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Medicare Advantage PFFS Plans

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What is a Medicare Advantage PFFS plan?

A Medicare Advantage Private Fee-for-Service plan, or PFFS, may be more flexible than some Medicare Advantage plans, both for you and for the plan itself.

  • The PFFS plan, not Medicare, decides its payment structure in terms of how much you pay for a doctor visit, and how much providers get paid (within government-regulated limits).
  • In many cases, you can see any Medicare-assigned provider you want, as long as the provider accepts the PFFS plan’s payment terms.

When you’re enrolled in any kind of Medicare Advantage plan — including a Private Fee-for-Service plan– you’re still enrolled in the Medicare program. Medicare Advantage plans must include all Original Medicare (Part A and Part B) benefits except hospice care, which is still covered under Part A. Available from private, Medicare-approved insurance companies, Medicare Advantage plans often include extra benefits, such as prescription drug coverage.

If you enroll in a Medicare Advantage PFFS plan, generally you can go to any Medicare-approved doctor or hospital that accepts the plan’s payment terms and agrees to treat you. Not all health-care providers accept Medicare Advantage PFFS plans, but if your PFFS plan has its own network, you can see any of the health care providers affiliated with that particular network. In addition, some Medicare Advantage PFFS plans may let you go out-of-network for certain services, but usually for a higher cost.

Here are some common questions and answers about PFFS plans:

Are prescription drugs covered? Sometimes. If your Medicare Advantage PFFS plan doesn’t offer prescription drug coverage, you can enroll in a Medicare Part D Prescription Drug Plan to get coverage.
Do I need to choose a primary care doctor? No.
Do I have to get a referral to see a specialist? No.


What you need to know before enrolling in a Medicare Advantage PFFS plan:

  • Medicare Advantage PFFS plans are different from Original Medicare, Part A and Part B, and Medicare Supplement plans.
  • Each PFFS plan decides how much you pay for services.
  • Some PFFS plans contract with a network of providers who agree to always treat you, even if you’ve never seen them before.
  • If you sign up for a PFFS plan that has a network, you may pay more if you choose an out-of-network doctor, hospital, or other provider.
  • Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
  • For each service, make sure ahead of time that your health-care providers agree to treat you under the PFFS plan and accept the plan’s payment terms. In an emergency, doctors, hospitals, and other providers are required to treat you.

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