Comprehensive Guide to Medicare PFFS Plans

Medicare Private Fee-for-Service (PFFS) plans operate on a fixed payment rate for individual medical services, meaning healthcare providers may accept the plan’s payment for some services but not for others.

As a specialized type of Medicare Advantage (Part C) plan, PFFS plans are offered by private insurance companies that partner with Medicare to deliver healthcare benefits.

These plans provide coverage for essential services such as doctor visits, hospital stays, and other medical care typically included under Original Medicare Parts A and B.

The payment amounts for services under PFFS plans are predetermined, and available plans vary by location and price, offering options tailored to your region.

What Does a Medicare PFFS Plan Cover?

PFFS plans cover all services traditionally included in Medicare Part A (hospital insurance) and Part B (medical insurance), including:

• Hospitalization
• Short-term inpatient rehabilitation
• Doctor appointments
• Preventive services
• Emergency room care
• Certain medical equipment
• Ambulance transportation

Moreover, many PFFS plans extend benefits to cover dental and vision care, with some also including prescription drug coverage.

If prescription drugs aren’t included, beneficiaries can opt to purchase a separate Part D prescription drug plan.

One of the key benefits of PFFS plans is the flexibility to retain or select your own doctors and specialists, making them an attractive alternative to Health Maintenance Organization (HMO) plans.

Unlike many other Medicare plans, PFFS members usually aren’t required to designate a primary care physician (PCP) or obtain referrals to see specialists. Additionally, some PFFS plans permit access to any Medicare-approved provider, eliminating concerns about network restrictions.

Pros and Cons of Medicare PFFS Plans

Healthcare providers decide individually whether to accept payment from your PFFS plan for each service, which means acceptance can vary by service.

It’s important to verify that your providers accept your plan for all needed treatments.

Some PFFS plans maintain provider networks, ensuring consistent acceptance within that network, but out-of-network providers may decline treatment except in emergencies and could charge higher fees.

Advantages

• No need to select a primary care physician or get referrals for specialists.
• Potentially broader coverage compared to Original Medicare, including vision, dental, and prescription drugs.
• Greater freedom to choose healthcare providers without strict network limitations.

Disadvantages

• Premiums can be higher than Original Medicare, with potentially significant copayments or coinsurance when using out-of-network providers.
• Some providers may not accept your PFFS plan, and coverage can vary by service.

Understanding the Costs of a PFFS Plan

Costs differ based on your state and specific plan. Generally, you pay a monthly premium for the PFFS plan in addition to your Medicare Part B premium, which is $185 per month in 2025.

You are also responsible for copayments and coinsurance at the time of service, which count towards your out-of-pocket maximum. In 2025, PFFS plans have a maximum out-of-pocket limit of $9,350; after reaching this limit, you pay nothing for covered services for the remainder of the year.

Frequently Asked Questions

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Can I keep my current doctor with a PFFS plan?

Absolutely! PFFS plans give you the flexibility to choose and maintain your preferred healthcare providers. Although many plans lack a defined network, if your PFFS plan includes one, you may incur higher costs when visiting out-of-network doctors.

Is a referral needed to see a specialist under a PFFS plan?

No referral is required. You usually don’t need to select a primary care physician, allowing you direct access to specialists.

Are prescription drugs covered by PFFS plans?

Prescription drug coverage is often included in PFFS plans, but coverage varies. Confirm with your plan provider or consider a standalone Part D plan if your PFFS plan does not include drug benefits.

How do PFFS plans stack up against Original Medicare?

Original Medicare covers essential hospital and medical services, but PFFS plans typically offer expanded benefits, including vision, dental, hearing, and prescription drugs, delivering more comprehensive healthcare coverage.

Final Thoughts

Medicare PFFS plans are a flexible Medicare Advantage option that can provide broader coverage than Original Medicare. Their appeal lies in the freedom to choose doctors and specialists without referrals. However, it’s important to verify provider acceptance and be mindful of potential higher costs if you use out-of-network services.

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