Are you a Texas resident? If so,
read about Medicare in Texas here.

Medicare Advantage PFFS Plans

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.

Need help?

Call to speak with a licensed
insurance agent now.

Touch to Call

1- TTY users 711

Or, enter your zip code to shop online

Enter your zip code to shop online

Browse Plans
Was this article helpful?
Yes
No
Thank you for your feedback!

The purpose of this communication is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealthInsurance Services, Inc. is not connected with or endorsed by the U.S. government or the federal Medicare program.

eHealth's Medicare website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency.

Medicare has neither reviewed nor endorsed this information.