Private Fee-for-Service (PFFS) Plans

What's a PFFS?

A PFFS is a type of Medicare Advantage Plan. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.  

Questions you may have about PFFS plans:

Do these plans charge a monthly premium ?Yes. These plans usually charge a premium, in addition to the monthly Part B (Medical Insurance) premium.
Do these plans offer Medicare drug coverage (Part D) ?
Sometimes. Prescription drugs may be covered. If your PFFS plan doesn’t offer drug coverage, you’ll need to join a separate Medicare drug plan (Part D) to get drug coverage.
Can I use any doctor or hospital that accepts Medicare for covered services?

You can go to any Medicare-approved provider or facility that accepts the plan’s payment terms, agrees to treat you, and hasn’t  opted out of Medicare (for Part A- and Part B-covered items and services).

If you join a PFFS plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network provider or facility who accepts the plan’s terms, but you may pay more. In an emergency, doctors, hospitals, and other providers must treat you.

Do I need to choose a primary care doctor ?No.
Do I have to get a referral to see a specialist?No.
What else do I need to know?
  • The plan decides how much you pay for services. The plan will tell you about your costs in the “Annual Notice of Change” and “Evidence of Coverage” that it sends each year.
  • You’ll need to show your plan membership ID card each time you go to a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment. You can’t use your red, white, and blue Medicare card to get heath care because Original Medicare won’t pay for your health care while you’re in a PFFS plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future.
  • Your plan can’t charge more than Original Medicare for certain services like chemotherapy, dialysis, and skilled nursing facility care.
  • If your plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment.
  • Check with the plan you’re interested in for specific information.