Expand Your Network with Medicare PFFS (Private Fee For Service)

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What is a Medicare PFFS plan?

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What is a private fee for service plan

A Medicare Private Fee for Service plan is a type of Medicare Advantage policy/plan also known as Medicare Part C administered by a private Insurance company. The PFFS plan offers the same coverage as Original Medicare though they aren’t the same because PFFS plans come with different restrictions and costs.

For example, PFFS plans are not allowed to charge higher than Original Medicare or certain kind of care such as chemotherapy, dialysis, and care received in a skilled nursing facility. However, the plan determines how much you must pay to get coverage, as well as how much it will pay doctors, caregivers, and hospitals from where you get care. 

If you sign up for the PFFS plan, you can see a specialist with any referrals and do not need to go through the rigours of selecting a primary care physician. You can decide to visit any healthcare provider who agrees to accept the PFFS plan’s conditions and terms of payment.

For some Private Fee for Service plans, there are networks of service providers who offer care to whoever is enrolled in the plan. In such an instance, enrollees must ensure that any provider they choose to visit out-of-network must agree with terms of the policy. 

What is covered under Original Fee-for-service Medicare

PFFS plans are much more flexible because they give you more freedom to get coverage from any Medicare approved doctor, healthcare provider or hospital as long as they accept the plan’s payment terms and agree to provide coverage for most of your health needs.

As you sign up for membership, you’ll be given an ID which will serve as a pass each time you visit a healthcare provider. Your provider may decide whether to accept your plan’s terms and conditions of payment or not. 

You must live within a coverage area or a network service area to get coverage for the PFFS plan you wish to join, own Medicare Parts A and B and do not have any kidney malfunction at the time you apply for membership.

Medicare rules restrict those with end-stage renal disease and those outside the coverage area to enroll for a Private Fee for Service plan. Other pre-existing conditions will not affect your eligibility.

PFFS plans are renewable each year, should your PFFS plan not be renewed, you will take a decision either to remain with Original Medicare or find a new PFFS plan and enroll in.

You can also qualify for PFFS plans if you do not have any other way of financing your healthcare cost prior to the deductible. PFFS plans serve as an alternative Medicare plan that are provided to people with overwhelming medical expenses and financial need.

Geographic location, ownership of previous Medicare policy, and the absence or presence of kidney disease can affect your eligibility for Private Fee for Service plans. These should be in your check list when considering to opt for a PFFS plan.


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In terms of cost, many plans charge a monthly premium in addition to the Part B premium. Plans may charge a higher premium depending on if you also enjoy coverage for Medicare Part D. 

Payment for enrollees may vary between insurance companies and locations because private insurance companies offer PFFS plans. Medicare allows what is called BALANACE BILLING which means that PFFS plan providers can charge up to 15% of the total cost of deductibles, copayment, coinsurances and other services.

You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of the service.

The standard monthly premium for Part B in 2021 is $148.50. The plan may however cost more if it includes a PDP.

All PFFS plans have to set an annual limit on out-of-pocket expenses. The reason for such limit is to protect plan holders from excessive costs if they require expensive treatment.

The maximum out-of-pocket cost for PFFS plans in 2021 is $7,550.

PFFS plans cannot charge more than Original Medicare charges for certain kinds of care, including chemotherapy, dialysis, and skilled nursing facility (SNF) care.

However, plans can charge higher copays for other services, such as home health, durable medical equipment (DME), and inpatient hospital care.

For the plan’s coverage, your PFFS Plan will cover everything covered for by Medicare Part A & Part B, such as:

  • Hospital stays
  • Doctor visits
  • Short-term rehabilitation stays
  • Preventive care
  • Emergency room visits
  • Medical equipment
  • Ambulance rides. 

Since PFFS is a Medicare Advantage plan, it could cover additional services like dental and vision care. Though not all PFFS plans include prescription drug coverage (Part D). However, if a PFFS plan does not provide coverage for your medications, you have the option to enroll in a stand-alone Medicare Prescription Drug plan.

PFFS plans are among the few Medicare Advantage Plans that allow enrollment into a separate plan for Prescription drug coverage if it’s not already included. 

Some PFFS plans contract with a network of providers who agree to always treat you even if you’ve never seen them before. Also, in cases of emergency, doctors, hospitals and other providers must provide the needed care.


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Before signing up for a Medicare Advantage plan, you need to first enroll with Medicare. You can also apply for Medicare through Social Security when you become eligible. After choosing your preferred plan, you’ll have to enroll directly through your preferred private insurance company. You must, however, live in a coverage area for the PFFS plan you wish to join.

You can enroll through the following ways:

  • By signing up online using the Medicare search tool
  • Through a paper enrollment form, usually obtained by calling the insurer
  • By calling the Medicare Helpline on – 800-633-4227

There are key dates you need to keep in mind when you want to enroll. The sign-up periods include:

Your 65th Birthday: you can sign up for Medicare plans, including PFFS plans, 3 months before your birthday and 3 months after that. For example, if you turn 65 in March, you’ll be eligible to sign up from January to July of that year. It is advisable that you sign up as soon as you’re eligible, that way, you start getting coverage on your birthday.

APRIL 1ST – JUNE 30TH: You can sign up for a Medicare Advantage plan during this enrollment period. It mostly applies if you did sign up for Medicare Part B during the open enrollment period from Jan 1st – March 31st.

You can also make changes to your existing Medicare Coverage twice a year during the open enrollment periods – from January 1st to March 31st and from October 15th to December 7th.

During the first enrollment period, you can switch from one type of Medicare Advantage plan to another. For example, you can switch from a POS plan to a PFFS plan (depending on your preferred choice)


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You may want to look at a few reasons why you should consider having a PFFS plan among your list of preferred choices. Well, here are a few advantages of the plan:

Unlike Most Medicare plans that only permits you to get coverage within the network, Private Fee for Service plans are not bound by network restrictions. Some PFFS plans avails you he freedom of receiving care from any Medicare approved doctor, hospital or healthcare provider, provided they accept the plan’s payment terms and agree to offer treatment.

Most providers consider a PFFS plan’s payment terms for each service provided. However, accepting a payment terms for one treatment doesn’t mean the provider might automatically accept a future payment terms for other services provided to the same patient.

Where there is an emergency, doctors, hospitals and other providers must treat you.

You are only required to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you receive at the time of service.

You may prefer to get your Medicare benefits through a PFFS plan rather than Original Medicare because the plan offers additional benefits and increased coverage, and also saves you the hassles of choosing a PCP