What are Medicare Advantage PFFS Plans?

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Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D). In most cases, you’ll need to use health care providers who participate in the plan’s network. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services. Some plans offer non-emergency coverage out of network, but typically at a higher cost. Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you’ll need it if you ever switch back to Original Medicare. Below are specific PFFS Plans explained.

Private Fee-for-Service plans are a type of Medicare Advantage plan seen mostly in rural areas that allows you to see any provider who accepts your plan and its payment terms.

What Are PFFS Plans?

Private Fee-for-Service plans are very different from the other forms of Medicare Advantage plans. You have increased flexibility for a lower price than a PPO, but acceptance is not guaranteed unless your plan uses a network of healthcare providers.

These plans do not require you to have a primary care physician and do not require you to get a referral from your primary care physician to see a specialist.

PFFS Plan Benefits

The key benefit of PFFS plans is that you can see any healthcare providers you want to, provided they accept your plan and its payment terms. This allows plan members more freedom to choose who and where they receive care from. Frequent travelers will find comfort in this plan type because it allows for coverage beyond a set geographical area.

Some PFFS plans use networks of healthcare providers; in this case, your coverage will be within that network, which is usually tied to your specific region.

PFFS Coverage Area

PFFS plans are typically more prevalent in rural areas without access to a wide variety of healthcare providers and specialists.

PFFS Plan Costs

With a PFFS plan, as with any other Medicare Advantage health insurance plan, you must pay premiums, deductibles, copayment, and coinsurance. Under a Medicare Advantage plan, you still have to pay your regular premiums for Medicare Part A and Part B directly to Medicare. This includes any additional charges, such as the Income Related Monthly Adjustment Amount (IRMAA). 

PFFS vs. HMO and PPO

PFFS plans differ widely from Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO) plans. They do not usually require primary care physicians or referrals and often do not have networks of healthcare providers. This increases flexibility. However, the downside is that you must ask your provider at the time of treatment whether or not they will accept your plan and its payment terms. This adds a degree of uncertainty and more of a responsibility on your part.

Finding a PFFS Plan

Rural areas have a great degree of success with PFFS plans due to the spread of providers. Networks don’t always make sense when there is a limit to the distance your plan members would be willing to drive to access care. These plans make it simple to receive care from any provider. You also have the benefit of not having to have a primary care provider within a set network: you don’t have to worry about switching providers and can continue to see your long-time provider. And if you’re not a frequent healthcare consumer or have not made a relationship with a provider, you don’t have to feel obligated to choose.

We routinely speak to seniors who are either now or soon eligible for Medicare. Many are confused and sometimes overwhelmed by the multitude of coverage options available. At the Medicare Help Desk, we help make sense of all this confusion.

We are an independent insurance agency that provides help to those on Medicare and helps them choose the appropriate coverage, including Medicare Supplements, Medicare Advantage, and stand-alone Prescription Drug Plans from over 30 different insurance carriers. Let the Medicare Help Desk explain your options and help you find the best Medicare Plan for you.

For more information on Medicare Advantage plans feel free to contact us via phone: 

(800) 414-2044.

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