Medicare Private Fee-for-Service (PFFS) plans are private companies that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, PFFS plans must provide you with the same benefits, rights, and protections as Original Medicare, but they may do so with different rules, restrictions, and costs. Some PFFS plans offer additional benefits, such as vision and hearing care.
Eligibility and costs basics
You must have both Parts A and B to join a Medicare PFFS plan, and generally you will continue paying your Medicare Part B premium. Your PFFS plan may also charge an additional premium, on top of the Part B premium. If you want Part D coverage, ask your PFFS plan if it offers Part D coverage. If your plan does not offer Part D coverage, you can enroll in a stand-alone Part D plan.
Typically, you cannot have a PFFS plan if you have End-Stage Renal Disease (ESRD), unless you were enrolled in one prior to developing ESRD and you chose to stay in that plan. Additionally, if you stayed in your PFFS plan after developing ESRD and the plan leaves your area, you have a Special Enrollment Period (SEP) to enroll in another PFFS plan in your area.
Benefits access basics
Once you have joined a PFFS plan, you should receive a benefit card from your plan. You will use your plan benefit card instead of your Medicare card when you go to the doctor or hospital.
Most PFFS plans have provider networks. You may pay less for your care when using in-network providers or facilities. All PFFS plans also must cover out-of-network care, but you may pay a higher cost.
If you plan to receive care from an out-of-network provider, you or your provider can request an advance organization determination (also called an advance coverage determination) from your plan. An advance organization determination is a request for your plan to confirm that a service is medically necessary and will be covered. If you plan to receive a costly service from an out-of-network provider, requesting an advance organization determination can help you avoid unexpected denials. Contact your plan for information about requesting an advance organization determination.
Medicare PFFS plans are not available everywhere. Call 1-800-MEDICARE or your State Health Insurance Assistance Program (SHIP) to find out if there is a PFFS plan available in your area. To enroll in a PFFS plan, call Medicare or the plan directly. Be sure to make an informed decision by contacting a plan representative to ask questions before enrolling.
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