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?
Do I have to get a referral to see a specialist?
What else do I need to know about this type of plan?
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- 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.
about Medicare Advantage Plans.
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