Private Fee-for-Service
Provider Questions & Answers

1. What is Today’s Options?
2. How is Today’s Options different from an HMO (Health Maintenance   Organization) plan?
3. Why would a Medicare beneficiary choose Today’s Options?
4. Does Today’s Options cover everything that Original Medicare covers? 
5. What qualifications must a healthcare provider have in order to be eligible to furnish services to Medicare beneficiaries who are enrolled in a PFFS plan?
6. What is a “Deemed” Provider?
7. What is a non-deemed provider?
8. What happens if a provider furnishes services to a Today’s Options member but the deeming conditions have not been met?
9. If a provider agrees to the terms and conditions and becomes a deemed provider, how does that provider stop from being a deemed provider?
10. How does a provider know that a Medicare Beneficiary is enrolled in Today’s Options rather than Original Medicare?
11. What utilization management practices does Today’s Options use?
12. Is a Medicare provider that accepts assignment required to accept a Today’s Options member for care?
13. Are there any circumstances when a hospital that does not accept Today’s Options may provide services to a Today’s Options member?  Can a hospital remain a non-deemed Today’s Options provider under these circumstances?
14. How much will a deemed provider be paid by Today’s Options?
15. If Today’s Options is required to reimburse providers using current Medicare allowable rates, how will the plan stay updated with the ongoing changes in Medicare benefits and payments?
16. Can a provider bill the beneficiary if Today’s Options will not pay?
17. How does a provider bill Today’s Options?
18. How does Today’s Options reimburse providers?
19. How long will it take Today’s Options to pay a provider?
20. What if the provider disagrees with a Today’s Options payment?
21. How can a provider find out more information about Today’s Options and Private Fee-for-Service plans?
22. Does Today’s Options have a Provider Manual available that our office staff may reference?
23. Where can I find information about Today’s Options?

1.  What is Today’s Options?

Today’s Options is a Medicare Advantage Private Fee-for-Service (PFFS) plan that is offered by Pyramid Life Insurance Company and American Progressive Life & Health Insurance Company of New York, under contract with the Medicare program.  The plan gives members the option to receive care from any physician or provider eligible to participate in Medicare and willing to accept the plan’s terms and conditions.  A PFFS plan is required by law to: (1) pay providers on a Fee-For-Service basis; and (2) not place providers at risk.

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2.  How is Today’s Options different from an HMO (Health Maintenance Organization) plan?

Pyramid Life Insurance Company and American Progressive Life & Health Insurance Company are indemnity insurance companies, not HMOs.  Today’s options pays providers 100% of current Medicare allowable rates and cannot place the providers at risk or base their reimbursement on utilization. 

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Today’s Options provides the freedom most beneficiaries want at an affordable premium.  Members are free to choose their own hospitals and physicians, including specialists, with no referral or prior authorization required.  Claims can be handled electronically and are paid promptly.  Members receive full benefits while they travel throughout the United States and if their travel takes them abroad, emergency and urgently needed services are reimbursable. 

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Yes.  By law, a PFFS plan must provide members with coverage for at least the same benefits they would receive under Original Medicare, with the exception of hospice.  The Hospice benefit is available through Original Medicare.  Today’s Options cost sharing amounts are different from those charged by Original Medicare.  In addition, Today’s Options offers extra benefits, including routine physicals and hearing and vision exams.  Any extra benefits offered by the plan are specified in the terms and conditions of participation.

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To be eligible to furnish care to a PFFS, enrolled physicians must be state licensed and have a Medicare billing number or be eligible to obtain one.  Institutional providers treating PFFS members, such as hospitals and skilled nursing facilities, must be certified to treat Medicare beneficiaries. 

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Today’s Options does not have contracts with an exclusive network of providers.  Rather, providers are considered “deemed” participants of the Today’s Options plan and are deemed to accept these terms and conditions when a Medicare participating provider: a) knows in advance of providing services that a Medicare beneficiary is a member (Today’s Options will provider members with an identification card); b) has been given reasonable opportunity to access the Terms and Conditions for providing services to a Today’s Options member (Providers may request a letter of agreement from Today’s Options with the “Terms and Conditions” restated and signed by the health plan); and c) subsequently provides services to that member. 

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A non-deemed provider is a provider who treats a Today’s Options member without meeting the deeming requirements.  A provider has not met the deeming requirements if he/she furnishes services to a Today’s Options member but is unaware of the patient’s enrollment in Today’s Options or doesn’t have a reasonable opportunity to learn the terms and conditions of the plan before furnishing services to a member. This might be the case if a provider does not know before offering emergency treatment that the patient is a Today’s Options member.

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If a provider furnishes services to a member of Today’s Options and the conditions of deeming have not been met, then the provider is considered a non-deemed provider.  In this case, a non-deemed provider is entitled to be paid the amount they would have received for the service under original fee-for-service Medicare.  It is important to note that a provider can choose whether they will provide services to a member in Today’s Options.  However, the provider cannot choose whether they are classified as a deemed or non-deemed provider. 

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As a provider, you have the choice to accept or deny the Today’s Options terms and condition.  If you decide not to accept the terms and conditions, you should inform the Today’s Options member that you do not accept the plan and that he/she will have to seek care from a provider who accepts the Today’s Options terms and conditions.  In this situation, if you provide services to the member (other than urgently needed or emergency services), you would be viewed as a deemed provider even if you did not accept the terms and conditions. 

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The member should present the provider with a Today’s Options Identification Card identifying them as a member of Today’s Options.  For reference, the identification card gives a toll-free phone number and website for the Today’s Options terms and conditions. 

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Unless required by law, Today’s Options will not build any utilization management controls into the plan.  It is the choice of the member and the attending physician that governs utilization.  Utilization is monitored, not managed, through notification for planned inpatient hospital admissions, inpatient mental healthcare visits, and outpatient surgical visits.  In addition, durable Medicare equipment or prosthetic device rentals or purchases costing $750 or greater are subject to notification.  Additionally, Today’s Options offers a Health & Wellness Services to its members.  Members who choose to participate in care coordination services will be provided with “best practice” care plans which will be shared with their physicians.

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No, providers are not required to see a member in the Today’s Options plan.  However, if a provider furnishes care to a Today’s Options member, and the deeming conditions have been met, the provider is bound by Today’s Options terms and conditions of participation.

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Yes.  Services provided only in an emergency room that are of an emergency nature do not constitute a “deemed” event.  Under these circumstances, a provider would remain a non-deemed provider under the Today’s Options plan.  If a hospital treats a member of Today’s Options for outpatient or inpatient services, the provider is automatically deemed and bound by the PFFS rules and regulations as well as Today’s Options Provider terms and conditions. 

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A deemed provider will be paid 100% of the current Medicare allowable rates.  Providers agree to receive all payments from Today’s Options – less any member cost sharing – as payment in full.  Providers, therefore, agree not to bill the members for services that are covered by the plan.   

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Today’s Options adheres to reimbursement updates and methodologies as they are implemented by CMS.  On a routine basis, Today’s Options submits reimbursement methodology to CMS and, upon approval, Today’s Options updates the payment information on its website.

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A provider who furnishes care can only collect from the beneficiary the cost sharing amounts allowed under the Today’s Options terms and conditions of participation.  If the care a provider furnishes is not covered under the plan, the provider can collect from the beneficiary if he/she has agreed in writing to pay for the services if they are not covered.  For example, a provider furnishes a hearing aide that is not covered by the plan to a beneficiary.  The provider can only collect from the beneficiary if, prior to receiving the hearing aide, the beneficiary had agreed in writing to pay for the hearing aide if it was not covered by their plan.  

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Providers are to bill Today’s Options using the same Medicare billing guidelines, forms, and codes as Original Medicare.  Today’s Options requires that all claims be submitted within 365 days from the date of service.

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Today’s Options will reimburse providers on a fee-for-service basis.  Today’s Options uses methodologies, posted on Today’s Options website, or reimburse the equivalent of Medicare allowable less any member cost-sharing amount of federal exclusions.

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Under federal law, PFFS plans are required to process 95% of all error free (known as clean claims) within 30 days of receipt by the plan.  Clean claims not processed within 30 days accrue interest.  On average, Today’s Options pays clean claims within 14 business days. 

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If a provider feels that a clean claim should have been paid differently, they have the right to dispute the payment from Today’s Options.  The Today’s Options Provider Dispute Resolution process includes the following methods of appeal: (1) an initial verbal inquiry; and (2) a formal written provider dispute resolution request.  To file a dispute, you may call Provider Relations from 8 AM to 11 PM EST, 7 days a week, at:

• American Progressive at 1-888-445-8699, or
• Pyramid Life at 1-866-568-8921
   

Or send a written dispute resolution request to:

Today’s Options
9990 Richmond Avenue, Suite 300 North
Houston, Texas 77042
Attn: Provider Dispute Resolution
Fax: 1-713-978-6703

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Providers may contact Today’s Options Member Services between 8 AM -11 PM EST, 7 days a week at:

• American Progressive: 1-888-445-8699
• Pyramid Life: 1-866-568-8921

Medicare has additional information on its website about Today’s Options PFFS plan through the Medicare Personal Plan Finder at www.medicare.gov.  The centers for Medicare & Medicaid Services (CMS) is responsible for the oversight of PFFS plans and also provides information about the operation of Medicare PFFS plans by accessing the CMS website at http://www.cms.hhs.gov/PrivateFeeforServicePlans/.

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Yes.  Today’s Options has a 2008 Provider Manual that is available through our website at www.todaysoptions.com.  A written manual has also been mailed to physicians and providers offices that have been identified by our members as their preferred healthcare providers.

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23.  Where can I find information about Today’s Options?

You can find information about Today’s Options on their website, which can be found at the following address: www.todaysoptions.com

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