PFFS Plans

[wehotex]

PFFS plans are not very prevalent in my market. As a result, I don't have a lot of experience with them since I've sold only about 1 0r 2 in the past.
When I call my current propect's providers if they will bill it, many don't even know what it is after my explanation. I am uncomfortable with not selling an established network of providers. The benefits on the Humana PFFS are richer than the Aetna PPO plan though, which is why I'm considering it. For those of you who sell this type of product, do you end up calling the providers beforehand to verify the participation? Does the carrier help you with it?

 

[AllGold]

The problem with PFFSs is the provider can accept it today and literally not accept it tomorrow at their whim. You're supposed to really emphasize to the client that they HAVE to ask before each and every appointment with the provider.

That and the 2011 CMS rules update on networks for PFFS plans have really killed off a lot of plans.

 

[Frank Stastny]

The problem with PFFSs is the provider can accept it today and literally not accept it tomorrow at their whim. You're supposed to really emphasize to the client that they HAVE to ask before each and every appointment with the provider.

That and the 2011 CMS rules update on networks for PFFS plans have really killed off a lot of plans.

That is one of the many reasons I don't sell MA/PFFS plans. I'm not comfortable selling a prospect a plan that their doctor may accept today but reject tomorrow. I've seen this happen too many times. Seniors get very upset if they have to change doctors.

 

[wehotex]

That is one of the many reasons I don't sell MA/PFFS plans. I'm not comfortable selling a prospect a plan that their doctor may accept today but reject tomorrow. I've seen this happen too many times. Seniors get very upset if they have to change doctors.

I've decided to offer my guy the Aetna PPO product. It has an established network, fixed copays and I don't feel as if I'm selling "thin air".

 

[healther]

For those of you who sell this type of product, do you end up calling the providers beforehand to verify the participation? Does the carrier help you with it?

I sell a good bit of these plans and open access PPO's here in SC. Yes, it is a VERY good idea to call the providers (should be mandatory) and confirm that they will accept the plan if the prospect is set on keeping their current providers. And yes make it very clear that the provider is not under contract to continue accepting the plan. For the average healthy senior the benefits are often difficult to turn down, but the biggest issue is making sure they are in the best plan for them. If you don't put them in the best plan for them, someone else will. I generally present the best Open Access plan and the best Network plan and highlight the differences allowing them to make the choice. That way if someone comes behind you selling the other, they have already ruled it out in their mind.

 

[Frank Stastny]

I generally present the best Open Access plan and the best Network plan and highlight the differences allowing them to make the choice. That way if someone comes behind you selling the other, they have already ruled it out in their mind.

Does CMS permit that?

I suggest to "healthier" seniors that they keep Medicare A & B rather than go with a PFFS plan. The out of pocket expense will generally be less than paying copays and giving up the right to choose their doctors and not have to worry about their doctor deciding to no longer accept the plan.

Medicare pays 80% of the approved amount for a doctor visit. The senior only pays the remaining 20% of the approved amount. Usually the approved amount is going to be $50 to $70. That's only $10 to $14. Medicare pays 100% of diagnostic testing.

 

[Todd King]

Does CMS permit that?

I suggest to "healthier" seniors that they keep Medicare A & B rather than go with a PFFS plan. The out of pocket expense will generally be less than paying copays and giving up the right to choose their doctors and not have to worry about their doctor deciding to no longer accept the plan.

Medicare pays 80% of the approved amount for a doctor visit. The senior only pays the remaining 20% of the approved amount. Usually the approved amount is going to be $50 to $70. That's only $10 to $14. Medicare pays 100% of diagnostic testing.

The only problem with doing that is when they have a bill for 100K because of having to go into the hospital for a triple by-pass or something like that. Now they have to come up with 20K!

 

[Frank Stastny]

The only problem with doing that is when they have a bill for 100K because of having to go into the hospital for a triple by-pass or something like that. Now they have to come up with 20K!

That is so unlikely to happen. I think you may be forgetting that Medicare dramatically reduces the amounts that they pay doctors and surgeons and Medicare pays 80% of the approved amount.

The hospital bill will not exceed $1,132 this year. That is the Medicare Part A Deductible. Medicare pays 100% of the cost after the senior pays the Part A Deductible.

$20,000? Not likely.

 

[healther]

That is so unlikely to happen. I think you may be forgetting that Medicare dramatically reduces the amounts that they pay doctors and surgeons and Medicare pays 80% of the approved amount.

The hospital bill will not exceed $1,132 this year. That is the Medicare Part A Deductible. Medicare pays 100% of the cost after the senior pays the Part A Deductible.

$20,000? Not likely.

If that was the case then yes I would tell them to stick with A&B. Explain to me how I have numerous customers that chose to pick a MA plan after they found out the hard way that a broken shoulder or broken hip ended up costing them over $10k out of pocket. I would honestly like to hear how this happens, not trying to argue or instigate. I originally thought the Part A covered all Hospital expenses, however, I have been taught that Part A covers your Hospital stay and your Part B covers what the doctors do (therefore you still have 20% coinsurance).

To answer your earlier question you can discuss multiple versions of MA products, PDP's and Med Supps in an MA appointment.
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The only problem with doing that is when they have a bill for 100K because of having to go into the hospital for a triple by-pass or something like that. Now they have to come up with 20K!

Heard this story more than once...

 

[Frank Stastny]

You guys may very well be right. The original concept of insurance was to protect people from catastrophic loss. I understand that. But, I hear agents say all the time that they only suggest MA plans to their prospects that are "healthy". If they aren't they they recommend a Med Supp.

How does that agent know that tomorrow that "healthy" person will suddenly become "unhealthy"? Seniors are like vintage cars, they can run like a top today and need a total overhaul tomorrow.

The post I originally responded to stated, "For the average healthy senior". My comments were based on that statement. Some how multiple by-passes came into play and now that "average healthy senior" is almost on their death bed.

So you guys need to decide, is that senior healthy or does he have one foot in the grave and how does one make that determination both today as well as "tomorrow"?

However, that still doesn't change my position on PFFS Plans. It's a personal thing, I don't like them and won't sell them. I refer those prospects who think they want one to other agents. They aren't in my comfort zone.