Powered by Q1Group LLC
Education and Decision Support Tools for the Medicare Community


What is a Medicare Advantage Private Fee-for-Service (PFFS) plan?


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?


Yes.  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. 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?

No. 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?

No.


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 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.

Still have more questions? Click here to let us know.






Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs


Browse FAQ Categories


Ask a Pharmacist*
Have questions about your medication?

» Answers to Your Medication Questions, Free!
Available Monday - Friday
8am to 5pm MST
*A free service included with your no cost drug discount card.







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.