TABLE OF CONTENTS

What you should know:
  1. Medicare Advantage Private Fee-for-Service (PFFS) Plans can provide comprehensive coverage for everything from doctor’s visits, preventive care, and lab services to hospital stays and nursing facility care.
  2. After joining, if you decide this plan isn’t the best option for your circumstances, you must wait until an applicable annual enrollment period to transfer back to Original Medicare or another approved Medicare plan.
  3. With a Medicare Advantage PFFS Plan, private insurance companies manage your healthcare services and allow you to choose Medicare-approved providers who accept the plan’s payment terms throughout the U.S.
  4. Enrollment in Original Medicare Parts A and B is necessary.

What is a Medicare PFFS Plan?

A Medicare PFFS plan is one of the four available Medicare Advantage plans. These plans are also referred to as Medicare Part C, which includes coverage for Parts A and B, called Original Medicare. Some Medicare PFFS plans also provide Part D prescription drug coverage.

What’s covered

All PFFS plans must cover the same benefits as Original Medicare Part A and Part B. How you pay for your portion of costs for services looks different. For instance, if you require hospitalization, your PFFS charges you a daily copay for a certain number of days. Original Medicare Part A charges a deductible for each benefit period.

Coverage for Part A and B includes:

  • Inpatient care in a hospital or Skilled Nursing Facility (SNF)
  • Short-term SNF care after a qualifying hospital stay
  • Home health care
  • Hospice care (service is covered under the Part A Hospice Medicare Benefit)
  • Outpatient medically necessary services needed to treat or diagnose your medical condition
  • Preventive care
  • Durable medical equipment (DME)
  • Ambulance services
  • Clinical research
  • Mental health care

PFFS plans also may include services that Medicare does not cover:

  • Prescription drug coverage (so you don’t have to purchase a standalone Part D prescription drug plan)
  • Vision, dental, and hearing care (you may pay an extra monthly premium for more comprehensive coverage)
  • Fitness club memberships

How the plan works

With a Medicare Advantage PFFS Plan, an insurance company manages your health care services. Your plan sets the amount it pays for a specific service and the amount of your copayment. Be sure to confirm that your plan is accepted before each treatment, as some providers may only allow the plan’s set fee for certain services. You can be treated by any healthcare provider that agrees to accept the plan’s payment terms, but they may refuse to do so at any time.

Advantages of a Medicare Advantage PFFS Plan Disadvantages of a Medicare Advantage PFFS Plan
  • You don’t need to have a primary care doctor.
  • You can see a specialist without a referral.
  • You can see any Medicare-approved provider that accepts the plan’s payment terms, anywhere in the country.
  • You can be treated by any participating providers if the plan has a network.
  • You only need to pay a set copayment amount when you get treatment. The health care provider bills the plan for the remainder of the cost.
  • You may receive additional benefits not included in Original Medicare Part A and Part B.
  • You can only see providers that accept the plan’s payment terms. Unless they’re part of a network, they may decide not to take the plan at any time, even if they’ve previously treated you.
  • Providers may refuse to see you unless it’s an emergency.
  • There may be higher copayment costs if you use a provider outside of the plan’s network.
  • PFFS plans are not as common as HMO or PPO plans and may not be available in your service area.

Compare your Medicare options

See how a Medicare PFFS compares to Original Medicare and other Medicare Advantage Plan types.
Plan type Costs Part A coverage Part B coverage Part D coverage Out-of-state care
Original Medicare Part B premium Yes Yes No Yes
Medicare Advantage HMO Part B premium plus plan premium Yes Yes Usually Emergency only
Medicare Advantage PPO Part B premium plus plan premium Yes Yes Usually Emergency, plus other care if in your plan’s network, or you pay more for out of network
Medicare Advantage PFFS Part B premium plus plan premium Yes Yes Sometimes Emergency, plus other care if contracted with your plan and agrees to treat you.
Medicare Advantage SNP Part B premium Yes Yes Yes Emergency and out-of-area dialysis plus other care if in your plan’s network

Who is eligible for a Medicare PFFS Plan?

You need to meet the following criteria to qualify for a Medicare Advantage PFFS plan:

  • Eligibility and enrollment in Original Medicare Parts A and B are necessary.
  • You must live in an area serviced by state-licensed and Medicare-approved HMO plan providers for no less than six months out of the year. You can search for an available plan in your area on the Medicare website.

How much does a Medicare PFFS Plan cost?

Expect to pay almost $300 per month for your Medicare Advantage PFFS plan. That includes the standard $170.10 Part B premium and an average plan cost of $110, depending on where you live. You’ll have additional costs when you use your coverage, including:

  • Copays: You may need to pay copays if you visit the doctor or receive other medical services. The insurer sets this amount.
  • Coinsurance: You may pay a percentage of the Medicare-approved service charge after you have exhausted your deductible for the year.
  • Deductibles: You may have to pay an annual out-of-pocket amount before your insurance begins to pay for services.
  • Out-of-network charges: These may apply if you seek care from a medical provider outside your plan network.
  • Additional services: Some plans that offer vision, dental, and hearing coverage may charge higher premiums and a separate drug deductible.

Costs vary from state to state, so it’s important to compare the plans available in your area for an accurate cost estimate.

See how costs compare for these PFFS plans in different areas of the country: (plans include drug coverage):

Plan name Monthly premium Deductible Copay Coinsurance Out-of-pocket max
Humana Gold Choice H8145-061 (Miami-Dade, FL) $102 $0 (health)

$200 (drug)

 PCP: $5

Specialist: $40

 20 – 25% $6,700 in and out of network combined
Humana Gold Choice H8145-008 (Cook County, IL) $146 $0 (health)

$380 (drug)

 PCP: $15

Specialist: $45

 50% $6,700 in and out of network combined
Humana Gold Choice H8145-123 (Denver County, CO) $90 $0 (health)

$300 (drug)

 PCP: $15

Specialist: $50

 20 – 25% $6,700 in and out of network combined

How do I enroll in a Medicare PFFS Plan?

To enroll in a Medicare Advantage Plan, you first need to be enrolled in Original Medicare Part A and Part B. After you’re enrolled in Original Medicare, you can enroll in a PFFS plan during your Initial Enrollment Period or during other enrollment periods throughout the year:

  • Initial Enrollment Period (IEP): This seven-month period starts three months before the month of your 65th birthday, the month of your birthday, and ends three months after your birthday month.
  • Initial Coverage Enrollment Period (ICEP): This is the enrollment period for those who want to enroll in a Medicare Advantage Plan and often occurs at the same time as the IEP for Original Medicare.
  • Annual Enrollment Period: This period runs from October 15th through December 7th.
  • Medicare Advantage Open Enrollment: Medicare beneficiaries who already enrolled in a Medicare Advantage Plan can switch plans between January 1st and March 31st.

Use the Medicare Plan finder to research available PFFS plans in your area. When you’ve chosen a plan, go to the insurer’s website to check for online enrollment options or contact the insurance company by phone or email to request a paper enrollment form. Before you enroll, make sure the providers you currently see (like your dialysis facility or kidney doctor) or want to see in the future (like a transplant facility) accept your plan’s terms.

You can also enroll by calling Medicare at 1-800-633-4227.

To enroll, you need your Medicare number and the date your Parts A and B coverage began. Your Medicare card has this information.

Who should get a Medicare Advantage PFFS Plan?

A Medicare Advantage PFFS plan might be a good fit if you:

  • Want to choose your healthcare providers without being restricted to a network of providers
  • Want to see specialists without a referral
  • Travel or live in different parts of the country for a portion of the year
  • Want a Medicare Advantage Plan along with a standalone prescription drug plan.
author-img
Roseann Birch
Medicare consultant

Roseann Birch has worked in the insurance industry for more than 35 years. In 2006, she moved to selling insurance and, by 2009, Birch made Medicare her area of expertise after observing the struggles of older adults to understand Medicare. Although many adults age 65 and older are eligible for Medicare, nearly just as many don’t understand how it works.

Birch has learned the ins and outs of Medicare and its variations and supplements to help beneficiaries and their families understand benefits. She finds there is often misinformation and makes it her mission to clear up the confusion so that everyone can enjoy the full extent of Medicare benefits.

author-img
Roseann Birch
Medicare consultant

Roseann Birch has worked in the insurance industry for more than 35 years. In 2006, she moved to selling insurance and, by 2009, Birch made Medicare her area of expertise after observing the struggles of older adults to understand Medicare. Although many adults age 65 and older are eligible for Medicare, nearly just as many don’t understand how it works.

Birch has learned the ins and outs of Medicare and its variations and supplements to help beneficiaries and their families understand benefits. She finds there is often misinformation and makes it her mission to clear up the confusion so that everyone can enjoy the full extent of Medicare benefits.

Sources