Private Fee-for-Service (PFFS) plans are Medicare Advantage plans (Medicare private health plans) you can enroll in as a different way to get your Medicare benefits.
PFFS plans must cover all services that a patient would receive under Original Medicare. This includes both inpatient services (Part A) and outpatient services (Part B).
PFFS plans may offer Medicare prescription drug coverage (Part D) but this is not required. If a PFFS plan does not offer drug coverage, you may join a stand-alone Medicare drug plan to get your prescription drugs (Part D).
PFFS plans may also choose to include benefits that original Medicare does not cover, like routine vision and dental care.
Starting in 2011, most PFFS plans have health care provider networks. If you see in-network doctors or other healthcare providers, you may pay less. However, PFFS plans cannot restrict you to its network of providers. PFFS plans must cover care received from any Medicare-approved doctor as long as that provider knows you are enrolled in the plan and agrees to treat you. Give your doctor your PFFS plan card so they know you are a member before they treat you.
It is best to know your care will be covered before you receive costly treatment from doctors who are outside of the PFFS plan network. To make sure your doctor is within the network, you or your provider can ask for a written decision about coverage from your plan before getting care. This is called an advance organization determination or advance coverage determination. Check your plan’s website or contact your plan for information about requesting an advance organization determination.
PFFS plans cannot require your primary care physician to write a referral before you see a specialist. PFFS plans also cannot ask you get approval from the plan before you get care. Finally, plans cannot charge higher copays depending upon whether you tell the plan before you get care. These practices were known as prior notification which is no longer allowed.