What is a Medicare Private Fee-for-Service (PFFS) Health Plan?

Mike Olmos by Mike Olmos | Licensed since 2010
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This article was updated on: 09/15/2018

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What is a Medicare Private Fee-for-Service (PFFS) Health Plan?

Did you know that Medicare Private Fee-For-Service (PFFS) plans may give you the freedom to choose any doctor you want, as long as he or she accepts the plan’s payment terms? And it gives providers flexibility, too, as you’ll read below.

A Medicare Private Fee-For-Service (PFFS) plan is a type of Medicare Advantage health plan offered by a private insurance company under contract to the Medicare program. The PFFS plan, rather than Medicare, largely determines how much it will pay for covered health-care services and how much members of the plan will pay. The main feature of a PFFS plan that distinguishes it from other types of Medicare Advantage plans is the latitude it may give Medicare beneficiaries and health-care providers.

 How does a Medicare PFFS plan work?

You may generally enroll in a PFFS plan if you have Medicare Part A and Part B and you live in the area where the PFFS plan provides coverage. (PFFS plans are not available in all areas of the United States. You can check to see what Medicare Advantage plans are available in your area by using the Compare Plans button on this page.)

Medicare PFFS plans generally let you go to any doctor or hospital anywhere in the U.S. that accepts Medicare assignment, is willing to provide care, and accepts your Private Fee-For-Service plan’s terms of payment. Some Medicare PFFS plans have provider networks.

Before enrolling in a PFFS plan, you may want to consider carefully the following features of this type of Medicare Advantage plan.

  • Benefits: PFFS plans provides all medically necessary health care services covered by Medicare Part A (hospital care) and Part B (medical care). Hospice benefits, however, are covered directly under Medicare Part A instead of through your PFFS plan.
  • Some PFFS plans may have extra benefits – for example, prescription drug coverage, routine dental care and/or routine vision care coverage.
  • If you choose to enroll in a PFFS plan that does not offer Medicare Part D prescription drug coverage, you may be able to enroll in a stand-alone Medicare Part D Prescription Drug Plan offered where you live by a Medicare-approved private insurance company.
  • Costs: PFFS plans may charge you a premium amount above the Medicare Part B premium. (You typically pay your Part B premium no matter what type of Medicare Advantage plan you may have, as well as any plan premium.)
  • PFFS plans may charge deductible, copayment and/or coinsurance amounts.
  • PFFS plans may charge a premium for extra benefits like prescription drugs. This premium is in addition to the Medicare Part B premium and, if applicable, the PFFS plan premium.
  • Some PFFS plans may allow doctors and hospitals to charge you up to 15% over the plan’s payment amount for services. The plan will inform you if this is the case.
  • Health-care providers: PFFS plans do not require you to select a primary care physician (PCP) to coordinate your care or to use a network of hospitals and doctors contracted with the plan to receive the benefits of your plan’s covered services. In fact, many PFFS plans don’t have networks of providers who participate in the plan.
  • You can use any doctor, hospital or other health-care provider in the United States who accepts Medicare assignment and the PFFS plan’s payment terms and conditions.
  • However, in many cases, the doctor, hospital, or other health-care provider can decide on a visit-by-visit or patient-by-patient basis, whether they will accept your PFFS plan and its payment arrangement.
  • If you enroll in a PFFS plan that has a full or partial network, you can see any of the network providers because they have agreed to treat all plan members. You can also choose an out-of-network doctor, hospital, or other provider who accepts the plan’s terms, but you may pay more for covered services received from an out-of-network provider.

How do I get care if I am enrolled in a PFFS plan?

Unless the PFFS plan you select has a network of participating providers, you will need to verify in advance of receiving services if a particular provider is willing to accept your plan. When you schedule to see a doctor or go to a hospital for inpatient or outpatient services, you must tell the provider that you’re enrolled in a Medicare Private Fee-for-Service plan. Your provider can decide if he or she will treat you as a member of a PFFS plan.

If the doctor or hospital agrees to treat you, you’ll typically pay only the cost- sharing amount required by your PFFS plan for covered services. The doctor or hospital bills your PFFS plan for the rest.

If your provider chooses not to accept your PFFS plan’s terms and conditions, then you will need to decide whether to receive the care from the provider but pay the medical expenses out-of-pocket, or find another provider who is willing to furnish the services and accept your PFFS plan’s terms and condition for payment.

If you don’t know whether your PFFS plan will pay for a service, you can call your plan and ask for confirmation that the plan will cover the service.

  • Note: You have the right to receive medically necessary emergency care anytime and anywhere in the United States without any prior approval from your PFFS plan. Emergency care in the United States is a covered benefit, typically.

Compared to other forms of Medicare Advantage plans, the PFFS plan is the most flexible in terms of its “network” – in that many PFFS plans have no formal network. Before deciding to enroll in a PFFS plan, however, it may be a good idea to find out if the plan has a network of participating providers. If so, check to see if the doctors and hospitals you use are participating in the plan’s network. Remember, if the plan does not have a provider network, you may want to discuss with your doctor and other health providers whether they will accept the Medicare PFFS plan’s terms and conditions.

Would you like some help comparing your Medicare coverage options and the type of plan that may meet your personal needs? I can help you.

  • Use the links below to schedule a phone call or have me email information to you.
  • Begin by searching for plans in your service area by clicking the Compare Plans button on this page.

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.

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