How PFFS Plans Work
A Medicare PFFS Plan is a type of
offered by a private insurance company. PFFS plans aren’t the same as
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.
If you join a PFFS Plan that has a contracted network of providers, you can also see any of the network providers who have agreed to always treat plan members. If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your plan may not cover your services, or your costs could be higher.
You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms, agrees to treat you, and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). Not all providers will.
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 separate
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?
- The plan decides how much you pay for services. The plan will tell you about your cost sharing in the “Annual Notice of Change” and “Evidence of Coverage” documents that it sends each year.
- 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.
- Check with the plan for more information.