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Private Fee for Service Plans and a Part D Plan

Private Fee for Service is a Medicare Advantage Plan where a Private Insurance company provides your Medicare Part A and Part B benefits. In a Private Fee for Service Plan, you can get Medical Services from any provider who accepts the terms and conditions of the plan. Private Fee for Service works differently than Original Medicare and Medigap insurance. Premiums will vary depending on the plans available in your area. Depending on the plans available in your area, some of the plans may include Dental, Vision, Hearing, Gym Memberships. Additionally, plans Include a Maximum out of Pocket which would put a cap on your financial exposure in a calendar year. Medicare Part D plans would vary based on the plan selected in your area.

Disclaimer:

A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan's terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept payment terms and conditions, or otherwise agree to treat you, you will not be able to receive covered services from them under this plan.

Is this option right for me?

If you would like the freedom to pick a stand alone Medicare prescription drug plan that meets your needs, this could be a good choice.
If you are willing to get your Medical Services from providers who are willing to accept this plans terms and conditions, this could be a good choice.
If you are willing to accept higher out of pocket costs when you receive medical services in exchange for lower monthly premiums, this could be a good choice.
If you would like to receive “Value Added” benefits like hearing, dental, vision and/or gym membership, this could be a good choice.
If you’d like a cap on your maximum out of pocket expense, this could be a good choice.

Advantages

Financial Exposure to Part A and Part B cost sharing is capped depending on the specifics of the plans in your area.
Premium can be lower than a Medicare Supplement depending on the specifics of the plans in your area.
Additional Value Added benefits may be available (like Dental, Vision, Hearing and Gym benefits) depending on the specifics of the plans in your area.
Ability to select a Standalone Medicare Part D plan which is suited to your specific prescription drug needs.
Limits exposure to cost for Medicare covered Prescription drugs.
Avoids Late Enrollment Penalty (LEP) for Medicare Part D Prescription Drug Benefits.

Disadvantages

Out of Pocket cost depends on your level of utilization of services in the Private Fee for Service Plan subject to the maximum out of pocket.
Must use providers who are willing to accept the terms and conditions of the plan.
Depending on your county of residence, Private Fee for Service plans may require a Network of Hospitals and Physicians.
Medicare Advantage plans are not Guaranteed Renewable like Medicare Supplement plans. In addition, the benefits can be changed on a calendar year basis.
For those who do not qualify for “Extra Help” paying for their Prescription Drugs, there would be a premium for Part D.

Costs

Hospital and Medical Insurance Coverage
	Premium for the Private Fee for Service plan will vary based on the county of your residence and the plan you choose to enroll in. Generally, there is cost sharing for Hospitalization, Doctor Office visits, diagnostic tests, x-ray, therapy, etc. You will need to review the Summary of Benefits for each of the specific plans in your area to determine the exact out of pocket costs. Plans include a Maximum out of Pocket limit which is a calendar year maximum.

Part D — Prescription Drug Coverage
For Medicare Beneficiaries who do not qualify for "Extra Help" paying for their prescription drugs would have the option of selecting any Stand Alone Medicare Prescription Drug program which is available in their state of residence.
Premium	Varies based on the plan selected.
Deductible	Varies from $0 to $310 (in 2011) based on the plan selected.
Copays	Varies based on the plan selected. Standard benefit is 25% co-insurance up to $2,840 (in 2011) in total drug cost. Some plans may have co-payments for Generics, Preferred Brands, Non-Preferred Brands and Specialty drugs in lieu of 25% co-insurance.
Coverage Gap or "Doughnut Hole"	Varies based on plan selected. Some plans may cover Generics in the Coverage Gap. Very Few plans cover some Brand name drugs in the coverage gap. Medicare Beneficiaries pays 100% of discounted Prescription Drug costs until their "True Out of Pocket Cost" is equal to $4,550 (in 2011).
Catastrophic Coverage	Once the "True Out of Pocket Cost" is reached, Medicare Beneficiary pays the greater of 5% or $2.50 for Generics and $6.30 for Brand Name Prescription drugs (in 2011).

Part D — Prescription Drug Coverage
Those who qualify for "Extra Help" from the Federal government in paying their prescriptions will have lower cost sharing (and possibly lower premium). To see the 2011 guidelines for cost sharing at the various levels of qualification, click here. To find out if you qualify for Extra Help, visit www.socialsecurity.gov, visit your local Social Security Office or contact your local Medicaid office.