Private Fee for Service (PFFS) Medicare Advantage Plans

The insurance company predetermines what it will pay for a service or procedure under a Private Fee for Service Plan, or PFFS, and what you are responsible for paying. Your expenses could include yearly deductibles, a set copayment, or a coinsurance percentage of the cost.

Any healthcare professional who accepts your insurance plan’s payment rates and agrees to treat you is eligible to participate in a Medicare PFFS plan. Additionally, you can see a specialist without a prescription from your primary care physician.

Even though they accept Medicare, not all healthcare providers will accept your plan.

Providers have the discretion to approve or reject your plan for each patient and each visit. A doctor who saw you three months ago can decide against accepting your next visit’s schedule. As a result, you might need to confirm that your plan will be accepted by your providers before each appointment.

Some insurance plans contain networks of medical professionals who have consented to always serve you at the prices set forth by your plan, even if you are a new patient. By visiting a network doctor, you can avoid asking every time and receive assurance that you will be seen for follow-up appointments.

Even if they reject your plan, all hospitals and healthcare facilities are still required to treat you in the event of an emergency.

What Are the Costs of Medicare PFFS Plans?

You will pay your Medicare Part B premium together with an additional premium for the Medicare Advantage plan if you choose a PFFS Medicare plan. The premiums, deductibles, copays, and coinsurance you pay can differ since every insurance provider sets its own prices.

What distinguishes PFFS from other Medicare Advantage plans?

Your expenditures with a PFFS plan are the same for both in-network and out-of-network physicians. Anyone who consents to accept the rates of your plan is visible to you. You may have more options and freedom in selecting healthcare providers as a result.

These are the other two primary categories of Medicare Advantage plans:

PPO plans: These programs work with a network of medical professionals. Your out-of-pocket expenses will be lower if you use providers in the network, even though you can visit a doctor outside the network. You can see a specialist without a referral if you have a PPO plan.

HMO plans – HMOs also have a provider network, but if you wish to see a doctor outside the network, you might not be covered or you might pay more. To see a specialist, you typically also need a recommendation from your primary care physician.

Sources:

https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/PFFS

https://www.cms.gov/Medicare/Health-Plans/PrivateFeeforServicePlans

https://www.medicarefaq.com/medicare-part-c/medicare-advantage-plan-pffs/