PFFS plans are fixed rate-based for individual medical services. Doctors may accept that rate for some services and not for others.
PFFS plans are a type of Medicare Advantage (Part C) plan. A PFFS plan is offered by a private insurance company that contracts with Medicare to provide your healthcare coverage.
PFFS plans cover things like your doctor’s appointments, hospital stays, and other medical benefits you’d receive with Original Medicare (Parts A and B).
The amount the PFFS will pay for each service is preset. The plans available to you will depend on where you live and can be found at various price points.
Your PFFS plan will cover everything that Part A (hospital insurance) and Part B (medical insurance) typically do. This includes:
- hospital stays
- short-term in-patient rehabilitation
- doctor’s visits
- preventive care
- emergency room visits
- certain medical equipment
- ambulance rides
Since a PFFS is a Medicare Advantage plan, it might cover additional services such as dental and vision care. Some PFFS plans also cover medications.
If your PFFS plan doesn’t cover medications, you can also purchase a separate prescription drug (Part D) plan.
PFFS plans can allow you the freedom to keep or choose your own doctors and specialists. For many people, this makes them an appealing alternative to Health Maintenance Organizations (HMO) plans.
You don’t need to choose a primary care physician (PCP) with a PFFS or get referrals to see a specialist. Some PFFS plans also allow members to use any Medicare-approved provider. This means you’ll never have to worry about going out of network.
Healthcare professionals choose whether or not to accept payment from your PFFS plan for each service you receive. This could mean that your doctor might accept your PFFS plan for one service but not another.
You’ll need to check that your plan is accepted for each service or treatment.
However, some PFFS plans do have a network. If your plan has a network, then those providers will accept your PFFS plan every time.
Out-of-network providers might not treat you at all unless you have an emergency medical situation. You’ll likely need to pay a higher cost if you do use an out-of-network provider.
Advantages
One advantage with a PFFS plan is that you don’t need to choose a PCP. This also means you won’t need a PCP to get a referral to see a specialist. You also might not need to worry about staying in the network.
With a PFFS, you can get coverage that goes beyond original Medicare, such as prescription drug and vision coverage.
Disadvantages
However, PFFS plan premiums can be more expensive than Original Medicare, and copayments and coinsurance might be high if you go out of network.
Also, some providers might not accept your PFFS plan, and some services might be covered while others are not.
Costs vary by state and your specific plan. You’ll normally need to pay a premium in addition to the one for your Part B plan.
In 2024, the standard Part B premium is $174.70 each month. You’ll also need to pay any copayments or coinsurance amounts at the time of service.
Examples of costs for PFFS plans in a few cities across the country are:
| City | Premium | Health deductible | PCP Copay |
|---|---|---|---|
| Atlanta, GA | $0 | $0 | $10 (in-network); $10 (out of network) |
| Little Rock, AK | $15 | $0 | $5 (in-network); $20 (out of network) |
| Madison, WI | $40 | $0 | $0 (in-network); $0 (out of network) |
| Albuquerque, NM | $60 | $0 | $15 (in-network); $15 (out of network) |
Keep in mind these are just examples. Plan prices may be different in your area.
Can you keep your doctor if you enroll in a PFFS plan?
Yes! PFFS plans allow you the freedom to choose and keep your own doctors. Many plans don’t have a specified network of doctors.
However, if your PFFS plan has a network, you might pay higher out-of-pocket costs if you leave the network.
Do you need a referral to see a specialist if you have a PFFS plan?
No — with a PFFS plan, you’re typically not required to choose a PCP. This means you won’t need a referral in order to get an appointment with a specialist.
Will a PFFS plan cover prescription drugs?
A PFFS is a type of Medicare Advantage plan, which often provides prescription drug coverage bundled into your overall coverage.
Check with the insurance company selling the PFFS plan to make sure prescription drugs are covered, unless you’d prefer to buy a separate Part D plan.
How does a Medicare Advantage PFFS plan compare to Original Medicare?
While Original Medicare offers basic in-patient hospital and outpatient medical coverage, a PFFS often covers much more. Additional coverage usually includes things like vision, dental, hearing, prescription drugs, and more.
Medicare PFFS plans are a type of Medicare Advantage plan that might offer more coverage than Original Medicare.
For some Medicare beneficiaries, the option to not choose a PCP and the ability to see specialists without a referral is ideal.
However, not all Medicare-approved doctors will accept all PFFS plans for payment. You might end up paying high out-of-pocket costs if you go out of network.
Your costs will depend on the plan you choose and your medical needs. You can use Medicare’s search tool to find and compare plans in your area.