Senior customer buying drugs in a pharmacy with a Private Fee Service Plan

What Is a Medicare Private Fee-For-Service Plan?

Private Fee-for-Service Plan – If you’ve started looking at different Medicare Advantage plans, you might have come across a private fee-for-service plan. These aren’t one of the most popular types of Part C plans, but when there are few options, these can be beneficial to some individuals.

This article will review what PFFS plans are, how they work, and a few of the advantages and disadvantages of these plans.

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What is a PFFS plan?

A private fee-for-service plan is a type of Medicare Advantage plan, but they work a bit differently than the more popular HMO and PPO plans. Like other MA plans, PFFS plans are an alternative to Original Medicare (Parts A and B). They will offer at least as much coverage as Original Medicare and sometimes include extra benefits like prescription drug coverage.

How do PFFS plans work?

In a PFFS plan, the insurance carrier decides what it will pay for medical services and how much their members will have to pay. Plans might include deductibles, copayments, or coinsurance costs.

Members must see healthcare providers who have agreed to accept the plan’s payment terms. Providers who accept Medicare will not necessarily always accept your PFFS plan. In addition, providers can choose to accept the plan on a visit-by-visit and patient-by-patient basis. That means that even if you find a provider who accepts your plan at one visit, they may not accept it at your next visit. (In emergency situations, no medical professional can deny care, regardless of what kind of insurance plan you have.)

Some PFFS plans do provide a network of healthcare professionals who have agreed to always accept the plan and all patients with that plan. This helps relieve the burden of the member having to check the provider’s plan participation status before each visit. In addition, it helps maintain continuity of care since you know you’ll be able to see that same provider the next time you need care.

If your PFFS plan includes prescription drug coverage, you will need to consult the drug formulary to find out how much your prescriptions will cost to refill. If the PFFS plan does not include drug coverage, you are allowed to purchase a stand-alone Medicare Part D plan.

Advantages of PFFS Plans

PFFS plans do not require members to designate a primary care physician, nor do they require specialist referrals. And while it’s best to use a network of providers, you aren’t necessarily limited to specific networks.

PFFS plans also have the advantage that all Part C plans do – they offer more benefits than are found in Original Medicare. Your plan might include prescription drug coverage, vision and hearing care, preventive and restorative dental care, gym memberships, etc. If your plan doesn’t include prescription drug coverage, PFFS plans are the only kind of Medicare Advantage plan that allows you to enroll in Part D.

Old wrinkled woman clenches fits, has strict angry expression, after learning disadvantages of PFFS Plans
It can be difficult for beneficiaries to keep track of which of their providers have agreed to accept their plan.

Disadvantages of PFFS Plans

The biggest disadvantage of PFFS plans is the potential of so many provider participation changes. It can be difficult for beneficiaries to keep track of which of their providers have agreed to accept their plan. Plus, it can be very time-consuming to have to check their participation status before each appointment, especially if you are someone who needs frequent medical attention.

Except in emergency situations, providers who are not in your plan’s network could even decline to treat you. If there are not many providers in your geographical area, this could pose a problem with your access to care.

How much do PFFS plans cost?

If you enroll in Part C, you must continue to pay the Medicare Part B premium. Your PFFS plan will also have a monthly premium, which will vary by plan and zip code. Some plans have $0 premiums but don’t forget that you will have other costs when you receive care.

If you are considering a PFFS Medicare Advantage plan, you should consult with one of our Medicare advisors to make sure you understand how these plans work and to compare them to other options in your area. Contact our office today to schedule an appointment with a licensed insurance agent.

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