Feb. 10--Insurance companies are selling seniors on private fee-for-service health plans to replace their Medicare because the plans allow patients to see any doctor they want anywhere in the United States.

Sounds great, except some doctors have never heard of these plans and don't accept them.

A federal agency ordered seven insurance companies to stop selling fee-for-service plans until they changed their marketing practices, and the Pima Council on Aging is telling buyers to beware.

Open enrollment for Medicare Advantage ends March 31.

Here's what you need to know about private fee-for-service health plans.

What is a private fee-for-service plan?

A private fee-for-service plan is one type of Medicare Advantage plan.

When you hear "Medicare Advantage," think "Medicare replacement," said Lydia Baker, of the Pima Council on Aging.

When you sign up for any Medicare Advantage plan, you agree to deal with a private insurer instead of the federal government. The plans emulate Medicare: A doctor sees a patient and gets paid on the Medicare fee schedule.

Health maintenance organizations (HMOs) are the most popular Medicare Advantage plans.

About 84 percent of Arizona Medicare Advantage beneficiaries are enrolled in HMO-style plans, while 11 percent have fee-for-service plans, said Jim Hertel, publisher of the Arizona Managed Care newsletter.

There are 45 private fee-for-service plans offered in Pima County, 23 with prescription coverage and 22 without.

With a private fee-for-service plan, you can ideally get medical care from any provider in the United States. That's a good option for travelers because HMO plans typically only cover care where you live, Hertel said.

That was a big draw for Rosanna Ikaika, a 67-year-old property manager in Tucson.

"I travel a lot, so when I go somewhere, I want to know I'm not going to have any trouble with my health plan," she said.





The plans also are needed in rural areas, where doctors aren't contracting with HMO plans, Hertel said.

However, the doctor is supposed to agree to your plan's terms and conditions of payment before before each visit.

That's where things can get tricky.

Doctors don't have to accept

Not all doctors agree to the terms. And they don't have to accept your plan because unlike with an HMO, the doctor doesn't have a contract with the insurance company.

Most complaints about private fee-for-service plans are from people who say their doctors won't see them, Baker said.

Some doctors aren't willing to go through the steps or have never heard of these plans, so they turn patients away, she said. Emergency care is the exception.

"It's almost up to the patient to educate the doctor, and that's a very difficult thing to do," Baker said.

Hertel said small insurance companies that sell these plans, such as Pyramid, are not household names for Arizona doctors.

Some physicians, "when presented with a private fee-for-service plan card, will elect to not see the patient because of their unfamiliarity with how it works and how they'll be paid," he said.

Still, plenty of doctors are accepting the plans with no problems. Hertel said many doctors accept familiar fee-for-service plans because they typically pay the doctor the same amount as regular Medicare would pay for a given service.

Larry Levey, executive director of Arizona Community Physicians, which has 44 medical offices, said the plans are simple to use and popular among winter visitors.

"There is no hassle. You just bill the health insurer, and they pay you," he said.

But doctors do need more information about them, Levey added. Health-care providers can't know all of the choices on the market, and insurance companies aren't educating them about the plans, he said.

"There's just sheer confusion, and the patients are being stuck in the middle," he said.

Some are pressured to buy

Insurers have a good incentive to sell private fee-for-service plans.

Of all the types of Medicare Advantage plans available, the private fee-for-service plans afford insurers the highest payments from the Medicare administration -- on average 117 percent of what it would pay for a traditional Medicare beneficiary, Hertel said.

An ongoing debate in Congress asks whether the administration should reduce those payments to free up more money for doctors' fees and other programs.

After receiving reports of deceptive marketing practices, the Centers for Medicare and Medicaid Services stopped seven insurance companies from marketing private fee-for-service plans until they better educated their agents. They were suspended in June and reinstated in September.

The companies are UnitedHealth Group, BlueCross BlueShield of Tennessee Inc., Humana Inc., Sterling Life Insurance Co., Coventry Health Care Inc., Universal American Financial Corp. and WellCare Health Plans Inc.

Some seniors choose private fee-for-service plans based on information they receive at a seminar offered by an insurance company, Baker said. The companies often throw in a free meal.

Most people who complain about their plans said they attended one of these events and "felt pressured to make a change to that product," she said.

She advises seniors not to make decisions at such events. Instead, get the information, review it with a family member and make sure regular doctors accept it, she said.

Ikaika said she bought her private fee-for-service plan through Universal Health Care at a meeting in a restaurant.

The company offered to pay the Part B premium for the first year and it "sounded good," she said.

"I don't know if that was the hook," Ikaika said, adding that her co-payments increased and her Part B rebate decreased this year. However, she has been satisfied with the company's customer service, she said.

Now, she's shopping around by attending more informational meetings to make sure she's getting a good deal, she said.

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Who can help

--The Pima Council on Aging has trained volunteers to counsel you in your Medicare decisions. Call the Medicare hotline at 546-2011.

--If you're shopping for a doctor who takes your plan, the Pima County Medical Society can give you a list of doctors in your neighborhood. Call 795-7985 for a list, then call the doctors to ask about your plan.

Medicare Advantage membership

Here are the five most popular Medicare Advantage insurers in Arizona, according to the Arizona Managed Care newsletter. Medicare Advantage open enrollment ends March 31.

Medicare Advantage total enrollment

Pacificare 100,089

Health Net 46,479

Humana 30,867

Cigna 30,772

Sun Health 18,005

Fee-for-service enrollment

Humana 19,136

Sterling 2,427

Pyramid 2,369

Universal Health 2,086

Secure Horizons 1,889

Source: Arizona Managed Care

--Contact reporter Becky Pallack at 573-4224 or at bpallack@azstarnet.com.



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