Medicare PFFS Plans: The Basics

Are you considering enrolling in a Medicare Advantage plan (Medicare Part C)? There are several different types of Medicare Advantage plans that may be available in your area. One type of Medicare Advantage plans is a Private-Fee-For-Service (PFFS) plan.

Couple lying in park

What is a Medicare Advantage PFFS plan?

You might consider signing up for a Medicare PFFS plan if you are interested in having some flexibility in your health care choices. 

Some of the features of a Medicare PFFS plan that may be attractive to some people who are comparing Medicare Advantage plans include: 

  • Flexibility to receive approved care from any health care providers who have agreed to the terms and conditions of payment set forth by the plan
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  • No requirement to select a primary care physician
  •  
  • Freedom to see a health care specialist without getting a referral

In the case of an emergency, you can receive treatment from any health care provider or hospital, regardless of whether they have agreed to the terms of your plan.

How is a Medicare PFFS plan different from other Medicare Advantage plans?

A Medicare PFFS plan may offer more flexibility in many cases than a Medicare Health Maintenance Organization (HMO) plan or a Medicare Preferred Provider Organization (PPO) plan.

  • A Medicare HMO plan typically requires plan beneficiaries to see health care providers who are in the plan’s approved network. If you’re enrolled in an HMO plan and see a doctor outside of your plan network, the costs for your care may not be covered.

  • A Medicare PPO typically also features a network of approved health care providers, but in most cases, beneficiaries are allowed to receive covered-care from doctors outside of their network. Any care or services received out-of-network, however, may come with higher out-of-pocket costs.

PFFS plans may or may not include provider networks. PFFS enrollees can generally see any provider they wish as long as that provider has agreed to the terms of the plan, but your out-of-pocket costs will typically be lower if you stay within the plan network, if your plan has one.

Provider payment rates may vary based on their specialty or location. Some out-of-network providers may choose not to cover your care, even if they have treated you before. 

It’s important to ask your doctor if they accept the payment terms of your Medicare Advantage plan before seeking treatment, regardless of which type of Medicare Advantage plan you have.

What do Medicare PFFS plans cover?

Like all Medicare Advantage plans, PFFS plans offer the same benefits that are covered by Medicare Part A (hospital insurance) and Part B (medical insurance).

Medicare PFFS plans may offer additional benefits not found in Medicare Part A and Part B (also called Original Medicare). These benefits can include (but aren’t limited to):

The list of additional benefits Medicare Advantage plans can offer may grow to include additional services in 2019.

Some of these new additional benefits could potentially include:

  • Transportation to doctor’s appointments
  • Grab bars for the home bathrooms
  • Air conditioners for beneficiaries who have asthma
  • Home-delivered meals and healthy food options
  • Aids for assistance with daily activates like dressing and eating 

The list of additional benefits offered by a Medicare PFFS plan will vary from one plan to the next. Not all plans are available in all areas.

Am I eligible for a Medicare Advantage PFFS plan?

If you want to enroll in a Medicare Advantage PFFS plan, you must first enroll in Medicare Part A and Part B. There must also be a Medicare Advantage PFFS plan available in your area in order for you to enroll. 

In most cases, you will not be able to enroll in a PFFS plan if you have End Stage Renal Disease (ESRD). If you have ESRD, you may be eligible for a Medicare Advantage Special Needs Plan (SNP).

How much does a Medicare PFFS plan cost?

If you enroll in a Medicare Advantage PFFS plan, you must continue to pay your Medicare Part A (if required) and Part B premiums while enrolled in the plan. Additionally, the PFFS plan may charge its own premiums, which you are responsible for paying.

There may be $0 premium plans available in your area.1

Some PFFS plans will have annual deductibles, and most PFFS plans will have some sort of cost-sharing measures such as copayments or coinsurance when you receive covered services.

How popular are Medicare Advantage PFFS plans?

Medicare PFFS plans are not as popular as some other types of Medicare Advantage plans. In 2017, 184,595 people in the United States were enrolled in a Medicare PFFS plan.2 This accounts for around 1% of all Medicare Advantage plan enrollment.

In comparison, almost two thirds of all Medicare Advantage beneficiaries were enrolled in a Medicare HMO plan in 2017, and around one third of enrollees were in a Medicare PPO plan.3

Enroll in a PFFS Medicare Advantage plan

You may want to consider a Medicare PFFS plan if you value flexibility in your health care options. 

To learn more and to compare Medicare Advantage plans that may be available in your area, speak with a licensed insurance agent by calling   TTY Users: 711 24 hours a day, 7 days a week.

 

1 You must continue to pay your Medicare Part B premium. $0 premium plans not available in all areas.
2 Kaiser Foundation. Medicare Advantage Total Enrollment, by Plan Type. Retrieved from https://www.kff.org/medicare/state-indicator/total-enrollment-by-plan-type/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
3 Kaiser Foundation. Medicare Advantage 2017 Spotlight: Enrollment Market Update. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update.

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MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts; enrollment in any plan depends upon contract renewal.

Plan availability varies by region and state. For a complete list of available plans, 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.

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