What Is a Medicare PFFS Plan?
A Medicare Private Fee-for-Service (PFFS) Plan is a type of Medicare Advantage (Part C) plan offered by private insurance companies. Unlike HMOs and PPOs, PFFS plans give you the freedom to receive care from any Medicare-approved provider—as long as they agree to your plan’s terms and payment conditions.
This flexibility comes with a caveat: not all providers will accept your PFFS plan, and provider agreement must be confirmed before every visit.
How Do PFFS Plans Work?
Medicare pays private insurers a set monthly amount to provide your Medicare Part A and Part B benefits.
The insurance company sets the plan rules, provider payment terms, and cost-sharing requirements.
You can use any doctor or hospital that accepts both Medicare and your plan’s payment conditions.
Most PFFS plans also include prescription drug coverage (Part D) and offer additional benefits like dental, vision, and hearing coverage.
Key Benefits and Limitations
Benefits:
No requirement to use a specific provider network
No need for referrals to see specialists
May include extra benefits like wellness programs and transportation
Often includes drug coverage
Limitations:
Doctors must agree to each visit individually—even if they’ve accepted your plan before
High risk for unexpected out-of-pocket costs if services are deemed not “medically necessary”
Some providers may refuse your plan altogether
Medicare Coverage Still Applies
If you join a PFFS Plan, your access to Medicare-covered services under Part A and Part B remains intact. This includes:
Part A: Hospital stays, skilled nursing facility care, hospice, and some home health services
Part B: Doctor visits, outpatient care, lab services, preventive screenings, and durable medical equipment
However, PFFS plans can decline coverage for services they determine are not medically necessary—potentially leaving you with large bills unless you appeal or secure an advance coverage decision.
Plan Availability and Costs
PFFS plan availability depends on your geographic location, and:
Premiums, copays, deductibles, and coinsurance vary significantly by plan and region
Some PFFS plans have $0 premiums, while others may have higher monthly costs in exchange for broader benefits
Out-of-pocket maximums apply, but can still be high if you frequently use out-of-network services
Important Considerations Before Enrolling
Always verify provider participation before every appointment or procedure
Be prepared to manage coverage decisions and appeal processes
Review each plan’s drug formulary and extra benefits
Understand how your PFFS plan works with your existing coverage, especially if you’re transitioning from Original Medicare or another Advantage plan
Let MedicareMall Help You Choose the Right PFFS Plan
Choosing a PFFS plan can feel overwhelming due to varying provider agreements, inconsistent costs, and unclear terms. MedicareMall’s licensed experts are here to:
Help you compare PFFS plans available in your area
Verify your provider participation and drug coverage
Assist with enrollment and appeals if necessary
Ensure you understand all cost-sharing rules and benefit restrictions
With over 20 years of experience, we’re committed to helping you find the right Medicare Advantage solution at the best possible price.