Module 2 - Medicare Advantage Private Fee-for-Service Plans

Question 1

What are the 4 main characteristics of MA Private Fee-for-Service Plans?

Answer 1

1. Individuals enrolled in PFFS plans may receive covered services from any provider in the U.S. who is eligible to provide Medicare services and agrees to accept the plan’s terms and conditions of payment. They are not limited to a network of plan providers.
2. Some PFFS plans contract with providers. If the PFFS plan has a network, enrollees may pay more if they see out-of-network providers.
3. Except for emergencies, enrollees must inform providers before receiving services that they are a PFFS plan member, so the non-network providers can decide whether to accept the plan’s terms and conditions.
4. Non-network providers that accept Original Medicare may choose not to accept PFFS plan enrollees. Therefore, an enrollee needs to confirm that their provider of choice will accept a PFFS plan before enrolling in one.

Question 2

Can an individual enrolled in a PFFS plan receive covered services from any provider int the U.S. who is eligible to provide Medicare services and agrees to accept the plan’s terms and conditions of Payment?

Answer 2

Yes. Individuals enrolled in PFFS plans may receive covered services from any provider in the U.S. who is eligible to provide Medicare services and agrees to accept the plan’s terms and conditions of payment. They are not limited to a network of plan providers.

Question 3

What happens if an enrollee sees an out-of-network provider when a PFFS plan has a network?

Answer 3

Some PFFS plans contract with providers. If the PFFS plan has a network, enrollees may pay more if they see out-of-network providers.

Question 4

Must an enrollee inform a provider that they are on a PFFS plan before receiving services from the provider?

Answer 4

Yes. Except for emergencies, enrollees must inform providers before receiving services that they are a PFFS plan member, so the non-network providers can decide whether to accept the plan’s terms and conditions.

Question 5

Can a non-network provider that accepts Original Medicare choose not to accept PFFS plan enrollees?

Answer 5

Yes. Non-network providers that accept Original Medicare may choose not to accept PFFS plan enrollees. Therefore, an enrollee needs to confirm that their provider of choice will accept a PFFS plan before enrolling in one.

Answer 6

Providers are prohibited from charging a PFFS enrollee more than the cost-sharing specified in the PFFS plan’s terms and conditions of payment.
- Cost-sharing may include balance billing up to 15% of the Medicare rate only if allowed in the plan’s terms and conditions of payment.

Balance billing happens when a doctor is eligible to accept Medicare but is not a Medicare “participating” provider under Original Medicare. Under Original Medicare, these non-participating providers are allowed to balance bill beneficiaries up to 15% over the Medicare payment amount.

PFFS plans may choose whether or not to allow non-participating providers to balance bill their members.

PFFS plans may choose to offer Part D benefits but are not required to do so