Understanding Private Fee-for-Service (PFFS) Plans
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan offered by private insurance companies. Unlike other Medicare Advantage options, PFFS plans may provide more flexibility when choosing doctors and hospitals.
During the Medicare Advantage Open Enrollment Period (OEP), Pay-For-Service (PFFS) plans give you the opportunity to review your current coverage and explore options that may better fit your healthcare needs. PFFS plans can offer flexibility in choosing providers who accept the plan’s terms, without requiring a primary care physician or referrals.
Know more about PFFS plans offerWhat Is a Private Fee-for-Service (PFFS) Plan?
A PFFS plan is a Medicare Advantage plan in which the insurance company—not Medicare—decides how much it will pay for covered services and how much you pay when you receive care. With a PFFS plan, you can generally see any Medicare-approved doctor, hospital, or provider who accepts the plan’s payment terms and conditions for that visit.
Understanding Private Fee-for-Service includes knowing that these plans operate differently from HMOs, PPOs, and other Medicare Advantage plan types. Unlike network-based plans, PFFS plans do not require you to choose a primary care physician or get referrals for specialist visits.
Key Features of PFFS Plans
1. Freedom to Choose Providers
With PFFS plans, you are not limited to a narrow provider network. You may visit any Medicare-approved provider who:
- Accepts Medicare
- Agrees to the plan’s payment terms for that specific visit
This can be helpful if you prefer flexibility, travel frequently, or want access to multiple doctors without needing a referral.
2. No Referrals or Primary Doctor Requirement
Most PFFS plans do not require members to have a primary care physician. You also do not need referrals to see specialists. This structure can provide more control over how and when you seek care.
3. Pre-set Costs and Cost-Sharing
PFFS plans set member cost-sharing amounts in advance, including:
- Copayments
- Coinsurance
- Deductibles
Since these amounts differ by plan, understanding Private Fee-for-Service cost structures before enrolling can help you manage your healthcare expenses.
4. Emergency and Urgent Care Coverage
Emergency care is covered nationwide. Urgent care is generally covered whether you are inside or outside the plan’s service area. Coverage rules may vary by plan, so reviewing plan documents can help you understand coverage expectations.
5. Extra Benefits May Be Included
Some PFFS plans may include benefits not covered by Original Medicare, such as:
- Dental
- Vision
- Hearing
- Fitness or wellness programs
The availability of these benefits varies and depends on each specific PFFS plan.
Speak to a Licensed Sales Agent
Connect with a licensed sales agent to explore your Medicare Advantage options and get clear answers to your Medicare questions.
Understanding Private Fee-for-Service Costs and Coverage
Understanding Private Fee-for-Service costs starts with knowing that each plan sets its own:
- Monthly premium (if any),
- Copayments or coinsurance amounts, and
- Deductibles and out-of-pocket limits.
Your share of the cost can depend on the type of service you receive and the payment amounts the plan has established for different types of providers. Some PFFS plans may also include coverage for prescription drugs, while others do not. If drug coverage is not included, you may need to consider whether enrolling in a separate Medicare Prescription Drug Plan (Part D) is an option for you.
How a PFFS Plan Works
After joining a PFFS plan, you will receive a plan ID card that you present each time you receive care. Before providing treatment, the provider must agree to:
- Treat you
- Accept the plan’s payment rules for that specific visit
Because providers may decide whether to accept the plan on a visit-by-visit basis, it may be helpful to call ahead to confirm whether a provider will accept your plan for that appointment. This step can help you avoid unexpected costs.
Is a Private Fee-for-Service Plan the Right Fit for You?
A PFFS plan may work well for individuals who:
- Prefer the flexibility of choosing Medicare-approved doctors and hospitals that agree to the plan’s terms
- Prefer not to have a primary care doctor or referral requirements
- Want to understand how PFFS plans compare to other Medicare Advantage options
By understanding Private Fee-for-Service features, you can better evaluate how this plan type aligns with your needs, health conditions, budget, and provider preferences.
Learn More, Choose Confidently
If you want help Understanding Private Fee-for-Service plans, you may speak with a licensed sales agent who can explain how these plans work and answer questions about available coverage options. This educational information can help you better understand how PFFS plans function and how they compare to other Medicare Advantage plan types.