Medicare Advantage plans come in several options. Private Fee-for-Service plans are one option. These plans are some of the least understood and least available options. Only 30 are offered nationwide. The plan determines how much you pay for services. The providers decide if they accept the Private Fee-for-Service Plans.

How Medicare Advantage Private Fee-for-Service Plans Work

PFFS plans are different than Medigap or Orignal Medicare. PFFS plans are a Medicare Advantage option.

Private Fee-for-Service plans allow the insurance company to determine how much it pays the health care providers and how much the beneficiary pays when using services.

The doctors can choose to accept or decline the terms and conditions for payment of the PFFS. You must verify that the health care providers accept and agree to the terms of the PFFS before receiving services.

Medicare Advantage Private Fee-for-Service Plans Provider Networks

Rural areas or counties with fewer in-network providers are where most PFFS plans are. Beneficiaries are allowed to visit any health care provider that takes Original Medicare. The health care provider must agree to accept the plan before each visit.

Some PFFS plans have in-network providers. When using the plan in-network, there is no need to ask the health care provider if they’ll accept the PFFS before services.

There isn’t a need to select primary care doctors when enrolling into a PFFS. Plan members don’t need referrals to see specialists. All hospitals, urgent care centers, or providers must treat you in an emergency.

Beneficiaries should know that if you see a health care provider with a PFFS plan today, there is a possibility that the provider could decide not to take the PFFS on the next visit. PFFS plans are on a case-by-case and patient-by-patient basis.

Medicare Advantage Private Fee-for-Service Plans & Part D

PFFS plans come in 2 options. You’ll choose between a PFFS with drug coverage or a PFFS without drug coverage.

Most Medicare Advantage plans don’t allow the beneficiary to enroll in a Part D plan. PFFS plans are an exception to this rule.
You can have a PFFS without drug coverage and enroll in a Part D drug plan that fits your needs.

Who is eligible for a PFFS plan?

Eligibility for a PFFS plan is the same as all Medicare Advantage plans. You must be enrolled in Medicare Part A Part B and live in the plans service area.

Private Fee-for-Service Plans are Ideal For

An ideal candidate for a PFFS would be a beneficiary looking for a plan with fewer restrictions. Since they aren’t any network restrictions, they can elect to visit any health care provider the beneficiary chooses, provided they accept the terms and conditions of the plan.

PFFS plans are an excellent option for Medicare Beneficiaries with prescriptions that are covered better by a stand-alone Part D drug coverage.

How Much Do Private Fee-for-Service Plans Costs?

Medicare beneficiaries must continue to pay their Medicare Part B premium and any plan premium. There will be co-pays, coinsurance, and possible deductibles. PFFS plans have a maximum out-of-pocket (MOOP). If the PFFS includes drug coverage, you’ll have deductibles, co-pays, and coinsurance for your prescriptions as well.

FAQs

Do you have to have Medicare Part A and Medicare Part B?

To join a Medicare Advantage plan, you must have both Medicare Part A and Medicare Part B. If you do not have both, you may not join any Medicare Advantage plan.

Can I get my health care from any doctor, hospital, or health care provider?

You can go to any Medicare-approved doctor or facility that accepts your plan’s terms and agrees to treat you. If your plan has a network, you can see any of the network providers who agree to the plan’s terms. You may also choose an out-of-network provider, but you will probably pay more.

If I join a Private-Fee-for-Service Plan, will I have to check with my doctors and hospital before each visit to see if they still accept it?

Yes, you will need to check with your doctors and hospital each time you plan to visit them. A doctor and hospital can change their mind at any time and not accept the coverage any longer.

Do I have to pay any premium for the Private-Fee-for-Service plan?

You will continue to pay the Medicare Part B premium, and you might also have to pay an additional monthly premium charged by the Private-Fee-for-Service plan.

Can I cancel my Private-Fee-for-Service plan at any time?

There are limitations on when you can join or cancel a Medicare Advantage plan. For most beneficiaries, you can only make a change during an Annual Election Period or during a Medicare Advantage Open Enrollment Period. However, you may be entitled to a Special Election Period.

How to Get Help Enrolling in a Private Fee-for-Service Plan

Give us a call or fill out our online request form. We have licensed agents standing by with access to the plans in your area. We’d love to help educate and help you with the enrollment process.

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by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.