Medicare Advantage Overview
Understanding Your Medicare PFFS Plan
Navigating your Medicare options can feel complicated, but we’re here to help you understand every choice. A Medicare Advantage Private Fee-for-Service (PFFS) plan is one of the options available to you. These plans offer a unique kind of flexibility by allowing you to see any Medicare-approved doctor who agrees to accept the plan’s payment terms and conditions. Let’s explore how PFFS plans work so you can decide if they are the right fit for your healthcare needs.
Keep reading or jump to our Highlights and Frequently Asked Questions.
What is a Medicare PFFS Plan?
A Private Fee-for-Service (PFFS) plan is a specific type of Medicare Advantage (Part C) plan offered by private insurance companies. Unlike HMOs or PPOs, PFFS plans generally give you the freedom to receive care from any doctor, hospital, or specialist in the U.S. that is eligible to receive Medicare payment and agrees to accept your plan’s terms. This flexibility can be a major advantage if you value a wide choice of providers.
How PFFS Plans Work
With a PFFS plan, the plan determines how much it will pay doctors and hospitals, and how much you will pay when you receive care. Here’s what you need to know about using your PFFS plan:
- Provider Acceptance: Before you get care, you must confirm that the provider or hospital accepts your PFFS plan’s payment terms for each visit. Even if you’ve seen a doctor before, it’s important to verify this every time, unless your plan has a network of providers who have already agreed to treat plan members.
- No Referrals Needed: You generally do not need a referral to see a specialist, giving you direct access to the care you need.
- Out-of-Pocket Costs: Your costs may include a monthly premium (in addition to your Part B premium), deductibles, and copayments or coinsurance for services.
Types of PFFS Plans
There are a couple of variations when it comes to PFFS plans, which can affect how you access care.
- PFFS Plans with a Provider Network: Some PFFS plans have a network of providers who have formally agreed to always treat plan members. You can still see out-of-network providers, but your out-of-pocket costs might be lower when you stay in-network.
- PFFS Plans without a Network: Other PFFS plans do not have a provider network. With these plans, you have the flexibility to see any Medicare-approved provider, as long as they agree to your plan’s terms before providing treatment.
PFFS Plans and Prescription Drugs
Many PFFS plans include prescription drug coverage (Part D) as part of the package. If you enroll in a PFFS plan that offers this benefit, you get your health and drug coverage combined in one simple plan. However, if your PFFS plan does not include drug coverage, you are permitted to join a separate Medicare Prescription Drug Plan (Part D) to cover your medication costs.
For more official details on how these plans work, you can always visit the Medicare website at Medicare.gov.
Medicare Can Be Confusing
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Medicare PFFS Plans
Frequently Asked Questions
Do I need to choose a Primary Care Physician (PCP) with a PFFS plan?
No, PFFS plans typically do not require you to have a Primary Care Physician. You have the freedom to see specialists and other providers without needing a referral, which simplifies your access to care.
What happens in an emergency if I have a PFFS plan?
In a medical emergency, you are covered to go to any hospital or urgent care facility in the United States. Providers are required to treat you, and they cannot deny you care based on your plan type in an emergency situation.
How do I know which doctors will accept my PFFS plan?
The best way to know for sure is to call the doctor’s office ahead of your appointment. Ask them directly if they accept your specific Medicare Advantage PFFS plan. If your plan has a provider network, you can also use the plan’s directory to find doctors who have already agreed to provide care.
Insurance Connection USA is a division of Garrison Enterprises a licensed Insurance agency and not connected with or endorsed by the United States government or the federal Medicare program. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Medicare has neither reviewed nor endorsed this information. Not connected with or endorsed by the United States government or the federal Medicare program.
Important Highlights
PFFS plans offer the flexibility to see any Medicare-approved provider who agrees to the plan’s payment terms.
Many PFFS plans include prescription drug coverage, but if not, you can enroll in a standalone Part D plan.
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