What is a PFFS Plan?
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan that determines how much it will pay providers and how much you pay when you receive care. Unlike HMO or PPO plans, PFFS plans don't have a traditional network - you can see any Medicare-approved provider who agrees to accept the plan's payment terms.
PFFS plans are less common than HMO and PPO plans and are generally available in rural areas where network-based plans have limited provider availability.
How PFFS Plans Work
- No network requirement - You can see any Medicare-approved doctor, specialist, or hospital
- Provider acceptance required - The provider must agree to the plan's payment terms for each visit (they are not contractually obligated to accept)
- No referrals needed - You can see specialists without a referral from a primary care physician
- Plan sets payment terms - The plan determines what it pays providers and what you pay as cost-sharing
PFFS Pros and Cons
| Pros | Cons |
|---|---|
| No network restrictions | Provider must accept plan terms each visit |
| No referrals required | Less predictable provider availability |
| Good option in rural areas | Often higher premiums than HMO plans |
| Flexibility to see any Medicare provider | Less common; fewer plan options |
PFFS vs. Original Medicare
PFFS plans are sometimes compared to Original Medicare because of their provider flexibility. Key differences:
- PFFS plans have an out-of-pocket maximum; Original Medicare does not (without Medigap)
- PFFS plans may include extra benefits (dental, vision, Part D); Original Medicare does not
- With Original Medicare, any Medicare-approved provider must accept you; with PFFS, providers can decline on a visit-by-visit basis
Frequently Asked Questions
Can Any Doctor See Me if I Have a PFFS Plan?
Any Medicare-approved provider can see you, but they must agree to the plan's payment terms for that visit. Unlike Original Medicare (where providers must accept Medicare assignment), PFFS providers can decline to accept the plan's terms on a visit-by-visit basis. Always confirm acceptance before your appointment.
Do PFFS Plans Include Prescription Drug Coverage?
Some PFFS plans include Part D prescription drug coverage (MA-PD plans), and some do not. If your PFFS plan doesn't include drug coverage, you can enroll in a standalone Part D plan.
Are PFFS Plans Available in My Area?
PFFS plans are most commonly available in rural areas. Use Medicare's Plan Finder at medicare.gov to search for PFFS plans in your zip code.