Medicare Private Fee-for-Service (PFFS) plans are Medicare Advantage plans that are sold and serviced by third-party insurance companies rather than the United States federal government. The PFFS plan provider decides how much it will pay participating hospitals, doctors, and other health care professionals, as well as how much you as the beneficiary will pay for various aspects of covered care.
What follows is a list of frequently asked questions (FAQ) relating to PFFS plans.
Do you have to have Medicare Part A and Medicare Part B?
To join a Medicare Advantage plan, you must have both Medicare Part A and Medicare Part B. If you do not have both, you may not join any Medicare Advantage plan.
Can I get my health care from any doctor, hospital, or health care provider?
You can go to any Medicare-approved doctor or facility that accepts your plan’s terms and agrees to treat you. If your plan has a network, you can see any of the network providers who agree to the plan’s terms. You may also choose an out-of-network provider, but you will probably pay more.
If I join a Private-Fee-for-Service Plan, will I have to check with my doctors and hospital before each visit to see if they still accept it?
Yes, you will need to check with your doctors and hospital each time you plan to visit them. A doctor and hospital can change their mind at any time and not accept the coverage any longer.
Are prescription drugs covered?
Some PFFS plans cover drugs. Those that do not may be supplemented by a Medicare Part D prescription drug plan.
Do I need to choose a primary care doctor?
Do I have to get a referral to see a specialist?
Do I have to pay any premium for the Private-Fee-for-Service plan?
You will continue to pay the Medicare Part B premium, and you might also have to pay an additional monthly premium charged by the Private-Fee-for-Service plan.
Will my Medicare Supplement/Medigap policy work with the Private-Fee-for-Service plan?
No. If you select to join a Private-Fee-for-Service plan (or any other type of a Medicare Advantage plan), the Medicare Supplement/Medigap policy will not coordinate with these plans. Medicare Supplement/Medigap coverage only works with Original Medicare.
What else should I know before joining a Private-Fee-for-Service plan?
It is important to understand what your copayments or coinsurance will be under the Private-Fee-for-Service plan. Every plan is different. You need to look at and understand how much you will have to pay each time you go for a doctor visit, a hospital stay, outpatient hospital visit, etc.
Can I cancel my Private-Fee-for-Service plan at any time?
There are limitations on when you can join or cancel a Medicare Advantage plan. For most beneficiaries you can only make a change during an Annual Election Period (October 15th through December 7th each year) or during a Medicare Advantage Open Enrollment Period (January 1st through February 14th each year). However, you may be entitled to a Special Election Period. For additional information, please contact the Medicare Advantage plan, 1-800-MEDICARE (1-800-633-4227) or SHIP (1-800-443-9354).