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(417) 633-7200


Springfield, Missouri


Medicare Advantage Private Fee-for-Service Plans

Private Fee-for-Service (PFFS) plans Medicare Advantage plans that are sold by private insurance companies who have been approved by the federal program to offer such plans. They will offer at least as much coverage as what Medicare Parts A and B offers, but usually come with extra benefits. Since these are not standardized, each carrier can dictate the coverage and costs for each plan.

Medicare Advantage PFFS Plan Benefits

Insurance companies who provide PFFS plans decide what they will pay for service and procedures. They also decide what the member will pay. Individuals with these plans will also be responsible for deductibles, a percentage of the dictated fee, and/or copayments.

Private Fee-for-Service plans will provide their members with a list of Medicare-approved healthcare providers that also accept the plan’s payment rates and terms. These providers agree to treat PFFS plan members and do not require any referrals, even for specialist providers.

However, not every provider who accepts Medicare assignments will accept the PFFS payment terms. Providers can actually decide on a patient-by-patient basis if they want to accept the terms and can also terminate that relationship at any time. This causes some hardship for PFFS plan holders as they will need to verify plan acceptance prior to every visit and may end up switching providers frequently. This disrupts the continuity of care.

There are some PFFS plans that have a network of providers who have agreed to continue accepting the plan’s payment terms and to see new and existing plan members. This will help relieve the burden of asking before every appointment. That being said, all providers and hospitals must treat you in an emergency situation, regardless of why kind of insurance you do (or do not) have.

Some Private Fee-for-Service Medicare Advantage plans include prescription drug coverage. If the plan does not provide that benefit, individuals will want to verify that they are still allowed to enroll in a stand-alone Part D plan.

Medicare Advantage PFFS Plan Costs

As with any Medicare Advantage plan, individuals with a PFFS plan must still pay their Medicare Part B premium. There will be an additional premium for the PFFS plan itself, and then the cost will vary based on the rules set by the private insurance company that is carrying the plan. Costs will include deductibles, copays, and coinsurance expenses.

PFFS plans may also allow “balance billing,” which means that providers can charge an extra 15% on top of the plan’s payment rate.

Comparing PFFS Plans to
Other Medicare Advantage Plans

In the other kinds of Medicare Advantage plans, like the HMOs and PPOs, the member’s out-of-pocket expenses will vary based on if they have services performed in or out of the plan’s network. Individuals can choose from any provider who is in the plan’s network. Going outside of the network may cause the member to pay more for services.

The expenses with a PFFS plan do not vary based on a provider being in or out of a network. Individuals with a PFFS plan can see any doctor who agrees to accept the plan’s payment terms. This will give beneficiaries more choices when it comes to their provider.

Comparing Medicare Advantage PFFS Plans to Original Medicare and Medicare Supplements

Original Medicare – Parts A and B – have more in common with Medicare supplements than Medicare Advantage plans. Coverage for all individuals who are enrolled in Parts A and B is exactly the same. Coverage for all individuals enrolled in a Medicare supplement is exactly the same. If a provider accepts Original Medicare, they will also accept your Medicare supplement plan.

Medicare Advantage plans are different. They do offer the same coverage as Medicare Parts A and B, at a minimum. However, since they are sold by private insurance companies and utilize provider networks, the freedom to choose providers is limited with these plans. Also, Medicare Advantage plans, including the PFFS plans, are not available everywhere.

PFFS plans also have copays, coinsurance, and other unpredictable out-of-pocket expenses. Medicare supplements, on the other hand, have much more predictable costs. Some of them nearly eliminate all of the individual’s healthcare expenses. Premiums for Medicare supplements are generally higher than those for Medicare Advantage PFFS plans.

Lastly, there is often prescription drug coverage built into Medicare Advantage plans. No Medicare supplement offers prescription drug coverage, so individuals must enroll in a separate Part D plan.

Finding the

Best Policy

A licensed agent can help you choose the best type of Medicare policy. We’ll ask you some questions about your lifestyle and health and then can give you options that will fit those needs. We’ll be able to look at different plans across many carriers, so you can choose the best possible plan.

After you choose, we’ll help you through the enrollment process and will file all the necessary paperwork. Our work doesn’t end there. We’ll reach out during important enrollment periods and make sure you still have the best plan available. All of these services come at no cost to you.

Medicare Advantage PFFS Eligibility and Enrollment

Any Medicare beneficiary who has already enrolled in Medicare Parts A and B is eligible to apply for a Medicare Advantage PFFS plan, with one exception. Individuals who have already been diagnosed with End-Stage Renal Disease (ESRD) are not eligible for any Medicare Advantage plan. Otherwise, an individual can enroll during their Initial Enrollment Period or during the Annual Enrollment Period. Some individuals may even qualify for a Special Enrollment Period.

Medicare Advantage PFFS plans are not available in all areas. Work with a licensed agent to find out which plans are available in your area.

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