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What is a Private Fee-for-Service Plan (PFFS) in Medicare Part D?


A Private Fee-for-Service Plan (or PFFS) is a type of Medicare Health Plan in which you may go to any Medicare-approved doctor or hospital that accepts Medicare and the Medicare Advantage Plan’s payment (or terms and conditions). The insurance company that operates the Medicare Advantage Plan determines what it will pay - rather than the Medicare making the decision.

You may pay more or less for Medicare-covered benefits. You may even have extra benefits the Original Medicare Plan doesn’t cover.

The key is that there is no established physician network.  You can visit any doctor or hospital that accepts Medicare and the terms and conditions of your Medicare Part D plan.  However, the doctor or hospital can decide on a visit-by-visit or patient-by-patient basis, whether they wish to accept your PFFS plan.

When compared to other forms of Medicare Advantage Plans (such as an HMO or PPO), the PFFS Plan is the most flexible in terms of its "network" - in that a PFFS has no formal network.

In the future, the number of PFFS Plans may shrink as Medicare is requiring a Medicare Advantage Plan to use its existing network whenever it is available.  So in counties where a company offers both HMO and a PFFS Medicare Advantage Plans, the company may merge the two into the existing HMO network.

If I join an PFFS...

Can I get my health care from any doctor, other health care provider, or hospital?


You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you.  Not all providers will.   If you join a PFFS plan that has a network, you can also see any of the network providers who have agreed to always treat plan members.  You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but you may pay more.

Are prescription drugs covered?

Sometimes. If you PFFS plan does not offer drug coverage, you can join a stand-alone Medicare Prescription Drug Plan (Part D or PDP) to get coverage. See PDP-Finder.com.

Do I need to choose a primary care doctor?

No.

Do I have to get a referral to see a specialist?

No.

What else do I need to know about this type of plan?
  • PFFS plans are not the same as Original Medicare or Medigap (Medicare Supplement).
  • The plan decides how much you must pay for services.
  • Some PFFS plans contract with a network of providers who agree to always treat you, even if you have never seen them before.
  • Out-of-network doctors, hospitals, and other providers may decide not to treat you, even if you have 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 a medical emergency, doctors, hospitals, and other providers must treat you.
  • If you need more, check with the plan.  You can find the plan's member services telephone number by clicking on the "benefits & contact info" button on our MA-Finder.com.
Click here to learn more about Medicare Advantage Plans.

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.