Private Fee-for-Service Plans
PFFS plans offer a unique approach to Medicare Advantage. See any Medicare-accepting provider who agrees to the plan's payment terms — with no network restrictions.
What Is a Private Fee-for-Service Plan?
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan offered by a private insurance company. Unlike HMO and PPO plans that use established provider networks, a PFFS plan determines on its own how much it will pay healthcare providers and how much you will pay when you receive care.
The key distinction of PFFS plans is that providers are not required to join a network. Instead, any Medicare-approved doctor, hospital, or other provider can accept you as a patient as long as they agree to the plan's terms and conditions of payment for that particular visit. This means you have considerable flexibility in where you receive care, but you must confirm that a provider accepts your PFFS plan before each visit.
PFFS plans cover all Medicare Part A and Part B services, and some also include Part D prescription drug coverage. Like other Medicare Advantage plans, they provide an annual out-of-pocket maximum that protects you from unlimited healthcare expenses.
How PFFS Plans Work
Plan Sets the Terms
Your PFFS plan establishes payment rates for each type of service. These terms outline what the plan pays, what you pay in copays or coinsurance, and any conditions of coverage.
Provider Agrees to Treat You
Before each visit, you confirm that the provider accepts your PFFS plan's terms. Providers can choose whether to accept PFFS patients on a case-by-case basis. They are not obligated to accept you simply because they participate in Medicare.
You Receive Care
Once the provider agrees, you receive care and pay your share as outlined in the plan's terms. The plan pays its portion directly to the provider at the agreed-upon rate.
Key Features of PFFS Plans
Provider Flexibility
See any Medicare-approved doctor, hospital, or specialist who accepts the plan's terms of payment — no network restrictions or referrals required.
Plan Sets Payment Terms
The plan determines how much it will pay providers and how much you owe. Providers must agree to these terms each time you receive care.
No Network Required
Unlike HMO and PPO plans, most PFFS plans don't maintain a provider network. You choose where to receive care on a visit-by-visit basis.
May Include Drug Coverage
Some PFFS plans include Part D prescription drug coverage. If yours does not, you can enroll in a separate stand-alone Part D plan.
Out-of-Pocket Maximum
Like all Medicare Advantage plans, PFFS plans cap your annual out-of-pocket spending, providing financial protection that Original Medicare does not offer.
Covers All Medicare Services
PFFS plans must cover all services that Original Medicare covers, ensuring you don't lose any existing benefits when you enroll.
Important Things to Know About PFFS Plans
While PFFS plans offer flexibility, there are several important details to understand before enrolling:
- Provider acceptance is not guaranteed: Just because a doctor accepts Medicare does not mean they must accept your PFFS plan. Providers decide on a visit-by-visit basis whether to accept the plan's payment terms. Always confirm before scheduling an appointment.
- Some PFFS plans have networks: While traditionally network-free, some PFFS plans have started contracting with provider networks. If your plan has a network, you may pay less for in-network care and more for out-of-network services.
- Drug coverage varies: Not all PFFS plans include Part D prescription drug benefits. If yours does not include drug coverage, you can join a separate stand-alone Part D plan. However, if your PFFS plan does include drug coverage, you cannot also enroll in a stand-alone Part D plan.
- Emergency and urgent care are always covered: Like all Medicare Advantage plans, PFFS plans cover emergency services anywhere in the United States, regardless of whether the provider normally accepts the plan's terms.
- Availability is limited: Fewer PFFS plans are available compared to HMO and PPO options. Availability depends on your county and the insurers offering plans in your area.
Is a PFFS Plan Right for You?
PFFS plans can be a good fit in certain situations. Consider a PFFS plan if:
- You live in a rural area where few HMO or PPO plans are available, and a PFFS plan provides access to more providers.
- You want the freedom to see any provider without being tied to a specific network, and you're comfortable confirming acceptance before each visit.
- You prefer a Medicare Advantage plan with an out-of-pocket maximum but don't want the network restrictions of an HMO.
- You understand the trade-offs of PFFS plans, including the possibility that a provider may decline to see you under the plan's terms.
At MAC Insurance, our licensed agents will help you understand whether a PFFS plan is available in your area and how it compares to HMO, PPO, and other Medicare Advantage options.
Have Questions About PFFS Plans?
PFFS plans work differently from other Medicare Advantage options. Let our licensed agents explain how they work and help you determine if a PFFS plan is the right choice for your situation.