Audio CD and written materials of AIS's audioconference on April 19, 2007

Medicare Private-Fee-for-Service: Health Plan Strategies for a Booming but Controversial Product

Prefer a Written Report? Order the report based on this audioconference. Private-fee-for-service (PFFS) plans are clearly the hottest product in Medicare Advantage (MA), with enrollment reaching 1.3 million beneficiaries as of February, up from just 209,000 in December 2005. Their attractiveness has spread far beyond rural areas because of the appeal of their non-network structure and the high reimbursement the plans typically get from the feds. But with the popularity has come complaints about alleged marketing violations, widespread rejection of PFFS by providers and resulting access issues for enrollees. And the likelihood of federal action to limit payments to MA plans even has some plan sponsors wondering if the PFFS program is sustainable. Get an inside look at the factors triggering the current boom and controversies, and what plans can do to make the most of the PFFS product opportunity.

Sponsored by Atlantic Information Services, Inc., publisher of Managed Care Week, Medicare Advantage News and Drug Benefit News

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It wasn't long ago that private-fee-for-service (PFFS) plans were but a blip on the Medicare map, offered by just a few sponsors and mainly in rural areas. How things have changed!

Most major health plan operators now are offering the product, which is a hybrid between fee-for-service and managed care, and they're doing it in wide geographical areas. There are 482 individual-market PFFS plans and 108 employer-group-market PFFS plans in 2007, according to CMS data.

Numerous factors are contributing to the explosive growth of PFFS plans, which are attractive to sponsors because of attractive federal payment rates for rural areas, relative freedom from state regulation, and the ability to expand rapidly. In addition, Congress recently allowed MA plans that don't cover drugs (a category including numerous PFFS products offered by many major health plans) to enroll customers throughout 2007 and 2008 without being subject to the lock-in dates governing Medicare drug-plan products. And enrollees like the PFFS concept because they are not limited to a provider network.

But PFFS plans have their unique pitfalls as well, and are attracting greater criticism and government scrutiny. Taking advantage of the PFFS product opportunity will require a thorough understanding of the problems some sponsors are now encountering.

Two of the nation's top Medicare managed care experts outline details of strategies that will help you seize the current and future opportunities in PFFS … and avoid the pitfalls ahead. Among the areas they cover are:

Speakers

JOHN GORMAN is president and CEO of Gorman Health Group, LLC, the leading consulting firm specializing in Medicare managed care and Part D. Before starting his company in 1996, Mr. Gorman served as assistant to the director of HCFA's Office of Managed Care under two directors. Prior to that, he was staff director to U.S. Rep. John Conyers Jr., then chairman of the House Government Operations Committee. Mr. Gorman specializes in strategic planning and business development for the health care industry, with particular emphasis on federal programs and regulation.

JEAN LeMASURIER is director, Employer Group Practice, at Gorman Health Group, LLC. She joined GHG after a 30-year career with CMS and its predecessor, most recently as senior advisor for the Employer Policy and Operations Group in CMS's Center for Beneficiary Choices. In that role, Ms. LeMasurier provided leadership on policy and operational issues related to implementation of the 2003 Medicare reform law. Before that, she spent six years as the acting director/deputy director of the Health Plan Benefits Group in the Center for Beneficiary Choices, responsible for purchasing and regulatory oversight of Medicare managed care services.

Moderator: Jim Gutman, vice president and executive editor at Atlantic Information Services, Inc.

 

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*Please note that shipping of CDs and materials will begin within three weeks of the conference.

 

Written Materials