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Medicare Advantage Private Fee-for-Service (PFFS)

Summary: Medicare Private Fee for Service (PFFS) plans help you cover healthcare costs. Your plan will cover at least everything Original Medicare covers but only if your healthcare provider and plan agree to the terms. There are regulations all PFFS plans stipulate before you can receive care but unlike other Medicare Advantage plans, you don’t have to worry about networks. Conducting due diligence is important before enrolling. Estimated Read Time: 5 min

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Table of Contents:

  1. What Is a Medicare Fee-For-Service Plan?
  2. How Does a PFFS Plan Work?
  3. How Much Do Medicare PFFS Plans Cost?
  4. What is the Difference Between Private Fee for Service Plans vs Original Medicare vs Medigap?
  5. Do PFFS Plans Have Drug Coverage?
  6. How to Enroll in a Medicare Advantage Private Fee for Service Plan

Medicare Private Fee for Service (PFFS) plans are sold by private insurance companies as a type of Medicare Advantage plan. All Medicare Advantage plans must offer at least as much coverage as Original Medicare and may operate as HMOs, PPOs, POS, or Private Fee for Service Plans. However, each type of Medicare Advantage plan is going to come with different factors that affect your coverage.

This includes what they pay for and how you can use your coverage. A PFFS plan can be a great option, but it’s important to understand your healthcare needs to know if they’re right for you. Below we review Medicare Advantage PFFS plans and how these plans may benefit you.

What Is a Medicare Fee-For-Service Plan?

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.

When you enroll in Medicare PFFS plans, your carrier provides coverage instead of the federal government based on its contract with the Centers for Medicare and Medicaid Services (CMS):

  • Private Fee for Service plans outline how much you pay for healthcare after negotiating coverage terms with doctors.
  • Each plan must cover at least everything Original Medicare covers, though some may cover additional services.
  • You pay premiums, deductibles, copays, and coinsurances when receiving healthcare until you hit your yearly out-of-pocket maximum. These will vary from plan to plan. With a Medicare 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. Plus, you do not need a referral from your primary care doctor to see a specialist.

However, not every healthcare provider will accept PFFS 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 Medicare Fee for Service 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 PFFS plan.

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How Does a PFFS Plan Work?

A Fee for Service plan works by eliminating the networks seen with other types of Medicare. So long as your doctor accepts Medicare and the terms and conditions of your specific PFFS Medicare plan.

All PFFS plans come with specific rules and guidelines that you must follow. These conditions can dictate the cost of your healthcare and how you access it. For example, you may need a referral to receive care from a specialist.

Another key feature is that a Medicare PFFS plan comes with a out-of-pocket maximum. This means once you spend a certain amount of money as defined in your plan, your healthcare costs are covered for the rest of the year.

PFFS eligibility works just the same as any other Medicare Advantage plan. So long as you are eligible for both Parts of Original Medicare and enroll in them, you can enroll in a Medicare Free for Service plan.

There is a lot that goes into any PFFS plan and with so many to choose from, it can feel a bit intimidating. Check out our short video below to breakdown how it all works:

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.

A key feature Medicare Private Fee for Service plans is that while you don’t have to worry about networks, doctors can set the prices of what they charge you. However, you can negotiate these costs with your doctor. Additionally, the availability and price of each Medicare PFFS plan can also change by ZIP Code.

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.

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The other two main types of Medicare Advantage plans are:

  • 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.
  • 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 Medicare Fee for Service 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.
  • Private Fee for Service plans may not be available in all locations
  • 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.

Original Medicare Medigap Vs PFFS Plans

Do PFFS Plans Have Drug Coverage?

Some Private Fee for Service Plans may offer 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. Be sure to review the available plans in your area before enrolling. Furthermore, review each plan’s formulary to ensure that the medication you need coverage for is covered by the PFFS you are enrolling in.

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

At MedicareFAQ, we offer free no-obligation quotes to help you find the right PFFS Medicare plan, Medicare Advantage plan, or Medicare Supplement plan. Call us at the number above, or complete our online rate form to speak with an agent about available options in your area.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Private-Fee-For-Service, Medicare. Accessed December 2023.
    https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/PFFS
  2. Private-Fee-For-Service Plans, CMS. Accessed December 2023.
    https://www.cms.gov/medicare/health-drug-plans/private-fee-for-service-plans
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

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