]

From my experience, providers taking some PFFS members and not others will usually be with a provider who as a rule does NOT accept it but makes an exception for a friend, etc.

I had a client call me becaue her Coventry PFFS card was refused by her imaging center. She was referred there by her dr for her mammogram X-ray.

I did a 3-way call to Coventry claims, and was assured they would handle it.

All the providers get paid the same amount of money as Orig Medicare would pay. Plus they usually get paid within 2 weeks by the MA company. So really they have an incentive to accept the MA.

Now the copays, which they get on the day of service, or they bill the client, come in quicker than waiting the traditional insurance way...which can take up to 2-3 months for payment.

Since most doctors taking Medicare patients accept assignment, I don't understand why they would be selective and not take patient B, but treat patient A, even if both have the same MA plan. I can understand why they don't participate in all plans, because of the additional paperwork.

I beleive that ins companies will be more aggressive in their contact and marketing this year to medical providers and these will become non-issues.





The copay

 

[midwestbroker]

What I have found in KC (Which is a HMO/PPO market)

Most people will choose a plan with a network so they know for a fact their doctors will take it.

People who are 65-69 generally have a good idea what a PPO is since that is usually what they had while they were working.

I avoid PFFS plans since they have been through all kinds of chaos if a PPO is available.

Some factors to look at:

- How long has the PPO been in that market (the longer usually the stronger the network)
- How is the network - some markets have multiple networks and some may not be in-network
- Cost - Some PFFS plans with Part D are $50+ per month while rival PPO's could be far less
- Benefits - They are all over the place depending on your market
- MOOP (Max out of pocket) costs

Hope this helps...