- Medicare Private Fee for Service (PFFS) plans are a type of Medicare Advantage plan.
- Medicare PFFS plans are offered by private insurance companies.
- Medicare PFFS plans are fixed rate-based for individual medical services, and doctors may accept that rate for some services and not for others.
- There are networks with doctors that accept PFFS rates for all services.
You might have seen Medicare Private Fee for Service (PFFS) plans mentioned if you’ve been looking into your Medicare coverage options. PFFS plans are less well-known than more standard plans such as health maintenance organizations (HMOs) or preferred provider organizations (PPOs). However, a PFFS plan offers benefits you might want to consider, including more flexibility when choosing doctors and coverage for more services than Medicare parts A and B.
PFFS plans are a type of Medicare Advantage (Medicare Part C) plan. A PFFS plan is offered by a private company that contracts with Medicare to provide coverage. These PFFS plans pay for appointments, hospital stays, and other medical needs in place of Medicare parts A and B.
The amount the PFFS will pay for each service is preset. The plans available to you will depend on where you live and can be found at many price points.
- hospital stays
- short-term rehabilitation stays
- doctor visits
- preventative care
- emergency room visits
- medical equipment
- ambulance rides
Since a PFFS is a Medicare Advantage plan, it might cover additional services such as dental and vision care. Some PFFS plans also cover medications. You can purchase a separate Medicare Part D (prescription drug) Plan if your PFFS plan doesn’t cover medications.
PFFS plans can allow you the freedom to keep or choose your own doctors and specialists. For many people, this makes them an appealing alternative to HMO plans.
You don’t need to choose a primary care physician (PCP) with a PFFS or get referrals to see a specialist. Some PFFS plans also allow members to use any Medicare-approved provider. This means you’ll never have to worry about going out of network.
Healthcare providers choose whether or not to accept payment from your PFFS plan for each service you receive. This could mean that your doctor might accept your PFFS plan for one service but not another. You’ll need to check every time and make sure your plan is accepted.
However, some PFFS plans do have a network. If your plan has a network, then those providers will accept your PFFS plan every time. Out-of-network providers might not treat you at all unless you have an emergency medical situation. You’ll likely need to pay a higher cost if you do use an out-of-network provider.
Pros of Medicare PFFS Plans
- You don’t need to choose a primary care physician.
- You don’t need referrals to see a specialist.
- You can get coverage beyond original Medicare.
- You can get prescription drug coverage with some PFFS plans.
- You might not need to worry about staying in-network.
Cons of Medicare PFFS Plans
- Premiums can cost more than original Medicare.
- Some providers might not accept your PFFS plan.
- Some services might be covered while others are not.
- Copayments and coinsurance costs might be high if you go out of network.
- PFFS plans are not available in all areas.
You can find Medicare PFFS plans in your area using the Medicare website. If you already have an insurance plan, you can check to see if your provider offers any PFFS plans. The exact plans and providers will depend on where you live, but you can find PFFS plans from several major insurance companies.
A Medicare Advantage plan is also referred to as a Medicare Part C plan. Advantage plans cover everything Medicare parts A and B do, and often add additional coverage, such as:
- mental health
- fitness plans (SilverSneakers)
- transportation to appointments
Medicare Advantage plans are offered by private companies. You can find HMOs, PPOs, PFFs, and other plan types. Some plans don’t have an additional deductible, but many do. Not all plans are available in all states.
The first step to getting a PFFS plan is to apply for Medicare through Social Security. You’ll need to be enrolled in Medicare parts A and B in order to purchase any Medicare Advantage plan, including a PFFS. You’ll also need to live in the coverage area of the PFFS plan you select. However, you won’t be able to purchase a PFFS plan if you have end stage renal disease (ERSD).
The cost of a Medicare PFFS plan will vary by state and your specific plan. You’ll normally need to pay a premium in addition to the one for your Medicare Part B plan.
In 2020, the standard Medicare Part B premium is $144.60 each month. You’ll also need to pay any copayments or coinsurance amounts at the time of service. Medicare allows PFFS plans to charge you up to 15 percent of the total cost of services.
You can shop for plans in your area and sign up online using the Medicare Find a Medicare plan tool .
Examples of costs in a few cities across the country are:
Sample costs for PFFS plans in 2020
|Little Rock, AK||$59||$150||$20|
Keep in mind these are just examples. Plan prices may be different in your area.
You’ll have several chances to enroll in a Medicare Advantage PFFS plan, but you’ll need to keep some key dates in mind. Sign-up windows include:
- Your 65th birthday. You can sign up for Medicare plans, including PFFS plans, up to 3 months before your birthday month and during the 3 months that come after. For example, if you turn 65 in July, you’ll be able to sign up from April until October of that year. Keep in mind that it’s a good idea to apply as soon as you’re eligible. That way, your coverage can start on your birthday.
- April 1– June 30. You can use this enrollment period to sign up for a Medicare Advantage plan if you signed up for Medicare Part B during the January 1– March 31 open enrollment.
Plus, twice a year, you can make changes to your existing Medicare coverage:
- January 1 – March 31. During this open enrollment period, you can switch from one type of Medicare Advantage plan to another. For example, if you currently have a Medicare Advantage HMO plan, you could switch to a PFFS plan during this window. You can’t switch from Original Medicare to a Medicare Advantage Plan during this time.
- October 15 – December 7. This is an open enrollment time for people who already have Medicare coverage. During this time, you can switch from an original plan to a PFFS plan or change your PFSS plan. You can also enroll in a Part D plan during this time.
Medicare PFFS plans are a type of Medicare Advantage plan that might offer more coverage than original Medicare. For some Medicare beneficiaries, the option to not choose a primary care physician and the ability to see specialists without a referral is ideal. However, not all Medicare-approved doctors will accept all PFFS plans for payment. You might end up paying high out-of-pocket costs if you go out-of-network.
Your costs will depend on the plan you choose and your medical needs. You can use Medicare’s search tool to find and compare plans in your area.