With so many different Medicare plans to choose from, it is often difficult to make sense of which plan does what and more importantly, which plan meets your particular coverage needs. In this article, we will exam Private Fee-for-Service Plans, which may be something you want to consider if Original Medicare Part A and Part B do not cover all of your health care needs.

Medicare Fee-for-Service plans are Medicare Advantage Plans that are offered by private insurance companies. Medicare Advantage is sometimes referred to as Medicare Plan C, so be aware that those terms of interchangeable. Private Fee-for-Service plans are not the same as Medigap plans, even though the latter are likewise third-party coverage solutions designed to augment existing Original Medicare coverage. Private Fee-for-Service plans are unique in that the plan itself determines how much doctors, hospitals, and other health care providers will be paid as a result of their services. The plan also determines how much you must pay for this care.

You can choose your own doctor

Private Fee-for-Service plans also differ from other Medicare plans by allowing you to choose any doctor, health care specialist, or hospital from which to receive the services you need, rather than restricting you to doctors and hospitals that are approved by Medicare and that function inside of Medicare’s ecosystem. Since it is beyond the scope of this document to specify which doctors or facilities will work with Private Fee-for-Service plans, you must contact your preferred provider and ask if they accept the terms of your particular Private Fee-for-Service plan. You may also join a Private-Fee-for-Service plan that has its own network, in which case you will be able to view information on network providers who have agreed to treat plan members. You can still opt for an out-of-network provider, but you may have to pay higher service costs.

Some Private Fee-for-Service plans offer prescription drug coverage, so again, you should shop around for your ideal plan by contacting your local health insurance providers. If your preferred Private Fee-for-Service plan does not cover prescription drugs, you can join a Medicare Prescription Drug plan to get supplementary coverage.

Since each Private Fee-for-Service plan is different, there are many considerations to take into account when deciding if they are right for you. You can find answers to many frequently asked questions about Private Fee-for-Service, including information about co-payments, co-insurance, and the likelihood of being treated by out-of-network doctors and specialists. You can also find even more information on the official Medicare site. Medicare stresses that you must “make sure that your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plans payment terms.” You will also be given a plan membership ID card which you will need to furnish instead of your original red, white, and blue Medicare card, so be sure you keep it in a safe place.

PFFS 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.

Are prescription drugs covered?

Some PFFS plans cover drugs. Those that do not may be supplemented by a Medicare Part D prescription drug plan.

Do I need to choose a primary care doctor?

No.

Do I have to get a referral to see a specialist?

No.

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.

Will my Medicare Supplement/Medigap policy work with the Private-Fee-for-Service plan?

No. If you select to join a Private-Fee-for-Service plan (or any other type of a Medicare Advantage plan), the Medicare Supplement/Medigap policy will not coordinate with these plans. Medicare Supplement/Medigap coverage only works with Original Medicare.

What else should I know before joining a Private-Fee-for-Service plan?

It is important to understand what your copayments or coinsurance will be under the Private-Fee-for-Service plan. Every plan is different. You need to look at and understand how much you will have to pay each time you go for a doctor visit, a hospital stay, outpatient hospital visit, etc.

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 (October 15th through December 7th each year) or during a Medicare Advantage Open Enrollment Period (January 1st through February 14th each year). However, you may be entitled to a Special Election Period. For additional information, please contact the Medicare Advantage plan, 1-800-MEDICARE (1-800-633-4227) or SHIP (1-800-443-9354).

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.
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