Medicare Private Fee-For-Service Plans

A Medicare Private Fee-for-Service plan is a type of Medicare Advantage plan (Part C) administered by a private insurance company. The plan determines how much you must pay when you get care. Doctors decide whether to accept patients with PFFS plans.

What Is a Private Fee-for-Service Plan?

Private Fee-for-Service plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay health care providers, and how much you must pay when you get care.

It’s important to make sure your doctors, hospitals and other health care providers agree to treat you under the plan — and that they accept the plan’s payment terms.

Some PFFS plans require you to seek care inside a provider network. These doctors and health care facilities have agreed to always treat plan members.

You can still see doctors outside your plan’s network as long as they accept the plan’s terms. However, out-of-network care often costs more.

Basics of PFFS Plans
  • You are not required to choose a primary care physician.
  • You do not need a referral from a primary care physician to see a specialist.
  • Not all PFFS plans include prescription drug coverage.
  • There is no guarantee that out-of-network providers will accept the plan’s payment terms.
  • In an emergency, doctors, hospitals and urgent care centers must treat you.
  • You will pay your Medicare Part B premium and a separate premium for your Medicare Advantage PFFS plan.

PFFS plans are much less common than other types of Medicare Advantage plans.

According to 2017 research by the Kaiser Family Foundation, Health Maintenance Organization (HMO) plans are the most common type of Medicare Advantage plan. About 63 percent of all Medicare Advantage enrollees are in HMOs.

In contrast, only 1 percent of Medicare Advantage enrollees are in PFFS plans.

Did You Know?
Prescription drugs may be covered under PFFs plans. If not, you can join a Medicare Part D plan.

Eligibility and Costs of PFFS Plans

To qualify for a PFFS plan, you must already be enrolled in Medicare Part A and Part B.

Typically, you cannot have a PFFS plan if you have end-stage renal disease, though there are a few exceptions.

Costs of a PFFS plan usually include your Medicare Part B premium as well as any premiums charged by your PFFS plan.

Some PFFS plans include prescription drug coverage. If it doesn’t, you still have options.

PFFS are one of the few Medicare Advantage plans that allow you to purchase stand-alone Medicare Part D plan separately if your plan does not already include prescription drug coverage.

Benefits of Medicare PFFS Plans

Medicare PFFS plans give you flexibility when it comes to primary care doctors and specialists.

Unlike some other Medicare Advantage plans — such as HMOs — a PFFS plan does not require you to choose a primary care physician.

You also don’t need a referral from a primary care physician to see a specialist.

Some PPFS plans may not maintain a network of providers. If this is the case, you will not be restricted to obtain care only from a specific network of doctors and facilities.

However, these providers must accept the plan’s payment terms and agree to treat you under those conditions. Not all providers will do this.

Medicare PFFS plans may not be available in your area. To enroll in a PFFS plan, call Medicare or the plan directly.

Tip
You can call 1-800-MEDICARE or your State Health Insurance Assistance Program (SHIP) to find out if there is a PFFS plan near you.
Source: State Health Insurance Assistance Programs

It’s important to ask a plan representative questions and carefully research plan details before making a decision.

Last Modified: August 10, 2020

3 Cited Research Articles

  1. Centers for Medicare & Medicaid Services. (2020, February 11). Private Fee-for-Service Plans. Retrieved from https://www.cms.gov/Medicare/Health-Plans/PrivateFeeforServicePlans
  2. Jacobson, G.; Damico, A. and Neuman, T. (2017, June 6). Medicare Advantage 2017 Spotlight: Enrollment Market Update. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/
  3. Medicare.gov. (n.d.). Private Fee-for-Service (PFFS) Plans. Retrieved from https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/private-fee-for-service-pffs-plans