Medicare Managed Care Plans vs PFFS (Private Fee for Service) Plans
Last Updated : 09/15/20184 min read
If you are eligible for Medicare, or about to become eligible, you may be considering a Medicare Advantage plan over Original Medicare (Part A and Part B). Medicare Advantage plans are offered by private insurance companies approved by Medicare and provide an alternative way to get your Medicare benefits. Although these plans, by law, must provide at least the same coverage as Original Medicare (except for hospice care, which is still covered under Part A), many offer additional benefits to help their members manage their health-care costs.
For example, some plans include Part D coverage for prescription drugs, as well as benefits for routine hearing, vision, and dental care. Managed care plans and Private Fee for Service (PFFS) are both types of Medicare Advantage plans.
There are many different types of Medicare Advantage plans available, each with different rules, guidelines, and benefits. Not every plan type may be available in every location and your premiums may vary depending on where you live. It’s important to remember, however, that you must continue to pay your monthly Part B premium, plus any premium your plan requires, if you enroll in Medicare Advantage. Let’s take a closer look at managed care plans vs PFFS.
What are Medicare Advantage managed care plans?
The term “managed care plan” generally refers to a health maintenance organization (HMO) plan, a Preferred Provider Organization (PPO) plan or Point of Service (POS) plan. Specifically, Medicare Advantage managed care plans may include the following features:
- You are required to get all your routine and non-emergency care from providers within the plan’s network in a managed care plan. In the case of PPO plans, you may have the option to see providers outside the plan’s network, but you will generally pay more out-of-pocket if you do. In some cases, the difference in cost between in network and out-of-network care can be quite significant.
- For an HMO and POS managed care plan, you are generally required to choose a primary care provider who acts as a gateway for all your medical care. This means that you may be required to get a referral to see a specialist and get prior authorization to have certain tests or procedures. Some PPO plans may include variations of this policy and not require you to choose a primary care provider.
- You usually have Medicare Part D prescription drug coverage with your Medicare Advantage managed care plans but if you know you want that coverage, be sure to check your plan information brochure.
How is a Medicare Advantage PFFS plan different from a managed care plan?
Medicare Advantage PFFS (Private Fee for Service) plans operate a bit differently than managed care plans. Under a PFFS plan, the plan determines what it will pay for any particular medical service or medication, and what you will pay. You usually can see any doctor or hospital that accepts your plan terms and you are not required to choose a primary care physician or get referrals for specialist care, unlike some managed care plans.
However, unlike other Medicare plans, doctors and hospitals are not required to accept your plan, even if they participate with Medicare. If you are enrolled in a PFFS plan, be sure to ask your provider before your appointment if they accept your plan, even if you’ve seen them before. A provider can choose to accept or decline your plan at any time for any non-emergency medical service.
Other things to keep in mind about PFFS plans that might be different from managed care plans:
- Some plans may have a network of providers who will see you and accept your plan, even if you’ve never been a patient before.
- Providers must treat you if you need emergency care.
- You may or may not have Part D coverage for prescription drugs with your plan.
Need more information on managed care vs. PFFS plans?
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*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
*A Private Fee-for-Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency.