Private Fee-for-Service (PFFS) plans are one of four main types of Medicare Advantage policy that private insurance companies administer. The plans have specific rules relating to costs paid to healthcare providers.

Private insurance companies offer Medicare Advantage plans to those who are eligible for Medicare benefits.

There are several plans available, depending on location and coverage requirements. One of these is the PFFS plan.

A PFFS plan offers the same coverage as original Medicare but may have different restrictions and costs. PFFS plans could also provide additional benefits, such as vision and dental care.

This article will look at Medicare Advantage PFFS plans, who offers these plans, the costs involved, how to enroll, and some alternative options.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

  • Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
  • Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
  • Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A person with pffs medicare reviews bills.Share on Pinterest
People eligible for Medicare may be interested in PFFS plans, which are a type of Medicare Advantage plan.

Medicare is health insurance run by the federal government for individuals aged 65 or older. Coverage is also available to those younger than 65 with specific health conditions.

A person can choose to receive their Medicare benefits by having an original Medicare plan or through Medicare Advantage.

Two different parts make up original Medicare. Part A covers inpatient hospital costs, while Part B covers outpatient medical costs.

Alternatively, private insurance companies offer Medicare Advantage plans. These plans provide the same cover as original Medicare and may also offer additional benefits.

Part D, also known as prescription drug plans (PDPs), is available to help cover the costs of prescribed medication. Private insurance companies also offer PDPs, and people can purchase these as a standalone plan or have them added to a Medicare Advantage policy.

According to the Kaiser Family Foundation, those enrolled in Medicare Advantage plans account for around 36% of all Medicare beneficiaries in 2020.

PFFS plans are another type of Medicare Advantage plan. A person who joins this plan can see a specialist without referrals, and they do not need to select a primary care physician (PCP).

Individuals can visit any healthcare provider who agrees to accept the PFFS plan’s conditions and payment terms.

Some PFFS plans have networks of service providers who offer care to anyone enrolled in the plan. To avoid additional costs, a person should ensure that any provider they visit outside of the network accepts the terms of the policy.

The amount a PFFS pays for each healthcare service is preset. The plan provider will decide how much the plan pays for services and how much a person will pay when receiving care.

PFFS plans are not allowed to charge more than original Medicare for some kinds of care, such as chemotherapy, dialysis, and care that someone receives in a skilled nursing facility.

PFFS plans may charge higher copayments for other services, such as home healthcare, durable medical equipment, and hospital care that a person receives as an inpatient.

Medicare Advantage plans typically include prescription drug coverage, but some PFFS plans do not. A person who wants cover for prescribed medication may also consider enrolling in a PDP.

Private insurance companies offer PFFS plans. The plans and private insurance companies that offer them vary by location.

A person can find a PFFS plan in their area using the search tool on the Medicare website.

Because private insurance companies offer PFFS plans, the costs can vary between companies and locations.

Medicare allows “balance billing,” which means that the PFFS plan providers can charge up to 15% of the total cost of deductibles, copayments, and other services.

In addition to a monthly premium that may be payable for a PFFS plan, a person will usually have to pay the Medicare Part B monthly premium.

In 2021, the standard monthly Part B premium is $148.50. The plan may cost more if it includes a PDP, however.

All PFFS plans have to set an annual limit on out-of-pocket costs. The limit protects plan holders from high costs if they need expensive treatments.

In 2021, the maximum out-of-pocket cost for PFFS plans is $7,550.

Individuals can enroll in a PFFS plan directly with their chosen plan provider during specific times, including the initial enrollment period (IEP) and April 1 through June 30 each year.

Medicare also allows people to change their existing Medicare coverage at two other times: during the IEP and the Medicare Advantage open enrollment period.

Before signing up for a Medicare Advantage plan, a person must first enroll with Medicare.

An individual can apply for Medicare through Social Security when they become eligible.

After deciding on a plan, a person should enroll by directly contacting the private insurance company they choose. Individuals can join in several ways, including:

  • online, by signing up through the Medicare search tool
  • by paper enrollment form, usually obtained by calling the insurer
  • by calling Medicare on 800-633-4227

A person must live in the coverage area for the PFFS plan they wish to join.

Medicare rules do not allow those with end stage renal disease to join a PFFS plan.

Other types of Medicare Advantage plan are available. The following sections will cover these in more detail.

Health Maintenance Organization plans

Health Maintenance Organization (HMO) plans are usually less expensive than other Medicare Advantage plans because they use a network of contracted healthcare professionals, hospitals, and clinics.

These service providers offer care to plan members at a discounted rate. Most HMO plans do not cover out-of-network care, except in an emergency.

A person must select a PCP to coordinate their care and refer them to specialists.

HMO Point of Service plans

An HMO Point of Service plan is more flexible than an HMO plan. A person will still need to select a PCP, but members can access healthcare outside of the HMO network at a higher cost.

Preferred Provider Organization plans

Members typically use a network of healthcare providers, but they do not need to select a PCP to coordinate their care.

A Preferred Provider Organization (PPO) plan usually provides benefits outside of the network with higher coinsurance or copayments.

Because the PPO plan is more flexible than the HMO plan, it usually costs more.

Special Needs Plans

Medicare designs Special Needs Plans (SNPs) for those with particular needs, such as those who:

  • have chronic conditions, such as chronic obstructive pulmonary disease
  • live in a long-term care facility, such as a nursing home
  • are eligible for Medicare and Medicaid

A PFFS plan is a type of Medicare Advantage plan.

People may prefer to receive their Medicare benefits through a PFFS plan rather than original Medicare because they could get additional benefits or increased coverage.

Some individuals may prefer a PFFS plan because they do not have to choose a PCP, and they can see a specialist without a referral.

Not all healthcare service providers accept payment through a PFFS plan. A person may need to pay higher out-of-pocket costs if they use out-of-network healthcare services.