A Private Fee-for-Service (or PFFS) plan is a type of Medicare Advantage plan with no established network of healthcare providers allowing you to visit any Medicare-approved doctor or hospital that accepts Medicare and the Medicare Advantage plan’s terms and conditions. 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.
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 key is that there is no established healthcare network.
On the positive side, members of a PFFS can visit any doctor or hospital that accepts Medicare and the terms and conditions of your Medicare PFFS 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 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 has no formal network.
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 merged the two plans into the existing HMO network. In 2020, there are only 41 PFFS plans
available across the country out of a nationwide total of 4,047 Medicare Advantage plans.
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?
Your PFFS Medicare Advantage plan can be a Medicare Advantage plan that includes drug coverage (MAPD) or a Medicare Advantage plan with without drug coverage (MA) If you PFFS plan does not offer drug coverage, you are permitted to join a stand-alone Medicare Part D prescription drug plan (PDP) to get coverage. See PDP-Finder.com
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.
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 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 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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