Private Fee-for-Service

Private Fee-for-Service (PFFS) Plans fall within the Medicare Advantage category. These plans are offered by private insurance companies and determine how much you must pay when you get care, as well as how much they will pay your doctor or healthcare provider.

Coverage and Network Options

PFFS Plans do not require you to select a primary care physician or get referrals. There is a possibility that PFFS Plans will have a provider network, but you can typically still receive care outside the network as long as the provider accepts the plan’s terms and conditions. You will also be expected to pay the coinsurance or copayment amount that is allowed by the plan for the type of service you get.

You should always show your healthcare provider your plan Membership ID card each time you go. It will be up to the provider to choose if they will accept your plan’s terms and conditions or not, so make sure you provide this to them before you receive your care. While you are in the PFFS Plan, Original Medicare will not provide coverage for you, so using your red, white, and blue Medicare card will be ineffective. However, you should still hold on to this card in a safe place in the event you choose to switch back to Original Medicare. 

In the event of an emergency, hospitals and doctors must treat you, and your plan must provide coverage.

Also, not all PFFS Plans include drug coverage. If you’re enrolling in one that doesn’t include drug coverage, consider also enrolling in a Part D plan.

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Considering a PFFS?

If you are considering a PFFS Plan, there are several enrollment periods in which you should take note of:

• Initial Enrollment Period: The Initial Enrollment Period begins three months before your 65th birthday and ends three months after your 65th birthday. Once you are enrolled in Original Medicare, you can enroll in a Medicare PFFS Advantage Plan. Or, if you become eligible for Medicare because you receive Social Security disability benefits and you are under 65, you can enroll in a Medicare Advantage Plan three months before becoming eligible and up to three months after.

• Annual Enrollment Period: The Annual Enrollment Period begins on October 15 and ends December 7. During this period, you can switch from Original Medicare to a Medicare Advantage Plan. If you are already enrolled in a Medicare Advantage Plan, you will have the option to switch to a new Advantage Plan.

• Special Enrollment Period: The Special Enrollment Period is limited to only those who qualify for it. To qualify, you must have experienced special circumstances, such as moving outside your plan’s service area and needing new coverage. Or, you delayed your Medicare enrollment because you were already covered by another health insurance plan but now need to enroll in Medicare.

If you think that a PFFS plan is right for you, consider talking to an insurance agent who can lay out all your options.  Working with insurance professionals ensures that you’re making the right decision and enrolling in the plan that’s best for you.