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.
- Written by Rachel Christian
Financial Writer and Certified Educator in Personal Finance
Rachel Christian is a writer and researcher for RetireGuide. She covers annuities, Medicare, life insurance and other important retirement topics. Rachel is a member of the Association for Financial Counseling & Planning Education.Read More
- Edited ByMatt Mauney
Matt Mauney is an award-winning journalist, editor, writer and content strategist with more than 15 years of professional experience working for nationally recognized newspapers and digital brands. He has contributed content for ChicagoTribune.com, LATimes.com, The Hill and the American Cancer Society, and he was part of the Orlando Sentinel digital staff that was named a Pulitzer Prize finalist in 2017.Read More
- Published: June 16, 2020
- Updated: November 1, 2022
- 3 min read time
- This page features 3 Cited Research Articles
- Edited By
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.
- 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 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.
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.
It’s important to ask a plan representative questions and carefully research plan details before making a decision.
3 Cited Research Articles
- Freed, M. & et al. (2022, August 25). Medicare Advantage in 2022: Premiums, Out-of-Pocket Limits, Cost Sharing, Supplemental Benefits, Prior Authorization, and Star Ratings. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-premiums-out-of-pocket-limits-cost-sharing-supplemental-benefits-prior-authorization-and-star-ratings/
- U.S. Centers for Medicare & Medicaid Services. (2022). 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
- U.S. Centers for Medicare & Medicaid Services. (2021, December 1). Private Fee-for-Service Plans. Retrieved from https://www.cms.gov/Medicare/Health-Plans/PrivateFeeforServicePlans
Calling this number connects you to one of our trusted partners.
If you're interested in help navigating your options, a representative will provide you with a free, no-obligation consultation.
Our partners are committed to excellent customer service. They can match you with a qualified professional for your unique objectives.
We/Our Partners do not offer every plan available in your area. Any information provided is limited to those plans offered in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.888-694-0290