Medicare Advantage Private Fee for Service Plans

Private fee for service plans will be sold by private insurance companies as an alternative to Medicare Parts A and B. By law, Medicare Advantage plans must offer at least as much coverage as Original Medicare. Medicare Advantage plans may operate as HMOs, PPOs, or Private Fee for Service Plans.

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Medicare Advantage PFFS Plans

In a Private Fee for Service Plan or PFFS, the insurance company decides what it will pay for a service or procedure, and what you must pay. Your costs may include annual deductibles, a percentage of the fee as coinsurance, or a flat copayment.

With a private fee for service plan, you can see any Medicare-approved healthcare provider who accepts your insurance plan’s payment rates and agrees to treat you. You do not need a referral from your primary care doctor to see a specialist.

However, not every healthcare provider will accept your plan – even if they do accept Medicare.

Providers can decide whether to accept your plan on a patient-by-patient and visit-by-visit basis. A doctor who treated you three months ago may decide not to accept your plan on your next visit. This means you may have to ask your providers if they’ll take your plan before every visit.

Some plans have networks of providers who have agreed to always accept your plan’s rates and treat you, even if you’re a new patient. Seeing a network doctor relieves you from having to ask every time and guarantees you’ll be seen for follow-up visits.

All hospitals and other providers must treat you in a medical emergency, even if they don’t accept your plan.

Some Private Fee for Service Plans offers prescription drug coverage. If you enroll in a plan without prescription coverage, you can also sign up for a standalone Medicare Part D prescription drug plan.

What will a PFFS Cost?

With a PFFS plan, you’ll pay your Medicare Part B premium, plus an additional premium for the Medicare Advantage plan. Because each insurance company sets its own rates, the premiums, deductibles, copays, and coinsurance can vary.

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A Private Fee for Service plan may also allow “balance billing” in which a provider is permitted to charge you an extra 15 percent over and above the plan’s payment rate.

How is PFFS different than other Medicare Advantage plans?

With a PFFS plan, your costs don’t vary between in-network and out-of-network doctors. You can see anyone who agrees to accept your plan’s rates. This potentially gives you greater choice and flexibility in choosing healthcare providers.

The other two main types of Medicare Advantage plans are:

  1. PPO plans – These plans operate with a network of healthcare providers. Although you can see a doctor outside the network, your out-of-pocket costs will be lower if you use providers in the network. With a PPO plan, you do not need a referral to see a specialist.
  2. HMO plans – HMOs also have a provider network, but you may not have coverage or may pay more if you want to see someone outside the network. You also generally need a referral from your primary care doctor to see a specialist.

What is the Difference Between Private Fee for Service Plans vs Original Medicare vs Medigap?

Original Medicare Parts A and B have standard premiums, deductibles, copays, and coinsurance. Medicare Supplement, or Medigap, insurance is private insurance that works alongside Original Medicare to pay healthcare costs that are not covered by Medicare. There are 10 standard Medigap plans to choose from.

Differences between Original Medicare/Medigap and a PFFS Plan include:

  • Original Medicare and Medigap allow you to use any doctor who accepts Medicare. Choices are more limited with a PFFS Plan because the provider must accept the plan’s payment rates and agree to treat you.
  • Plans may not be available in all localities.
  • These PFFS Plans generally have copays, coinsurance, and other unpredictable out of pocket costs. Medigap plans, particularly Plan F and Plan G, can virtually eliminate these costs – your main cost is the monthly premium.
  • PFFS Plans may have built-in prescription drug coverage. With Original Medicare and Medigap, you’ll need a Part D prescription drug plan.

How to Enroll in a Medicare Advantage Private Fee for Service Plan

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.


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