Medicare Private Fee-For-Service Plans

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.

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

According a 2022 research study by the Kaiser Family Foundation, Health Maintenance Organization (HMO) plans are the most common type of Medicare Advantage plan. About 59% of all Medicare Advantage enrollees are in HMOs.

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.

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.

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