WHAT’S A PRIVATE FEE-FOR-SERVICE (PFFS) PLAN?

Private fee-for-service (PFFS) plans are similar to Original Medicare. You can generally see any doctor, other healthcare provider, or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay doctors, other healthcare providers, and hospitals, and how much you must pay when you get care.

Out-of-pocket costs vary by plan and provider. In some cases, you must stay in-network for PFFS providers. These plans may not be available in every county or state.

WHAT ARE SOME EXAMPLES OF PFFS PLANS?

  • Some PFFS Plans use a coinsurance model where you pay a certain percentage of allowable charges.
  • Some PFFS Plans use a copayment, or set amount, in determining your cost-sharing amount.
  • Some PFFS Plans have deductibles as well you’ll have to meet each year.

WHAT ARE THE ADVANTAGES OF A PFFS PLAN?

  • A Private Fee-for-Service (PFFS) plan does not require you to choose a primary care physician.
  • No referrals are needed from a primary care physician to see a specialist.
  • Many PFFS Plans have no network restrictions.
  • Each service is individually assessed by the provider, regarding whether to accept the PFFS plan’s payment terms or not. Furthermore, accepting payment at one time does not mean the provider will continue to do so at those terms.

BENEFITS OF A PFFS PLAN

  • You have greater overall provider choice.
  • There may or may not be a provider network. If the PFFS Plan has a preferred provider network, these health care providers always agree to treat you even if you’ve never been seen there before.
  • You can typically still go out-of-network if there is an in-network plan if the providers accept the plan’s payment terms and conditions.
  • In an emergency, doctors, hospitals, and other providers must treat you.
  • 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.
  • The plan must cover any service that’s considered medically necessary under Original Medicare.
  • You have the right to ask the plan for an “advance coverage decision” if you’re not sure whether a medical service or item is paid for. This is a written, binding document from your PFFS plan stating whether it will cover the service.

DISADVANTAGES OF PFFS PLANS

  • Finding a local provider may be challenging.
  • Because providers are not locked into terms of service payments, out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
  • It can be a hassle every time you see the doctor, hospital, or other health care providers to ask if they will accept the PFFS plan’s payment terms.
  • 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 health care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS plan.

WHAT ARE THE COSTS OF A PFFS PLAN?

  • You continue to pay Medicare Part B premium.
  • You pay a separate premium for your Medicare Advantage PFFS plan.
  • You pay any cost-sharing expenses set by your PFFS Plan (such as copayments and coinsurance) at the time you receive the service. After that, the provider bills your plan for the remaining amount.
  • Some Medicare PFFS plans allow “balance billing,” which lets providers charge up to 15 percent over what the plan pays for a covered service. In this case, you pay the remaining balance or the difference between what the provider charges and the plan’s reimbursement.

DO PFFS PLANS OFFER PRESCRIPTION DRUG COVERAGE?

  • Not all PFFS plans include prescription drug coverage. If a PFFS plan does not offer coverage for your medications, you always can enroll in a stand-alone Medicare Prescription Drug plan (Medicare Part D) during the Annual Election Period (AEP), which takes place from October 15 to December 7 every year. You can also switch to a different Medicare Advantage plan during this time.
  • PFFS plans are one of the few types of Medicare Advantage plans that allows enrollment into a separate plan for prescription drug coverage, if it’s not already included.

ARE PFFS PLANS FOR YOU?

It’s impossible to make a definitive answer to this question because there are so many options when it comes to Medical Advantage Plans, including PFFS plans. If you like the structure of a managed care plan and don’t mind paying more for provider flexibility, a Medicare Advantage PPO plan may be a good option. On the other hand, if cost is a concern, you might pay less under an HMO plan.

Your options may be limited by what is offered in your area. To a large extent, the Medicare Advantage plan that’s best for you will depend on what your health needs are. If seeing a specific doctor is important to you, make sure the provider accepts any Medicare Advantage plan you’re considering.

Medicare Advantage plans themselves can vary greatly in what they cover and how much you pay, depending on the insurance company selling the policy. It’s always a good idea to shop around and compare prices.

Something important to keep in mind is this: you are not locked into a Medicare Advantage Plan for life. If you don’t like your PFFS or any other Medicare Advantage Plan, you have the opportunity to enroll in a different one each year during the Open Enrollment Period for Medicare Advantage from October 15 to December 7, which is the same window for enrolling in prescription drug coverage. You can even go back to Original Medicare if you so desire.

Medicare Advantage Plans are all about options. They were first introduced to give the consumer choices and, ultimately, more control over their health care. No one knows your needs better than you, and there’s not one size that fits all when it comes to health care.

MedicareGov Directory in St. Louis specializes in Medicare Advantage Plans. We’ve helped thousands of people decide which Medicare Advantage Plan, including PFFS plans, is right for them. We’ll offer patient advice based on your medical care usage history, your current health condition, and what may happen in the future. MedicareGov Directory is here for you. Contact us today!