A Private Fee-for-Service (or PFFS) plan is a type of Medicare Advantage plan that may have no established network of healthcare providers allowing you to visit any Medicare-approved doctor or hospital that accepts both Medicare and the Medicare Advantage plan’s terms and conditions. However, if you join a PFFS plan that has an established healthcare network, you can also see any of the
network providers who have agreed to always treat plan members.
Like other Medicare Advantage plans, your plan may provide you with extra or supplemental benefits that Original Medicare doesn’t cover such as dental, vision, health club memberships, or hearing aid coverage. The insurance company that operates the PFFS Medicare Advantage plan
determines what it will pay - rather than Medicare making the decision. You may pay more or less for Medicare-covered benefits.
The key is that a PFFS plan may not have an established healthcare network or have an established network and allow you to visit providers outside the network, if the provider accepts the plan's terms and conditions.
On the positive side, members of a PFFS can visit any doctor or hospital that accepts Medicare and the terms and conditions of the Medicare PFFS plan. However, a non-network doctor or hospital can decide on a visit-by-visit or patient-by-patient basis, whether they wish to accept your PFFS plan coverage.
When compared to other forms of Medicare Advantage Plans (such as an HMO or PPO), the PFFS plan is the most flexible and portable since the PFFS plan.
The continued decrease of PFFS plans.
Since first introduced, the number of PFFS plans has shrunk as Medicare requires a Medicare Advantage plan to use the plan's existing healthcare network whenever it is available. So, in counties where a company offered both Medicare Advantage HMO and PFFS Medicare Advantage plans, the company may have merged the two plans into the existing HMO network.
In 2021, there are only 33 PFFS plans
available across the country out of a nationwide total of 4,568 Medicare Advantage plans (as compared to 41 PFFS plans
in 2020 out of a nationwide total of 4,047 Medicare Advantage plans.)
If I join a Medicare Advantage Private-Fee-For-Service plan . . .
Question: 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.
Question: Are prescription drugs covered?
Your PFFS Medicare Advantage plan can be a Medicare
Advantage plan that includes Part D drug coverage (MAPD) - or a Medicare
Advantage plan without drug coverage (MA). If you PFFS MA plan does
not offer drug coverage, you are permitted to join a stand-alone
Medicare Part D prescription drug plan (PDP) to get coverage. To see
all Medicare Part D plans in your state you can use our Medicare Part D
Plan Finder (https://PDP-Finder.com
) - to start, just click on your state.
Question: Do I need to choose a primary care doctor?
You can visit any doctor that accepts Medicare and the PFFS plan's terms and conditions.
Question: Do I have to get a referral to see a specialist?
Question: Can a healthcare provider accept my PFFS plan on one visit and not accept the same plan on another visit
As noted above, a (non-network) doctor or hospital can
decide on a visit-by-visit or
patient-by-patient basis, whether they wish to accept your PFFS plan
coverage. So, it is possible that your Medicare Advantage PFFS plan is
accepted during one visit and not accepted for a subsequent visit.
However, the PFFS plan may have an established healthcare network with
healthcare providers who "have agreed to treat the plan members". (See
p. 65, 2021 Medicare & You Handbook
Question: What else do I need to know about this type of plan?
- PFFS plans are not the same as your Original Medicare Part A and Part B coverage or a Medigap plan (Medicare Supplement).
- The PFFS plan decides how much you must pay for services.
- Some PFFS plans may contract with a network of providers who agree to always treat you, even if you have never seen them before.
- Doctors, hospitals, and other providers may decide not to treat you, even if you have seen them before.
- For each visit or service you get, you must make sure your
doctors, hospitals, and other providers agree to accept tour PFFS plan
and accept the plan's payment terms.
- In a medical emergency, doctors, hospitals, and other providers must treat you.
- If you need more information about the PFFS Medicare Advantage
plan coverage, please check with the plan and review the plan
documentation. You can find the plan's member services telephone number
by clicking on the "benefits & contact info" button without
Medicare Advantage Plan Finder located at https://MA-Finder.com - to begin, just enter your Zip Code and click the green button or choose your state and then country.
(from annual Medicare & You Handbook
Click here to learn more about
Medicare Advantage (MA and MAPD) plans.
Still have more questions? Click here to let us know.
references include: annual Medicare & You Handbook