A Medicare Private Fee-for-Service (PFFS) Plan

A Medicare Private Fee-for-Service (PFFS) Plan is a type of Medicare Advantage Plan that allows beneficiaries to receive healthcare services from any provider that accepts the plan's payment terms and conditions. PFFS plans do not have a network of providers, but providers must agree to accept the plan's payment terms and conditions on a case-by-case basis.

Here are some key features of Medicare PFFS Plans:

• Provider choice: PFFS plans allow beneficiaries to receive healthcare services from any provider that accepts the plan's payment terms and conditions, without needing to be in a specific network.

• Coverage limitations: PFFS plans may limit coverage for certain services or medications, and the plan's payment terms and conditions may change from year to year.

• Cost-sharing: PFFS plans may have cost-sharing arrangements, such as copays or coinsurance, for healthcare services. The amount of cost-sharing depends on the plan and the specific service received.

• Referrals: PFFS plans generally do not require participants to obtain referrals from a primary care physician to see a specialist.

• Premiums: PFFS plans may charge a monthly premium in addition to the Medicare Part B premium.

Example:

For example, let's say a Medicare beneficiary enrolls in a PFFS Plan with a $25 monthly premium. The beneficiary sees a provider for a service that costs $200, and the plan's payment terms and conditions specify that the provider will be reimbursed at 120% of the Medicare fee schedule. The plan will pay the provider $240 for the service, and the beneficiary's cost-sharing arrangement may include a $30 copay for the service.

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