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What Is a PFFS Plan?

October 6, 2016

A “Private Fee-for-Service plan” is a type of Medicare Advantage plan.  PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other healthcare providers and hospitals, and how much you must pay when you get care.  PFFS plans are offered by private insurance companies that are contracted with Medicare. The out-of-pocket costs for each service could vary by plan and provider; in some cases, you get your healthcare from any doctor, other healthcare provider, or hospital in PFFS Plans.  Furthermore, the availability of these plans depends on the county and state in which you reside.

Advantages of a Medicare Advantage PFFS plan

Unlike a Health Maintenance Organization (HMO) plan, a Private Fee-for-Service (PFFS) plan does not require you to choose a primary care physician. Accordingly, a member of a PFFS plan does not need a referral from a primary care physician to see a specialist.

Not every PFFS plan is bound by network restrictions. Whereas many Medicare Advantage plans require the beneficiary to remain in-network to receive treatment, some PFFS plans offer the freedom to seek services from any Medicare-approved doctor, healthcare provider or hospital, provided they accept the plan’s payment terms and agrees to treat you. Not all providers will.

Providers consider a PFFS plan’s payment terms for each service provided.  Just because a healthcare provider accepts a PFFS plan’s payment terms for one treatment does not mean they will automatically accept all future payment terms for other service provided to the same patient.

What to consider when selecting a private fee-for-service (PFFS) plan

Private Fee-for-Service (PFFS) plans allows you to see specialists without referrals. Fewer network limitations may also be considered a plus for some, although there is no guarantee that your healthcare provider will accept this insurance each time you require treatment.

What else should you know about this type of plan?

  • Not all PFFS plans include prescription drug coverage. If a PFFS plan does not offer coverage for your medications, you have the option to enroll in a stand-alone Medicare Prescription Drug plan (Medicare Part D). PFFS plans are one of the few types of Medicare Advantage plans that allows enrollment into a separate plan for prescription drug coverage, if it’s not already included.
  • Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before.
  • Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
  • For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms.
  • In an emergency, doctors, hospitals, and other providers must treat you.
  • Show your plan membership ID card each time you visit a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment. You can’t use your red, white, and blue Medicare card to get heath care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future.
  • You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service.