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PFFS | Private Fee For Service Plan

What is a PFFS plan?

PFFS (Private Fee-For-Service)

Like all Medicare Advantage plans, PFFS plans are offered by private insurance companies that have a contract with Medicare. Among Medicare Advantage plans, PFFS plans are less commonly used because most Medicare Advantage enrollees sign up for HMO or PPO plans.

Pros of PFFS Plans

  • You can see any Medicare-approved provider that accepts the terms of your PFFS plan and agrees to treat you.
  • You can see providers in any U.S. state or territory.
  • You don’t need to select a primary care physician, but you can.
  • You can visit a specialist without a referral.
  • Your out-of-pocket costs are capped each year.

Con of PFFS Plans

They are not offered as widely as other types of Medicare Advantage plans (HMO or PPO)
Providers can refuse to treat you at any time, if it is not an emergency. 

What does a private fee-for-service (PFFS) plan cover?

All Medicare Advantage plans, including PFFS plans, cover everything that traditional Medicare does. Some plans include additional benefits, such as vision, hearing, dental, and prescription drug coverage. If a plan doesn’t offer prescription drug coverage, you can sign up for it separately through Medicare Part D.

With all Medicare Advantage plans, Medicare pays the private insurance company a flat fee to administer your health care benefits. However, PFFS plans differ from other Medicare Advantage plans because the insurance company, not Medicare, determines how much it pays health care providers for each service you use.

The insurance company also sets the amount that you pay for services, known as your out-of-pocket costs. This is a big difference between PFFS plans and traditional Medicare, which has no annual cap on out-of-pocket costs.

On a PFFS plan, you can visit any doctor or facility that meets these requirements:

  • Is approved by Medicare. You can confirm if a provider is Medicare approved on the homepage of Medicare.gov, under “Find doctors, providers, hospitals, plans & suppliers.”
  • Accepts your plan’s payment terms. It’s not guaranteed that all providers will accept the terms, even if they’ve treated you before. You must reconfirm every visit.
  • Agrees to treat you. Providers are required to care for you only in an emergency situation.

Some PFFS plans have a network of providers who will always accept you as a patient. You can visit an out-of-network provider if you choose (assuming they meet the qualifications above), but you will often pay more than you would at an in-network doctor or facility.

In a PFFS plan, you do not have to select a primary care doctor, but you can if you prefer. You also do not need a referral to see a specialist. PFFS plans may be good for beneficiaries who are wanting a wider range of provider options. With a PFFS plan, you can see any health care provider as long as they accept Medicare and the payment terms of your plan. A PFFS plan also affords a beneficiary a little more freedom to direct their own care. People on PFFS plans can see a specialist without having to visit a primary care physician first.

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