Medicare Advantage PFFS Plans

checkmark Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: September 14, 2020

What You Should Know

  • 1 A Private Fee-for-Service Plan (PFFS) is a Medicare Advantage health plan provided by private insurers.
  • 2 As a Medicare Advantage plan, a PFFS must cover the same services as Original Medicare.
  • 3 PFFS plans may also provide additional benefits, such as vision, dental, hearing, and prescription drug coverage.
  • 4 The main benefit of a Private Fee-for-Service plan is that it offers you the ability to choose who provides your care and the flexibility to see doctors and specialists throughout the United States.

A Private Fee-for-Service Plan (PFFS) is a Medicare Advantage health plan provided by private insurers. It covers the same services as the federal government’s Original Medicare Parts A and B and may offer additional benefits, such as vision and dental care.

This plan may be attractive to those who want flexibility in choosing their healthcare providers without the restriction of a network. Plan members may see any Medicare-approved doctor or healthcare provider in the United States that agrees to the PFFS plan’s set payment rates.

What is a Medicare PFFS Plan?

A Private Fee-for-Service Plan (PFFS) plan is a type of Medicare Advantage Plan that offers you a choice in how you receive Medicare coverage. It falls under Medicare Part C and is an alternative to other private insurance plans, such as Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plans.

What a Medicare PFFS plan covers

As a Medicare Advantage plan, a PFFS must cover the same services as Original Medicare. These include:

  • Part A hospital insurance for inpatient care at a hospital, long-term care facility, skilled nursing facility, or home health services
  • Part B medical insurance for physician services, ambulance transportation, medical tests, preventive screenings, mental health care, occupational or physical therapy, dialysis, CPAP devices, walkers, and blood sugar monitors.

PFFS plans may also provide additional benefits, such as vision, dental, hearing, and prescription drug coverage. Though, if prescription drug coverage is not included, you can enroll in a separate Part D plan.

How does a PFFS plan work?

A PFFS plan sets both the amount it pays for a specific service and the amount of your copayment. Be sure to confirm that the plan is accepted before each treatment, as some providers may only allow the plan’s set fee for certain services. You can be treated by any healthcare provider that agrees to accept the plan’s payment terms, but they may refuse to do so at any time. 

Advantages of a Medicare PFFS Plan

The main benefit of a Private Fee-for-Service plan is that it offers you the ability to choose who provides your care and the flexibility to see doctors and specialists throughout the United States. In contrast, an HMO plan only pays for treatment by providers in their network.

Here are some other benefits of a PFFS plan:

  • You don’t need to have a primary care doctor.
  • You can see a specialist without a referral.
  • You can see any Medicare-approved provider that accepts the plan’s payment terms, anywhere in the country.
  • You can be treated by any participating providers if the plan has a network.
  • You only need to pay a set copayment amount when you get treatment. The health care provider bills the plan for the remainder of the cost.
  • You may receive additional benefits not included in Original Medicare Part A and Part B.
  • Your out-of-pocket expenses are capped.

Disadvantages of a Medicare PFFS Plan

  • You can only see providers that accept the plan’s payment terms. Unless they’re part of a network, they may decide not to take the plan at any time, even if they’ve previously treated you.
  • Providers may refuse to see you unless it’s an emergency.
  • There may be higher copayment costs if you use a provider outside of the plan’s network.
  • PFFS plans are not as common as HMO or PPO plans and may not be available in your service area.

Who is eligible for a Medicare PFFS Plan?

Similar to other Medicare Advantage plans, you can qualify for a PFFS plan if:

  • You’re enrolled in Original Medicare Part A and Part B
  • You live in a region served by the plan you’d like to sign up for
  • You aren’t enrolled in a Medigap plan
  • You don’t have end-stage renal disease

How much does a Medicare PFFS Plan cost?

Medicare PFFS plans vary in cost depending on the insurance company and where you live. Your costs include:

  • Monthly premiums, including Part B
  • Deductibles
  • Copayments

To help you find a PFFS plan in your service area and compare costs, use Medicare’s online plan finder tool.

How do I enroll in a Medicare PFFS Plan?

You must first be enrolled in Original Part A and Part B. There are several windows of opportunity for you to sign up for a Medicare Advantage PFFS plan, depending on your situation:

  1. Your initial enrollment period is a seven-month window around your 65th birthday. It begins three months before and ends three months after the month of your birthday.
  2. Medicare’s fall open enrollment period takes place each year from October 15th to December 7th. You can enroll in a Medicare Advantage PFFS plan or switch between plans during this time.
  3. If you have Medicare Part A coverage and you enrolled in Medicare Part B during the General Enrollment Period between January 1st and March 31st, you can enroll in a PFFS plan between April 1st and June 30th.
  4. If you already have a Medicare Advantage plan, you can switch to a PFFS plan during Medicare’s open enrollment period of January 1st to March 31st.
  5. If you need to enroll in Original Medicare at any other time during the year because you retire or no longer have a company health insurance policy, Medicare may provide you with a special enrollment period for a PFFS.

Steps for enrolling in a PFFS plan

Once you’ve found a PFFS plan that’s right for you, contact the plan or visit its website. Make sure you have your Medicare number and know the date that your Medicare coverage started.

Depending on the plan, you may be able to enroll in one of the following ways.

  • Submitting an online form on the plan’s website
  • Mailing a hard copy enrollment form to the plan
  • Calling the plan provider directly

You can also contact Medicare to enroll by calling 1-800-633-4227.

Who should get a Medicare PFFS Plan?

A Private Fee-for-Service plan could make sense for you if you’re interested in a private Medicare Advantage plan that offers Parts A and B coverage along with additional benefits, such as vision, dental, and hearing.

A PFFS plan offers flexibility for those who want to choose their healthcare providers without being restricted to a network of providers. It may also be ideal for people who would like to have greater control of their health care and the ability to see specialists without a physician’s referral.

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Contributing Expert:

Roseann Birch, Medicare Consultant

With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.

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Reviewed by:

Leron Moore, Medicare Consultant

With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.