How PFFS Plans Work
A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. 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.
Can I get my health care from any doctor, other health care provider, or hospital?
In some cases, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans.
You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will.
If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but your costs will usually be lower if you stay in the network.
Are prescription drugs covered?
Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn't offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.
Do I need to choose a primary care doctor?
You don't need to choose a primary care doctor in PFFS Plans.
Do I have to get a referral to see a specialist?
You don't have to get a referral to see a specialist in PFFS Plans.
What else do I need to know about this type of plan?
- Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before.
- Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
- For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms.
- In an emergency, doctors, hospitals, and other providers must treat you.
- Show your plan membership ID card each time you visit 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 the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future.
- You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service.