Medicare Plans by Turning 65 Solutions


Medicare Advantage Private Fee-for-Service

One of the Medicare Advantage plan types provided by private insurers is the Medicare Private Fee-for-Service plan. Medicare requires these private plans to provide the same coverage as Original Medicare. But Private Fee-for-Service (PFFS) plans offer extra benefits that Medicare does not provide.


How Does PFFS Work?

When you purchase a PFFS plan, you do not have to select a primary care physician and you do not need a referral to see a specialist. Here is how it works:

  • You must be enrolled in Original Medicare to have this plan.
  • There may be a healthcare provider network, so talk to a licensed Medicare agent to make sure.
  • you can visit out-of-network doctors if they accept your provider’s payment as payment in full, but first, check with the healthcare provider.
  • The same goes for any healthcare provider. Non-network providers may choose to accept a PFFS plan on a case-by-case basis.
  • Also, you will continue to pay your Part B premium, and maybe your plan’s premium too, if the provider requires so

What separates PFFS plans from the rest is that the insurance company decides 1) how much it will pay your healthcare provider, and 2) how much you pay for a covered health service. With other plans, Medicare dictates these rates.

What a Private Fee-for-Service Plan Covers

ince a PFFS plan is a type of Medicare Advantage plan, if offers extra benefits that Original Medicare does not, which can include:

  • Nutrition programs
  • Fitness memberships
  • Over-the-counter drugs
  • Adult day-care services
  • Dental, Hearing, and Vision
  • Transportation to doctor visits

The benefits you are eligible for depending on your area and plan providers. Usually, a PFFS plan includes a Part D plan. If not, however, you will need to join an independent Part D plan to get prescription drug coverage.

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What Is the Difference Between PFFS, HMO, and PPO?

The biggest difference with PFFS is that the insurer regulates how much it will pay your healthcare provider and how much you pay for a covered health service. With other plans, Medicare determines these rates.

But the key differences between PFFS and other Medicare Advantage plans are:

  • PFFS plans often do not have a network of providers. They are contracted with any Medicare-approved healthcare provider who accepts the payment terms.
  • If something is not covered that is medically necessary, you are able to ask for an “advance coverage decision.”
  • Typically, the plan will include a prescription drug plan. If not, you can add a Medicare Part D plan. This is not allowed for PPO or HMO plans that do not include Part D coverage.
  • Before each visit, you may need to confirm whether a healthcare provider will cover the service under your plan.

Ron Ray is a licensed Medicare insurance agent who can explain the major differences in the plans available in your area. Then he will decide which plan is right for you.


When to Enroll in a PFFS

f you are eligible for Medicare, then you are eligible for a Medicare Advantage plan. But there are certain times at which you can enroll:

Initial Coverage Election Period (ICEP)

ICEP is a seven-month period that is your first opportunity to choose a Medicare health plan. It starts three months before the month you turn 65 and ends three months after the month you turn 65. If you are under 65 and you receive Social Security disability, you are eligible for Medicare in the 25th month after you begin receiving your Social Security benefits.

Annual Election Period (AEP)

Also known as open enrollment, the AEP is from October 15 through December 7 each year. Once January hits, coverage for your selected Medicare Advantage plan will begin. During this time, you may also add, change, or drop current coverage.

Medicare Advantage Open Enrollment Period

During this period, you can make a switch between Medicare Advantage plans or you can end it to return to Original Medicare.

Special Election Period

Many factors can stimulate a special election period and they are unique to an individual. It’s best to speak with a licensed Medicare insurance agent to find out whether you qualify for a special election period. However, there are a few common situations, like if you move outside your Advantage plan’s service area, move into a nursing home, or qualify for additional aid, you could be eligible for this special election period. You can institute changes to your Medicare Advantage plan during this period or go back to Original Medicare.

If you have questions about Private Fee-for-Service plans or you would like a quick quote, we can help. Call 830-328-4353 today.