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Medicare Advantage
PFFS Plans

Private Fee-for-Service (PFFS) plans are a type of Medicare Advantage plan offered by private insurance companies approved by the federal program. These plans must provide at least the same level of coverage as Medicare Parts A and B, but often include additional benefits. Unlike standardized plans, each carrier has the discretion to determine coverage and costs for their plans.

PFFS plans can have full or partial provider networks, and in some cases, they may not have a network at all. Regardless of the type of network, PFFS plan enrollees can see any provider who accepts Medicare payment and agrees to the plan’s payment terms and conditions.

Medicare Advantage PFFS Plan Benefits

Private Fee-for-Service (PFFS) plans will provide members with a list of Medicare-approved healthcare providers who accept the plan’s payment rates and terms. These providers agree to treat PFFS plan members without requiring referrals, including specialist providers.

However, not all providers who accept Medicare assignments will accept the PFFS payment terms. Providers can decide on a patient-by-patient basis and terminate the relationship at any time. This creates difficulties for PFFS plan holders, who must verify plan acceptance before every visit and may frequently switch providers, disrupting continuity of care.

Some PFFS plans have a network of providers who agree to accept the plan’s payment terms and see new and existing plan members, relieving the burden of verifying acceptance before every appointment. In emergency situations, all providers and hospitals must treat patients, regardless of insurance coverage.

Some Private Fee-for-Service Medicare Advantage plans include prescription drug coverage, while others require enrollment in a stand-alone Part D plan.

All in all, PFFS plans will cover everything that Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) typically do which includes:

  • Hospital stays
  • Short-term in-patient rehabilitation
  • Doctor’s visits
  • Preventive care
  • Emergency room visits
  • Certain medical equipment
  • Ambulance rides

Medicare Advantage PFFS Plan Costs

Insurance companies offering PFFS plans have the power to determine what services and procedures they will cover and how much the plan member will pay. While Medicare Part B premiums remain the same, individuals with a PFFS plan will also have to pay an additional premium determined by the private insurance company carrying the plan. When utilizing coverage, there may be additional costs including copays (set by the insurer), deductibles (annual out-of-pocket amount before insurance coverage begins), out-of-network charges (for care received outside the plan’s network), and additional services such as vision, dental, hearing, and separate drug deductibles, which may result in higher premiums. PFFS plans may also allow providers to charge an extra 15% on top of the plan’s payment rate, known as “balance billing.”

Comparing PFFS Plans to Other Medicare Advantage Plans

In contrast to HMOs and PPOs, out-of-pocket expenses for Medicare Advantage PFFS plans do not depend on whether a service is in or out of the plan’s network. PFFS plan members have the freedom to choose any provider who agrees to the plan’s payment terms, giving them more provider options.

When comparing and selecting a Medicare Advantage plan, it’s important to consider your stance on plan components such as Part D prescription drug coverage, referral requirements for specialist care, contracted network of doctors and hospitals, and the ability to use providers outside of the network. Additionally, you should consider your financial resources, the amount of flexibility you may need from a plan, and any specific needs requiring special care.

Comparing Medicare Advantage PFFS Plans to Original Medicare & Medicare Supplements

Original Medicare, consisting of Parts A and B, resembles Medicare supplements more than Medicare Advantage plans in terms of coverage. The coverage is the same for everyone enrolled in Parts A and B and for everyone enrolled in a Medicare supplement plan. If a provider accepts Original Medicare, they will also accept the patient’s Medicare supplement plan.

On the other hand, Medicare Advantage plans are different because they are sold by private insurance companies and use provider networks, which limits the patient’s freedom to choose providers. Additionally, Medicare Advantage plans, including PFFS plans, may not be available everywhere, and they often have copays, coinsurance, and other unpredictable out-of-pocket expenses. In contrast, Medicare supplements have more predictable costs, with some nearly eliminating all of the individual’s healthcare expenses. However, the premiums for Medicare supplements are generally higher than those for Medicare Advantage PFFS plans.

Lastly, Medicare Advantage plans often include prescription drug coverage, while no Medicare supplement offers it. Thus, individuals must enroll in a separate Part D plan to have prescription drug coverage. When selecting a plan, it is essential to consider these factors, such as coverage, costs, and prescription drug coverage, and determine which one best suits an individual’s needs.

Finding the Best Policy

A licensed agent can assist you in selecting the most suitable Medicare policy. By asking questions about your health and lifestyle, we can recommend options that best match your requirements. We can also compare various plans offered by different carriers, enabling you to select the most appropriate one.

Once you have decided on a plan, we will guide you through the enrollment process and handle all of the required documentation. Our services don’t end there. We will keep in touch with you during critical enrollment periods to ensure that you still have the best available plan.

Medicare Advantage PFFS Eligibility & Enrollment

If you’re a Medicare beneficiary who is already enrolled in Medicare Parts A and B, you’re generally eligible to apply for a Medicare Advantage PFFS plan, except for individuals who have been diagnosed with End-Stage Renal Disease (ESRD). You can enroll during your Initial Enrollment Period or Annual Enrollment Period, and some individuals may qualify for a Special Enrollment Period.

It’s important to note that Medicare Advantage PFFS plans may not be available in all areas, so it’s best to work with a licensed agent to find out which plans are available in your specific area.

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