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Medicare Advantage PFFS Plans: What You Should Know

What’s a PFFS Plan?Jump to
Pros of a PFFS PlanJump to
Cons of a PFFS PlanJump to
Other types of Medicare Advantage PlansJump to

What’s a PFFS Plan?

While researching your Medicare Advantage Plan options, you may see plans designated with the letters “PFFS.” These are Medicare Advantage Private Fee-for-Service (PFFS) Plans and are sold by private insurance companies as an alternative to Original Medicare (Medicare Part A and Part B) offered by the U.S. Government.

PFFS Plans are different from other Medicare Advantage Plans. Your insurance provider determines how much it pays the health care provider for each service and how much you will pay to get care.

Another defining detail for PFFS Plans is the flexibility in who you can see to get your health care.

Medicare Advantage Plans have a “network” of preferred doctors, hospitals and health care providers that accept your health insurance plan which typically charge less for services than if you went to a doctor outside of the plan’s network. Some plans, like Health Maintenance Organization (HMO) Plans, require primary care doctors and referrals from in-network providers to get your services.

While some PFFS Plans have a network, the freedom to keep or choose your own doctor accepting your PFFS Plans makes it a great alternative to more network-restrictive plan types.1

Pros of a PFFS Plan

Each Medicare Advantage Plan type has its pros and cons. Here are some qualities that make PFFS Plans an attractive option.

No Primary Care Providers or Referrals

As stated above, Medicare Advantage PFFS Plans do not require you to choose a Primary Care Provider (PCP). This also means that you’re not required to get a referral to see a specialist, giving you greater freedom to see the doctors you want for your services.1

Prescription Drug Coverage

Prescription drug coverage may be covered in PFFS Plans. If the plan doesn’t offer drug coverage, you can join a separate Medicare Prescription Drug Plan (PDP).

Out-of-Pocket Costs

Medicare Advantage PFFS Plans typically have out-of-pocket maximums, which put a cap on how much you must spend before the plan covers the rest of your health care costs for the rest of the year. Original Medicare doesn’t have an out-of-pocket maximum unless you have supplemental coverage like Medigap.

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Cons of a PFFS Plan

Each health care plan is unique and may have less than attractive qualities than other Medicare Advantage Plan types. Some of these negatives may not be an issue, while others are worth considering. It’s all based on your situation.

Not Always Covered

If your plan has a network, make sure your doctor accepts your PFFS Plan. Health care providers can choose whether to accept payment from your PFFS Plan for each health care service you get.

In-network doctors and hospitals will accept your PFFS Plan every time. Out-of-network providers may not treat you or may accept your PFFS Plans payment for one service but not another. The only exception is if you need emergency care.2

Before you get any services, ask your doctor or hospital if they accept your plan’s payment terms.


You may pay more for your health care services if you see a doctor or go to a hospital that accepts your plan’s payment terms but is outside your PFFS Plan’s network.


PFFS Plans may not be available in your area. In 2022, there are only 30 PFFS Plans available in the U.S. compared to 201 plans in 2012.3

Other Types of Medicare Advantage Plans

Medicare Advantage comes in different plan types. There are five different Medicare Advantage Plan types available, including PFFS Plans. Those plans include:

Ready to Talk But Don’t Know Where to Start? Here is a List of Questions to Help You Get Started

  1. How does a Medicare Advantage PFFS plan differ from other Medicare Advantage plans?
  2. Can you explain the concept of ‘Private Fee for Service’ in a Medicare PFFS plan?
  3. What are the differences and similarities between a Medicare Advantage PFFS plan and Original Medicare?
  4. How does prescription drug coverage work in Medicare Advantage PFFS plans?
  5. Can I use any healthcare provider with a Medicare Advantage PFFS plan or am I limited to in-network providers?
  6. Are there out-of-network provider options available with Medicare Advantage PFFS plans?
  7. How do private insurance companies factor into Medicare Advantage PFFS plans?
  8. What additional benefits are offered by Medicare Advantage PFFS plans that are not covered by Original Medicare?
  9. How does the plan’s payment terms work with Medicare Advantage PFFS plans?
  10. What is the difference between a Medicare Advantage PPO plan and a Medicare Advantage PFFS plan?
  11. Are there any restrictions on seeing specialists with Medicare PFFS plans?
  12. Does a Medicare Advantage PFFS plan include prescription drug coverage or will I need a separate prescription drug plan?
  13. How does Medicare PFFS plan differ from a Medicare Advantage HMO plan?
  14. Can I see any Medicare approved provider with a Medicare Advantage PFFS plan?
  15. What are the costs associated with using an out of network provider under a Medicare PFFS plan?
  16. Do all Medicare Advantage PFFS plans offer the same benefits as Original Medicare?
  17. How much can I expect to pay doctors under a Medicare PFFS plan?
  18. How do Medicare beneficiaries choose between a Medicare Advantage PPO, HMO, and PFFS plan?
  19. Are the prescription drug benefits the same across different PFFS plans?
  20. Can a primary care physician be an out of network provider under a Medicare Advantage PFFS plan?
  21. What are the advantages and disadvantages of choosing a PFFS plan over other Medicare Advantage plans?
  22. How does the federal government regulate Medicare Advantage PFFS plans?
  23. Are all healthcare providers covered under a Medicare Advantage PFFS plan, or only Medicare approved providers?
  24. Do PFFS plans cover the same health services as other Medicare Advantage plans?

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Education is crucial in finding the right Medicare solution for you. With so many Medicare resources out there, it can be difficult finding a source you can trust. That’s why Ensurem has a Compliance Program dedicated to ensuring our Medicare content meets Centers for Medicare & Medicaid Services (CMS) regulations. So, you can rest assured you’re getting the information you need to make the right coverage decisions.

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1Private Fee-for-Service (PFFS) Plans,”, Accessed Feb. 15, 2022.
2 Private Fee-for-Service (PFFS) Plans, Pages 18-19, “Understanding Medicare Advantage Plans,” Centers for Medicare & Medicaid Services, Accessed Feb. 15, 2022.
3Medicare Advantage 2022 Spotlight: First Look,” Kaiser Family Foundation, Accessed Feb. 15, 2022.

Denise Austin, 65, Ensurem Ambassador

Best-Selling Author, Creator of Fit Over 50 Magazine

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