What Is a PFFS Medicare Plan

What Is a PFFS Medicare Plan

A PFFS Medicare plan, or Private Fee-for-Service plan, is a type of Medicare Advantage plan that lets you see any doctor or hospital that agrees to accept the plan's payment terms and is willing to treat you. Instead of using a fixed network, the plan sets the amount it will pay for each service, and you pay any difference if a provider charges more.

How PFFS Plans Work

With a PFFS plan, Medicare pays a set amount toward your covered services, and the plan pays its share directly to the provider. You are responsible for copayments, coinsurance, and deductibles outlined in the plan's terms. You can use any provider that accepts the plan, which gives you flexibility, but not all providers agree to PFFS terms, so it is important to confirm before receiving care.

What PFFS Plans Cover

PFFS plans must cover at least the same services as Original Medicare (Part A and Part B), and many also include Part D prescription drug coverage. Some plans offer extra benefits such as dental, vision, or hearing care, but coverage details vary by plan and insurer.

PFFS vs Other Medicare Plans

• PFFS vs HMO: HMOs require you to use a fixed network and often need referrals, while PFFS plans do not.
• PFFS vs PPO: PPOs use a network with better coverage in-network, whereas PFFS plans pay based on their own fee schedule at any accepting provider.
• PFFS vs Original Medicare: Original Medicare has no network rules but does not cap out-of-pocket costs unless you add Medigap; PFFS plans may include out-of-pocket maximums.

Things to Consider

Before joining a PFFS plan, check whether your current doctors accept the plan's payment terms. Review the plan's cost-sharing structure, including copayments and deductibles, and confirm whether prescription drug coverage is included or needs a separate Part D plan. Availability also varies by county and state.