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PFFS Plans: Private Fee for Service, Explained

The least known Medicare Advantage type. No network in the usual sense, but a catch worth understanding before you choose one.

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What a PFFS plan is

A Private Fee for Service plan is a Medicare Advantage plan that sets its own payment terms for doctors and hospitals. Instead of building a fixed network, the plan publishes what it will pay, and you can see any provider who agrees to those terms.

The catch

The provider decides, visit by visit, whether to accept the plan's terms. Your longtime doctor can take the plan in March and decline it in June, and a new doctor can decline it before your first appointment. Some PFFS plans do also run a network with providers who always accept, which softens this, but the visit by visit rule is what makes PFFS different from everything else.

Network
Sometimes none, sometimes partial. Any provider who accepts the plan's terms can treat you.
Referrals
Not needed.
Primary doctor
Not required.
Drug coverage
Included in some PFFS plans, not all. If not included, you can add a separate Part D plan, which most other Advantage types do not allow.
Always ask before every visit. With a PFFS plan, the right habit is one question at the front desk: do you accept this plan's terms of payment? If the answer is no, that visit is not covered.

Who a PFFS plan suits

Honestly, a narrow group. PFFS can suit people in areas with few other Advantage options, or people whose regular providers have confirmed they accept the plan. For most people, an HMO or PPO gives more certainty. We say that plainly because our advice does not change with the plan we sell: it changes with your situation.

A Medicare member confirming that a clinic accepts their PFFS plan
Not sure if PFFS is right for you?
It usually is not, but sometimes it is exactly right. A licensed agent will give you a straight answer.
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