A Private Fee-For-Service, or PFFS, plan is a type of Medicare Advantage (MA) plan that is administered by a private insurance company. PFFS plans are an alternative way to get your Medicare benefits.
Medicare pays the PFFS plan a set amount of money every month to provide health care coverage on a fee-for-service arrangement. Unlike Original Medicare, with a PFFS plan the insurance company, not Medicare, decides how much you will pay for the services you get.
What Do PFFS Plans Cover?
PFFS plans are required to cover all the same benefits as Original Medicare, including the same hospital coverage you would get with Part A, and the same outpatient services you would get with Part B. When you enroll in a PFFS plan, you are still enrolled in the Medicare program with the same protections as someone with Original Medicare. One exception is that you must pay for services not covered by the PFFS plan if the plan says the services arenāt medically necessary. Plan members do have some recourse, however, to appeal claims in cases where they believe a service was medically necessary yet was not covered by the PFFS.
The PFFS plan determines how much it will pay doctors, other medical providers, and hospitals. You donāt need to choose a primary care doctor with a PFFS plan, nor do you need a referral to see a specialist. Not all PFFS plans have networks, although most do, as of 2011. If you join a PFFS plan that has a network, you can see any Medicare-approved doctor or other health care provider, and go to any hospital that accepts the planās payment terms and agrees to treat you. Itās important to note that not all providers will agree to your planās terms, so check with the provider beforehand.
What about Prescription Drug Coverage?
Similar to Medicare Advantage plans, some PFFS plans cover prescription drugs, but, unlike MA plans, if the PFFS plan you choose does not offer prescription drug coverage, you can still enroll in a Medicare Prescription Drug plan. If the plan you choose offers prescription drug coverage, you must get your drug coverage from that plan.
Advantages of PFFS Plans
- Similar to other Medicare Advantage plans, PFFS plans may include benefits that Original Medicare does not cover, such as vision, dental, and hearing care.
- You donāt need a referral to see a specialist with a PFFS plan.
What Are My Costs on a PFFS Plan?
You must pay the monthly Medicare Part B premium ($104.90 for most people in 2015), plus any additional monthly premium the PFFS plan charges above the Part B premium. You also must pay any additional monthly premium for extra benefits (vision, dental, etc.), and any applicable deductibles, coinsurance, or copayment amounts. Itās important to note that PFFS plans may let providers charge up to 15% over the planās payment amount (referred to as ābalance billā) for services if the provider has a written contract with the Medicare PFFS plan or has met certain conditions.
Consult with an Expert
For more information about Medicare enrollment and choosing the option thatās best for you, consult with the experts at CA Medicare.
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