Medicare Advantage Plans: Private Fee-for-Service (PFFS) Plans - dummies

Medicare Advantage Plans: Private Fee-for-Service (PFFS) Plans

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Medicare Private Fee-for-Service (PFFS) plans don’t offer managed care. They directly pay providers for each covered service, similar to the way traditional Medicare works. After 2010, when a change in the law placed PFFS plans under more regulation and provided more consumer protections, many of these plans withdrew from Medicare. In 2013, only 4 percent of people enrolled in the MA program chose PFFS plans. Here are their main features:

  • Eligibility: You must have Parts A and B and live in the service area of the plan you select (even though you aren’t limited to seeing providers in that area). You can’t join a plan if you have kidney failure (ESRD), but if you develop it while already enrolled, you can stay in the plan.

  • Choice of doctors and hospitals: You can go to any doctor or hospital anywhere in the country if the provider accepts the plan’s conditions and payment rates. You don’t need a referral to see a specialist, and the plan can’t require you to ask for preauthorization before covering treatment. But many providers don’t accept PFFS plans.

    Also, providers are allowed to accept or reject the plan for each service visit — so if they accept it once, you have no guarantee they’ll do so next time. To be sure of where you stand, you or the provider can ask the plan for a written decision on coverage before you receive each service.

  • Extra benefits: PFFS plans may offer extras like routine vision, hearing, and dental care and fitness classes or gym memberships if they choose.

  • Prescription drug coverage: Not all PFFS plans offer Part D drug coverage. If you join a plan that doesn’t, you can enroll in a stand-alone drug plan to obtain coverage (unlike HMOs and PPOs).

For more information, see the official publication “Your Guide to Medicare Private Fee-for-Service Plans.”