What Is a Medicare PFFS Plan?

What Is a Medicare PFFS Plan?
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What Is a Medicare PFFS Plan?

What Is a Medicare PFFS Plan?
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A Private Fee-for-Service, or PFFS, is a type of Medicare Advantage Plan that lets you pay for individual services that you may need instead of paying for a package that includes services you don’t require. 

According to the Kaiser Family Foundation (KFF), PFFS plans were the least common type of Medicare Advantage Plan in 2017, responsible for only 1%.

This article will tell you everything you need to know about PFFS plans, what they offer, how much they cost, and what alternatives may be worth exploring.

What Is a Medicare Private Fee-for-Service (PFFS) Plan?

Private Fee-for-Service (PFFS) plans are a type of Medicare Advantage Plan, also known as Medicare Part C.

A PFFS plan is bought through private insurance companies that are in contract with Medicare to provide you with the healthcare coverage you need.

The plan determines how much Medicare will pay doctors, other healthcare providers, and hospitals, and how much you must pay when you receive treatment. 

PFFS plans provide coverage for things like:

  • Doctor's appointments.

  • Hospital stays.

  • Other medical benefits you would receive with Original Medicare (Part A and Part B).

The amount that a PFFS plan will pay for a particular service is preset. The plans that you can take out will depend on where you live.

Key Point: What Is a Medicare Advantage Plan?

Medicare Advantage is health cover for Medicare beneficiaries that is offered by private health insurance companies.

These plans provide the same coverage as Original Medicare (Part A and B) and often have additional benefits that government-run Medicare doesn't offer.

If you need assistance with finding a plan that will offer you exceptional customer service, contact PolicyScout today. Our agents can help you find 5-star Medicare plans in your area.

An elderly couple that are happy because they have a Medicare PFFS plan.

Source: Unsplash

What Is Covered by a Medicare PFFS Plan?

Your PFFS plan will cover everything that Medicare Part A (hospital insurance) and Part B (medical insurance) does.

Some of these medical expenses include:

  • Hospital stays.

  • Short-term in-patient rehabilitation (including care in a skilled nursing facility, hospice care, or some home health care).

  • Doctor’s visits.

  • Preventive care.

  • Emergency room visits.

  • Certain medical equipment (such as wheelchairs).

  • Ambulance rides.

Key Point: What Is Preventive Care?

Preventive care or services refer to healthcare that is aimed at preventing illness or detecting illness at an early stage.

Preventive services aim to begin treatment when it is likely for them to perform best.

Examples of preventive care include:

  • Blood pressure, diabetes, and cholesterol tests.
  • Cancer screenings.
  • Vaccinations against diseases.

Because PFFS is a Medicare Advantage Plan, it may also provide additional coverage for services such as dental and vision care.

Your PFFS plan may also offer prescription drug coverage. However, if it doesn’t, you can join a Medicare Part D plan, which covers prescription drugs.

Key Point: Which Provider Will Help Me with a PFFS?

You can go to any Medicare-approved doctor, healthcare provider, or hospital that:

  • Accepts the plan's payment terms.
  • Agrees to treat you.
  • Hasn’t opted out of Original Medicare (not all providers will).

An elderly couple who are happy because their preventative care can be covered by a Medicare PFFS plan.

Source: Pexels

Understanding Medicare PFFS Plans Better

Doctors, healthcare providers, and hospitals can decide whether or not they will accept payment from your PFFS plan for a particular service or treatment you receive.

Simply put, your doctor or healthcare provider may accept your PFFS payment for one service, but not another.

To avoid being caught without coverage, you should check that your PFFS plan is accepted for every service or treatment that you require.

Some PFFS plans have a network that includes multiple healthcare providers or doctors that accept your plan. 

If your plan has a network, then those providers will accept your PFFS payment every time.

Providers that are out of the network may not treat you unless there’s a medical emergency. 

If you do receive a service or treatment from an out-of-network healthcare provider, you will most likely pay more compared to an in-network provider.

To learn more about PFFS plans, we’ve listed some of the key pros and cons that can help you decide if this type of plan is right for you.

However, if you are still unsure about Medicare and Medicare Advantage Plans, contact a PolicyScout consultant at 1-888-912-2132 or Help@PolicyScout.com for assistance and answers to all your questions. 

Pros of a PFFS Plan

One major advantage that comes with a PFFS plan is that you don’t need to choose a primary care physician (PCP). This means that you can receive care from any physician that accepts your plan.

This also means that you won’t need a PCP referral to visit a specialist if needed. 

With a PFFS plan, you can get additional coverage that Original Medicare may not provide. This could include drug, vision, and dental coverage.

Cons of a PFFS plan

Although getting additional coverage that Original Medicare may not offer is a positive factor, premiums with a PFFS plan can cost more than Original Medicare.

Co-payments and coinsurance costs may also be higher if you receive services out-of-network.

Some healthcare providers, doctors, or hospitals may not accept your PFFS plan, and they may also cover some services and not others.

Terms You Should Know:

Premiums: These are payments made to insurance companies in exchange for insurance coverage.

Deductibles: These are amounts that Medicare beneficiaries must cover before their Original Medicare or Medicare Advantage will cover qualifying medical expenses.

Coinsurance: This is the portion of costs that beneficiaries must pay for medical treatments, services, and tests. For example, with Medicare Part B, the coinsurance rate is 20%.

Two people deciding whether or not to get a Medicare PFFS plan.

Source: Pexels

Medicare Advantage PFFS Costs

As previously mentioned,  the amount PFFS plans pay for each doctor, healthcare, or hospital service is preset.

The plan provider decides in advance how much the plan pays per service and how much the plan owner will pay when receiving the service or treatment.

A PFFS plan is not allowed to charge more than Original Medicare does for certain kinds of care which may include: 

  • Chemotherapy.

  • Dialysis.

  • Care that is received in a skilled nursing facility (SNF).

Key Point: What Is a Skilled Nursing Facility (SNF)?

An SNF is a nursing facility with the staff and equipment to give skilled nursing care.

In most cases, an SNF can also provide skilled rehabilitative services and other related health services.

A Medicare PFFS plan’s cost will vary depending on your location. 

Typically, you would need to pay a premium in addition to the one you already have for your Medicare Part B plan.

In 2022, the standard Part B premium amount is $170.10 (or higher depending on your income). For your PFFS time of service, you’ll also need to pay co-payments or coinsurance.

Key Point: Frequently Asked Questions (FAQs)

Do PFFS plans cover prescription drugs? Sometimes. If your Medicare Advantage PFFS plan doesn’t offer prescription drug coverage, you can enroll in a Medicare Part D Prescription Drug Plan to get coverage.
Do I need to choose a primary care doctor for my PFFS? Yes and no. PFFS plans allow you the freedom to choose and/or keep your own doctors.
Do I have to get a referral to see a specialist with my PFFS? No. A PFFS plan does not require you to choose a PCP. This means you won’t need a referral in order to get an appointment with a specialist.

An elderly lady researching the Medicare PFFS plan costs.

Source: Pexels

Some Alternative Medicare Advantage Plans

Medicare Advantage does not only have PFFS plans. It can also offer you Health Maintenance Organization (HMO) Plans, Preferred Provider Organization (PPO) Plans, and Special Needs Plans (SNP).

Health Maintenance Organization (HMO) Plans

Health Maintenance Organization (HMO) plans are usually less expensive than other Medicare Advantage Plans.

This is because of the network of contracted healthcare professionals, hospitals, and clinics that the plan uses.

These healthcare providers offer care to HMO members at a discounted rate. Like PFFS plans, most HMO plans do not cover out-of-network care, except in an emergency.

However, an HMO member must choose a PCP to organize and oversee their care and refer them to specialists.

According to the Help Advisor, HMO plans were the most common type of Medicare Advantage Plan in 2021.

HMO plans accounted for 2,205 (62%) of the 3,550 Medicare Advantage (Part C) Plans available.

Preferred Provider Organization (PPO) Plans

PFFS and HMO Medicare Advantage Plans typically work with a network of healthcare providers without having to select a PCP to coordinate their care.

If care or service is administered outside of this network it will cost the plan owner.

However, a PPO plan provides benefits outside of the network with higher coinsurance or copayments.

A PPO is more flexible than an HMO plan, and is, as a result, more expensive.

Special Needs Plans (SNP)

Medicare Special Needs Plans (SNPs) are Advantage Plans for people with particular needs, such as:

  • Chronic conditions, like chronic obstructive pulmonary disease.

  • Living in a long-term care facility, such as a nursing home.

A couple researching the alternative Medicare Advantage Plans.

Source: Pexels

What Else Does Medicare Cover?

Although you may get medical coverage through Original Medicare, sometimes it may not meet all your requirements. 

That is why Medicare Advantage is available, and more particularly, plans such as PFFS.

If you’re currently unsure about Medicare or curious about the other plans available, get in touch with one of our professional consultants for tailored advice. Send us an email at help@policyscout.com or give us a call at 1-888-912-2132.

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