Private Fee for Service (PFFS) Medicare Advantage Plans

Medicare Private fee for service (PFFS) plans are sold by private insurance companies as a type of Medicare Advantage plan. By law, Medicare Advantage plans must offer at least as much coverage as Original Medicare and may operate as HMOs, PPOs, or Private Fee for Service Plans. Below we review PFFS Medicare Advantage plans and how these plans may benefit you.

PFFS Medicare Advantage Plans

In a Private Fee for Service Plan or PFFS, the insurance company pre-determines 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 Medicare PFFS plan, you can see any Medicare-approved healthcare provider who accepts your insurance plan’s payment rates and agrees to treat you. Plus, 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 for 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.

However, all hospitals and medical providers must treat you in case of an emergency, even if they do not accept your plan.

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

How Much Do Medicare PFFS Plans Cost?

With a PFFS Medicare plan, you will 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 you pay can vary.

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 locations
• 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 Medicare 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

At MedicareFAQ, we offer free quotes to help you find the right PFFS Medicare plan, Medicare Advantage plan, or Medicare Supplement plan. Call us at the number above, or fill out our form to speak with an agent about available options in your area.

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