Providers are the link to this season with MAPDPs

[Cenla Agent]

With Humana, you can download the latest directory from their website. They put out one for every plan at least every 2 months or so. You can also search on the site for providers in particular areas or by name. The latter is the most up to date option. Contacting the provider directly to confirm that they're contracted isn't a bad idea either Sometimes they are not listed but may be in the process of getting contracted.

 

[retread]

Make sure you don't miss the point of the action by CMS over the PFFS marketing this last summer. Providers under PFFS plans have the right to deny service to anyone on a PFFS plan from visit to visit, without justification. Providers under other MA plans do not have that luxury. If a provider is under contract to a network, he must honor it. PFFS plans, however, have a loose provision. I have a client whose doctor has given up on him because he won't do the things the doctor asks. At the point of frustration, the doctor tells him, "Just don't come back". Under a PFFS plan, he can say that.

 

[GreenSky]

Make sure you don't miss the point of the action by CMS over the PFFS marketing this last summer. Providers under PFFS plans have the right to deny service to anyone on a PFFS plan from visit to visit, without justification. Providers under other MA plans do not have that luxury. If a provider is under contract to a network, he must honor it. PFFS plans, however, have a loose provision. I have a client whose doctor has given up on him because he won't do the things the doctor asks. At the point of frustration, the doctor tells him, "Just don't come back". Under a PFFS plan, he can say that.

Point very well taken. I've gone full circle on the PFFS vs. Network Plans.

When PFFS came out 2 years ago I thought it was the 2nd coming of canned beer. After working with the plans I am convinced that unless CMS requires all providers to accept them (goes against my libertarian beliefs), they are doomed to failure. My guess is that 2009 will be the last year of these plans.

I reallly don't like the death traps called HMOs but I have enrolled probably 500 peoplke into them. Not MY choice of plan design but if the person can't afford a supplement and wants the HMO, I'll find he or she the best benefits.

PPO plans seems to make the most sense. You can have both in and out of network benefts and don't have to worry about the doctor. Just stay in network as we who are under 65 do and everyone is happy.

I have a number of PFFS clients in one county in Arizona. Their Pyramid plan is going to $49 without drugs. There is a PPO available with great benefits at the same price with drugs. Seems like a no-brainer to me.

I really wish there was a PPO choice in California worth a damn.

Rick

 

[Cenla Agent]

Point very well taken. I've gone full circle on the PFFS vs. Network Plans.

When PFFS came out 2 years ago I thought it was the 2nd coming of canned beer. After working with the plans I am convinced that unless CMS requires all providers to accept them (goes against my libertarian beliefs), they are doomed to failure. My guess is that 2009 will be the last year of these plans.

I reallly don't like the death traps called HMOs but I have enrolled probably 500 peoplke into them. Not MY choice of plan design but if the person can't afford a supplement and wants the HMO, I'll find he or she the best benefits.

PPO plans seems to make the most sense. You can have both in and out of network benefts and don't have to worry about the doctor. Just stay in network as we who are under 65 do and everyone is happy.

I have a number of PFFS clients in one county in Arizona. Their Pyramid plan is going to $49 without drugs. There is a PPO available with great benefits at the same price with drugs. Seems like a no-brainer to me.

I really wish there was a PPO choice in California worth a damn.

Rick

The trap with PPO is staying in network. Many seniors are not used to this type of plan and wrongly assume that their PCP is doing his due diligence and referring them to only other network providers, which is not always the case, leaving the member with unexpected out of network bills. For this reason, in some scenarios, an HMO really is simpler, especially if there is a good network in their local area and they do not travel much.

 

[midwestbroker]

Your best bet is to call the provider at the clients home and ask the billing department.

If you are enrolling someone during AEP, and they find that their doc is not in network, they can always change back in OEP.

The flip side to this is what they are paying for out of network. If the PPO is 80/20, then sometimes what they pay is less then the co-pay.

Example:
Client sees an out of network specialists - his 20% for the office call is $18.00. If the Dr wants to run some lab work, the client will take the Rx and go to Lab One (in network lab) and there has no in network co pay.

The normal specialists co pay is $30. He actually saves money by going out of network for basic services.

 

[retread]

Exactly!! I had this same experience, with a client whose specialist was not in the network. I wrote to him on her behalf, and the next time I saw this client, she said "Don't change anything. My out of network expense is less than I would pay if he was in network."!!