How Medicare Advantage PFFS Plans Work

There is no perfect Medicare plan. But certain features may start to feel more (or less) important to you as you weigh the options. The following lists summarize a few advantages and disadvantages of PFFS plans.

Pros of PFFS Plans

• You can see any Medicare-approved provider that accepts the terms of your PFFS plan and agrees to treat you.
• You can see providers in any U.S. state or territory.
• You don’t need to select a primary care physician, but you can.
• You can visit a specialist without a referral.
• Your out-of-pocket costs are capped each year.

Cons of PFFS Plans

• They are not offered as widely as other types of Medicare Advantage plans (HMO or PPO).
• The number of providers who accept the plan terms may be limited.
• Providers can refuse to treat you at any time, as long as it’s not an emergency.

All Medicare Advantage plans, including PFFS plans, cover everything that traditional Medicare does. Some plans include additional benefits, such as vision, hearing, dental, and prescription drug coverage. If a plan doesn’t offer prescription drug coverage, you can sign up for it separately through Medicare Part D.

With all Medicare Advantage plans, Medicare pays the private insurance company a flat fee to administer your health care benefits. However, PFFS plans differ from other Medicare Advantage plans because the insurance company, not Medicare, determines how much it pays health care providers for each service you use. This is what the “fee-for-service” part of the plan name references.

The insurance company also sets the amount that you pay for services, known as your out-of-pocket costs. Fortunately, Medicare sets an upper limit on your total out-of-pocket costs each year ($6,700 in 2019), and some plans offer lower maximums. This is a key difference between PFFS plans and traditional Medicare, which has no annual cap on out-of-pocket costs.

If you join a PFFS plan, you will receive a benefit card. Use this card instead of your red, white, and blue Medicare card when you seek medical care. Keep the Medicare card, though, in case you decide to switch back to original Medicare at some point.

On a PFFS plan, you can visit any doctor or facility that meets these requirements:

• Is approved by Medicare. You can confirm if a provider is Medicare approved on the homepage of Medicare.gov, under “Find doctors, providers, hospitals, plans & suppliers.”
• Accepts your plan’s payment terms. It’s not guaranteed that all providers will accept the terms, even if they’ve treated you before. You must reconfirm at every visit.
• Agrees to treat you. Providers are required to care for you only in an emergency situation.

Some PFFS plans have a network of providers who will always accept you as a patient. You can visit an out-of-network provider if you choose (assuming they meet the qualifications above), but you will often pay more than you would at an in-network doctor or facility.

In a PFFS plan, you aren’t forced to select a primary care doctor, but you can if you’d like. You also don’t need a referral to see a specialist. Some people prefer not needing to communicate with a primary care doctor before you see a specialist—but it makes you more responsible for coordinating your own care.

Remember, you can change your Medicare plan every year during specific enrollment periods and when certain life events happen to you. Find out exactly when you can change your Medicare Advantage plan.

PFFS plans are best for people who want the following:

• A wider range of provider options. With a PFFS plan, you can see any health care provider as long as they accept Medicare and the payment terms of your plan.

• Freedom to direct their own care. People on PFFS plans can see a specialist without having to visit a primary care physician first.

If you want a plan that likely includes coverage for prescription drugs, vision, dental, and hearing, plus the freedom to see a wide range of providers and the protection of an annual limit on your out-of-pocket costs, a Medicare Advantage PFFS plan may be the right choice for you.