What is a Medicare Advantage PFFS?
Key Takeaways
- A Medicare Advantage Private Fee-for-Service (PFFS) plan works differently from the more common HMO and PPO plans.
- On a PFFS plan, you can see any doctor or provider who agrees to the plan’s terms.
- Healthcare providers may only accept the plan’s terms for certain services.
A Medicare Advantage Private Fee-for-Service (PFFS) plan is one type of Medicare Advantage plan offered by private insurance companies. A PFFS plan works differently from the more common HMO and PPO plans.
Unlike some Medicare Advantage plans, a PFFS lets you see any Medicare participating doctor or healthcare provider who agrees to the plan’s terms and payment rates.
In this article, you’ll learn more about how a Medicare Advantage PFFS plan works, how it differs from other plans, and whether one might be the right choice for your healthcare needs.
Ready for a new Medicare Advantage plan?
Types of Medicare Advantage Plans
Original Medicare is made up of two parts: Part A, which covers hospital care, and Part B, which covers medical care like outpatient visits and preventive services. Medicare Advantage (MA) plans, also called Medicare Part C, are an alternative to Original Medicare. These plans are required to offer at least the same coverage as Medicare Advantage, but they often include additional benefits like Medicare Part D prescription drug coverage, dental, vision, and hearing.
While Original Medicare allows you to see any healthcare provider nationwide who accepts Medicare, most MA plans have networks of doctors, hospitals, pharmacies, and other healthcare providers. In-network providers have agreed to work with the plan and accept its payment terms, which are sometimes limited by location. Seeing an out-of-network doctor typically costs more and may not be covered at all, depending on your plan.
Different types of Medicare Advantage plans handle provider networks in various ways:
- HMO (Health Maintenance Organization): Limits care to a network of providers but typically offers lower premiums when compared to other plans. To see a specialist, you will need a referral from your primary care physician.
- PPO (Preferred Provider Organization): You have coverage if you see a doctor outside of your plan’s network, but you will pay more out of pocket than you would for an in-network provider. You generally don’t need a referral to see a specialist.
- PFFS (Private Fee-for-Service): Unlike HMOs and PPOs, PFFS plans don’t rely on a traditional network. Instead, you can see any doctor or provider who agrees to the plan’s terms. You aren’t required to choose a primary care doctor or get a referral for a specialist.
Understanding the Medicare Advantage PFFS
A PFFS Medicare Advantage plan can be an option if you want more freedom in choosing your healthcare providers or you travel often. Unlike other Medicare Advantage network types, PFFS plans don’t require you to stay in-network.
Keep reading to learn more about what makes Medicare PFFS unique and the costs associated with this type of plan.
Key Features of Medicare Advantage PFFS Plans
- You do not need to choose a primary care physician
- You do not need a referral to see a specialist
- You can see any Medicare-approved provider who accepts the plan’s terms.
- The plan will tell you how much each service costs
- Providers can choose to accept or decline the plan’s terms on a case-by-case basis
Costs For PFFS Plans
- Premium: The monthly amount you pay to be enrolled in an insurance plan. Medicare Advantage premiums vary depending on the plan’s provider, the coverage provided, and any additional benefits.
- Deductible: The amount you spend out of pocket for covered services before the plan starts to pay.
- Copay: A fixed dollar amount you pay for specific services, like a doctor’s visit or lab test. PFFS plans set their own copay amounts, which can vary.
- Coinsurance: The percentage of the cost you pay for a covered service after meeting your deductible.
- Out-of-network fees: While PFFS plans may not have a set network, if you visit a provider who doesn’t accept the PFFS plan’s terms, you could be responsible for the full cost of care.
- Out-of-pocket maximums: This is the maximum amount you will pay in a year for covered services. Once you reach this limit, the plan covers 100% of approved costs for the rest of the year.
See It In Action
Imagine a scenario where you slip and fall while on vacation, resulting in an injury to your hip:
- A visit to the emergency room: You are taken to a local hospital for immediate care. Since this is an emergency and the hospital accepts your PFFS plan’s terms, the visit is covered. You may be charged a copay for the emergency room visit and a portion of the ambulance cost, as specified by your Medicare Advantage plan.
- Specialist evaluation: The ER doctor advises you to see an orthopedic specialist. You contact a specialist to schedule an appointment, but the office informs you that they do not accept your PFFS plan’s payment terms.
- Finding alternative care: Using your plan’s directory, you find a specialist who agrees to the terms of your plan. After attending the appointment and discussing more imaging, you pay the specialist’s copay as specified by your PFFS plan.
- Diagnostic testing: The orthopedic specialist orders an MRI to evaluate the extent of your hip injury. Once you verify coverage, you complete the MRI and pay the coinsurance amount specified in your plan.
With a PFFS Medicare Advantage plan, you’re always covered in the event of an emergency, no matter where you are. However, for non-emergency care, it’s essential to be proactive — reach out to doctors and specialists beforehand to confirm they accept your plan’s terms and costs. This ensures you receive the care you need without unexpected costs or complications.
PFFS Medicare Advantage Plans vs. Other Networks
| PFFS | PPO | HMO | HMO-POS | |
| Average premium | High | High | Low | Low |
| Average network size | Large | Large | Moderate | Large |
| Designated primary care physician | Not required | Not required | Required | Required |
| Referrals to seek specialist care | Not required | Not required | Required | Required |
| Out-of-network care coverage | Covered | Partially covered | Not covered | Partially covered |
Medicare Advantage PFFS vs. PPO
Medicare Advantage PFFS (Private Fee-for-Service) and PPO (Preferred Provider Organization) plans both offer alternatives to Original Medicare. The key difference boils down to the provider network (or lack thereof).
PPO plans have networks of doctors, hospitals, and specialists. You can get care outside of the plan’s network, but it will typically cost more. PFFS plans, on the other hand, don’t rely on networks. As long as your provider agrees to the plan’s payment terms, you are able to go anywhere, offering more flexibility.
When it comes to referrals, PPO plans often cost less if you stay in-network. Neither type of plan requires a referral to visit a specialist, but PFFS plans stand out for their lack of network restrictions. This makes them a good option for people who want more freedom to choose their provider.
Are Medicare Advantage PFFS Plans Good For You?
What Medicare Advantage plan type is right for you depends on your personal healthcare needs, lifestyle, and budget. Each plan type offers unique benefits, so it’s important to consider what matters most to you.
A Medicare Advantage PFFS plan could be a great fit if you want flexibility and independence in your healthcare choices. These plans let you see any doctor or provider who agrees to the plan’s terms, making them especially appealing if you travel often or don’t want to worry about staying within a network. You also don’t need referrals to see specialists.
Think about your priorities and compare your options to find the plan that suits your needs.
Ready for a new Medicare Advantage plan?
Enrolling In Medicare Advantage
Carefully evaluate your options when you choose a Medicare Advantage plan. While the monthly premium is one important factor, there is more to consider. Here are some things to think about when you compare plans:
- Total costs: Look at premiums, deductibles, copays, and coinsurance. Consider the plan’s out-of-pocket maximums as well.
- Provider access: Check whether your preferred doctors, specialists, and hospitals are within the plan’s network.
- Additional benefits: Some plans include extras like dental, vision, hearing, or wellness programs. Take some time to decide what extra benefits are important to you.
Think about your healthcare habits. Do you travel often? Do you see a lot of specialists? Do you prefer a more structured approach with predictable costs? These are important questions to ask yourself when comparing plans.
Once you’ve considered all the factors, it’s time to enroll.
Enrollment Periods
To enroll in or make a change to a Medicare Advantage plan, you must already be enrolled in Medicare Parts A and B. Medicare Advantage enrollment occurs during specific enrollment periods throughout the year:
- Initial Enrollment Period (IEP): This is the seven-month window surrounding your 65th birthday and is when many people first become eligible for Medicare.
- Annual Enrollment Period (AEP): Each year from October 15 – December 7, you can join or switch Medicare Advantage plans.
- Medicare Advantage Open Enrollment Period (OEP): From January 1 – March 31, those enrolled in Medicare Advantage can make a single change to their plan.
- Special Enrollment Period (SEP): You may be eligible to enroll in or switch to a different Medicare Advantage plan under special circumstances, such as moving.
If you know the plan you want, you can enroll directly through the insurance carrier. Or, for help comparing your options, contact a licensed insurance agent who will answer your questions.
Putting It All Together
Medicare Advantage PFFS plans are just one type of Medicare Advantage plan. A PFFS plan may be a good fit for you if you value flexibility in choosing providers without a network. By understanding the ins and outs of Medicare Advantage PFFS plans, you can determine if this option meets your healthcare needs.