PFFS vs PPO: What’s the difference

Pamela Cannaday by Pamela Cannaday | Licensed since 2011

This article was updated on: 09/15/2018

Medicare Advantage, also known as Medicare Part C, is an alternate way to get your health care benefits under Original Medicare (Part A and Part B). Here’s a look at the difference between a Medicare Advantage PFFS vs PPO plan.

What is a Medicare Advantage PFFS* plan?

PFFS stands for “Private Fee for Service,” and it is one type of Medicare Advantage plan. These plans, like all Medicare Advantage plans, are offered by private insurance companies contracted with Medicare, so the insurance company can determine what they will pay and what you will pay for your medical care. Some PFFS plans use a coinsurance model, where you pay a certain percentage of allowable charges, while others use a copayment, or set amount, in determining your cost-sharing amount. Depending on the plan you choose, you may also have to meet a deductible each year.

You do not need to choose a primary care doctor under PFFS plans, and you do not need a referral to get specialist care. You can use your PFFS plan at any health care Medicare-approved provider that accepts the terms of your plan. Not every provider will accept the payment terms under a PFFS plan, so it’s important to ask before you get care to avoid any unpleasant surprises. Even if you’ve been seen by a provider in the past who accepted your plan, you should still ask each time you make an appointment, because providers do not have to accept PFFS plans.

If you need emergency care, however, doctors and hospitals are required to treat you, even if they do not accept your plan.

Some PFFS plans have a network of providers who will agree to always treat you under the terms of your plan, even if you haven’t been a patient there before.

PFFS plans may or may not include Medicare Part D coverage for prescription drugs; be sure to check the details of any plan you are considering if you want this coverage.

What is a Medicare Advantage PPO** plan?

A Preferred Provider Organization, or PPO plan, is a type of Medicare Advantage plan that uses a network of doctors, hospitals, and other health care facilities to help keep costs lower for their members. While you can usually get your care from any provider, you pay less if you use those in your plan’s network.

In most cases, similar to PFFS plans, you aren’t required to choose a primary care doctor or get referrals for specialist care in a PPO plan. However, if you choose an out-of-network specialist or facility, you will likely pay more (and in some cases, significantly more) than if you stayed within your plan network.

Again, because Medicare Advantage plans are offered by private insurance companies, the amount you’ll pay in deductibles, coinsurance, and copayment amounts will vary from plan to plan.

Most PPO plans do include Medicare Part D prescription drug coverage, but be sure to read any plan materials carefully before you enroll just to be sure.

What else should I know about Medicare Advantage PFFS vs PPO plans?

Not all types of Medicare Advantage plans (including PFFS and PPO plans) may be available in every location, and PFFS or PPO plan benefits may vary depending on where you live and company offering the particular plan. Your premium may also vary by plan type and location.

You must continue to pay your Part B premium, plus any premium required by your plan, for as long as you are enrolled.

If you don’t like your PFFS or PPO Medicare Advantage plan, you have the opportunity to enroll in a different one each year during the Open Enrollment Period for Medicare Advantage and Prescription drug coverage, which runs from October 15 to December 7.

Need more information on Medicare Advantage plans?

I am happy to answer your questions about PFFS or PPO Medicare Advantage plans. You can schedule a phone call or request an email by clicking on the buttons below. You can also find out about PFFS or PPO Medicare Advantage plan options in your area by clicking the Compare Plans button.

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.

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. 

Pamela Cannaday |
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