Medicare Advantage Private Fee-for-Service
Medicare Advantage PFFS Explained
Medicare Advantage Private Fee-for-Service (PFFS) plans are a unique offering among Medicare Advantage options, provided by private insurers and matching the essential benefits of Original Medicare with additional advantages.
Navigating PFFS Plans
PFFS plans stand out as they don’t necessitate selecting a primary care doctor or obtaining specialist referrals. Here’s a quick guide:
A network of healthcare providers may be available; confirm with a Medicare specialist.
Out-of-network providers may be seen if they agree to the plan’s terms, which should be verified beforehand.
You need to be enrolled in Medicare Parts A and B to join a PFFS plan.
Alongside your Part B premium, there might be an additional premium for the PFFS plan.
Notably, payment amounts to healthcare providers and your share of costs are determined by the plan, unlike other plans where Medicare decides these rates.
What PFFS Plans Cover
Adult day-care services
Dental care
Fitness Membership
Nutritional support
Services for chronic conditions
Transportation to medical appointments
Vision care
Wellness programs
Over-the-counter medication allowances
These benefits depend on the specific plan and location, and usually, PFFS plans come with Part D coverage. If not, you’ll need to join a separate Part D plan for prescription coverage.
Enrollment Periods for Medicare MSA
The defining feature of PFFS plans is the insurer’s control over payment rates to providers and your share for covered services — a contrast to other Medicare Advantage plans where Medicare sets these prices.
Key distinctions between PFFS and other Medicare Advantage plans include:
PFFS plans typically don’t have a strict network, associating with any Medicare-approved provider accepting the plan’s terms.
You can request an “advance coverage decision” to confirm if a service is covered.
PFFS plans often include Part D coverage, unlike some HMO and PPO plans.
For each service or visit, you may need to confirm if the provider accepts your PFFS plan.
Enrolling in a PFFS Plan
Eligibility for a PFFS plan mirrors that for Medicare, with enrollment periods being:
Initial Coverage Election Period
A seven-month window around your 65th birthday or from the 25th month of receiving Social Security disability benefits.
Annual Election Period
From October 15 to December 7 every year, with changes effective from January 1 of the upcoming year.
Open Enrollment Period
Allows existing Advantage plan members to switch plans or revert to Original Medicare early in the year.
Special Election Period
Triggered by individual circumstances, such as relocating outside your plan’s service area, qualifying for additional assistance
For tailored advice and assistance in selecting the right PFFS plan, it’s wise to consult a licensed Medicare insurance agent.
Diamond Financial Group provides expert consultation and solutions for health insurance, life insurance, and Medicare across the United States. Our mission is to ensure every individual has the protection they need to secure their future.
We are not connected with or endorsed by the United States government or the federal Medicare program. We do not offer every plan available in your area, and any information we provide is limited to those plans we do offer in your area. Please get in touch with 1-800-MEDICARE to get information on all your options.
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