Private Fee-for-Service

Medicare Advantage Plans are alternatives for people who want different coverage than what Original Medicare offers. There are six types of plans. A Private Fee-for-Service (PFFS) is one of these 6. While it still covers what it is required to cover by Medicare guidelines, it differs in reimbursement and pay.

PFFS Overview

A PFFS is a type of plan in which the insurer pays providers a certain amount based on the service. The benefit is that it gives the consumer greater flexibility when choosing a provider provided that the healthcare provider participates in this type of plan. 

Adding to the confusion, PFFS plans may or may not use provider networks. In either case, the consumer can choose their provider. If your PFFS does not have a network, you have complete freedom. If your PFFS does have a network, you can see anyone in that network. You can also pay more to see someone out-of-network. 

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Pros and Cons of a PFFS

PFFS plans are ideal for people who want more flexibility when choosing providers in and out of network. You can choose any hospital or healthcare provider that accepts the plan’s terms and will treat you. Additionally, a PFFS reduces the hurdles you need to receive care. Specifically, you do not need a referral and often don’t need prior authorization.

The disadvantages of a PFFS are the cost and finding a provider. Many PFFS plans charge a monthly premium. They may also have their own deductibles, copayments, and coinsurance. For example, in 2020, the out-of-pocket limit for PFFS plans was $6,700, which is relatively high compared to other Medicare options. Additionally, it places some of the burdens on the consumer to determine whether or not their provider accepts PFFS plans. Out-of-network doctors and hospitals may decide not to accept this plan and, therefore, not treat you, even if they have seen you before.

You should check with a representative to understand each plan’s benefits before deciding which plan is best for you.