PFFS Plans

Medicare Private Fee-for-Service (PFFS) plans are a type of Medicare Advantage plan (Part C) provided by private insurance companies. They are required by Medicare to provide the same level of coverage as Original Medicare (Part A and Part B). The difference between Original Medicare and Medicare Supplements is that each PFFS plan decides how much you need to pay for services. However, Private Fee-for-Service (PFFS) plans offer additional benefits not provided by Medicare.

How does a Medicare Private Fee-for-Service plan work?

With a PFFS plan, you don’t need to choose a primary care physician nor do you need a referral to see a specialist. This means that you can go to any healthcare provider that accepts Medicare Assignment as a term of payment offered by the Medicare plan. But, it is good to know that not all providers need to accept that.

This is how it operates:

  • There could be a healthcare provider network. You need to talk to a licensed Medicare insurance agent to be sure how that specific plan works.
  • Even if there is a network, you can typically still go out-of-network if the providers accept your plan’s payment terms and conditions. Just check with the healthcare provider first, before you take a visit.
  • This goes for any healthcare provider. Non-network providers can choose to accept a PFFS plan on a case-by-case basis. For example, healthcare providers can accept your plan just for one visit. If they accepted your plan one month ago that doesn’t mean it will be acceptable for them when you decide to visit them again. So to be sure it is best to check it before the actual office visit.
  • All healthcare providers are obligated by law to treat you in a case of medical emergency regardless of if they accept your current healthcare plan or not

The biggest difference with this plan is that the insurance carrier determines how much it will pay your healthcare provider and how much you pay for a covered health service. With other types of Advantage plans, Medicare sets these rates.

What are the costs of PFFS?

You will need to be enrolled in Original Medicare – Parts A and B and also continue to pay your Part B premium along with a separate premium for your PFFS plan if there is one. Also, your residence must be in a service area that provides a Medicare Advantage plan. Each insurance company has its own payment list so the cost can be variable. The best thing to do is to consult with a licensed Medicare insurance agent.

Also, the provider is allowed to charge you an extra 15% over and above the plan’s payment rate. Once you have agreed with the costs you can see in-network and out-of-network doctors and don’t pay extra money if they accept the terms of your plan rate.

What does a Private Fee-for-Service plan cover?

A PFFS plan is a type of Medicare Advantage plan. This means it offers additional benefits that Original Medicare does not.

Such benefits can include, but are not limited to:

  • Adult day-care services
  • Dental
  • Fitness memberships
  • Hearing
  • Nutrition programs
  • Over-the-counter drugs
  • Services and support for those with chronic conditions
  • Transportation to doctor visits
  • Vision
  • Wellness programs

The benefits you are eligible for will depend on your area and plan providers.

Typically, this plan does include a prescription drug coverage (Part D) plan. If not, you’ll need to join a standalone Part D plan if you want to be covered for medications.

What is the difference between PFFS, HMO, and PPO?

Most notably, the biggest difference with this plan is that the insurance carrier determines how much it will pay your healthcare provider and how much you pay for a covered health service. With other plans, Medicare sets these rates.

But here are the key differences between PFFS and other Medicare Advantage plans:

  • Most often, PFFS plans do not have a network of providers you are required to visit. They are contracted with any healthcare provider that accepts the Medicare payment terms (Medicare Assignment).
  • If something is not covered that is medically necessary, you have the ability to ask for an “advance coverage decision.”
  • Usually, the plan will include a prescription drug plan. But, if not, you can add a stand-alone Medicare Part D plan. This possibility is not allowed for HMO or PPO plans that don’t include Part D coverage.
  • You might have to confirm before every visit whether a healthcare provider will cover the service under your plan.
  • Unlike PFFS and PPO plans if you have an HMO plan you will need a referral from your primary doctor to see a specialist

It is important to talk with a licensed Medicare insurance agent to explain key differences in plans available in your area before coming to a decision on what’s right for you.

How to choose between PPFS, HMO, and PPO?

Every Medicare Advantage plan has pros and cons so the best option is to talk with a licensed Medicare insurance agent, like those at Temmen Insurance, and choose what option is best for you.

In general, the plan which is best for you depends on your medical condition and needs. Also, it is important to check what plans are available in your living area because not every plan provides a service for the whole country. Also, you will need to check if every doctor which is of high importance to you (if you have one) accepts the term of the plan you wish to choose.

When can I enroll in a PFFS?

If you are eligible for Medicare, you are eligible for any Medicare Advantage plan. But there are specific times at which you can enroll:

Initial coverage election period — Your initial coverage election period is a seven-month period that starts three months before the month you turn 65 and ends three months after the month you turn 65. If you are under 65 and receive Social Security disability, you qualify for Medicare in the 25th month after you begin receiving your Social Security benefits. If that is how you are becoming eligible for Medicare, you can enroll in a Medicare Advantage plan three months before your month of eligibility until three months after you become eligible.

Annual election period — Also known as open enrollment, the annual election period for Medicare Advantage is from October 15 through December 7 every year. Coverage for the Part C plan you choose to enroll in will begin on January 1 next year. During this time, you can also add, change, or drop current coverage.

Medicare Advantage Open Enrollment Period — During this open enrollment period, you are able to change from one Medicare Advantage plan to another of the same or lesser value or drop Part C coverage to return to Original Medicare.

Special Election Period — There are several things that can trigger a special election period and they are unique to an individual. It is best to speak to a licensed Medicare insurance agent to find out if you qualify for a special election period. However, there are a few common instances such as, if you move outside your Medicare Advantage plan’s service area, qualify for Medicare Extra Help, or move into a nursing home you might qualify for a special election period. During this Special enrollment period, you can make changes to your current Medicare Advantage plan or return back to the Original Medicare.


Get a free quote

Get Live Support

Talk to An Expert

We represent all major companies and organizations that serve the senior market..