Medicare Private Fee-for-Service (PFFS) plans are private companies that the federal government pays to administer Medicare benefits. Like all Medicare Advantage Plans, PFFS plans must provide you with the same benefits, rights, and protections as Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , but they may do so with different rules, restrictions, and costs. Some PFFS plans offer additional benefits, such as vision and hearing care.
Eligibility and costs basics
You must have both Parts A and B to join a Medicare PFFS plan, and generally you will continue paying your Medicare Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. . Your PFFS plan may also charge an additional premium, on top of the Part B premium. If you want Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. coverage, ask your PFFS plan if it offers Part D coverage. If your plan does not offer Part D coverage, you can enroll in a stand-alone Part D plan.
Benefits access basics
Once you have joined a PFFS plan, you should receive a benefit card from your plan. You will use your plan benefit card instead of your Medicare card Everyone who enrolls in Medicare receives a red, white, and blue Medicare card. It lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It also shows your Medicare number, which serves as an identification number in the Medicare system. If you get Medicare through the Railroad Retirement Board, your card will say “Railroad Retirement Board” at the bottom. If you are enrolled in a Medicare Advantage Plan, you will also have a card from that plan (see Medicare Advantage Plan Card). when you go to the doctor or hospital.
Most PFFS plans have provider networks. You may pay less for your care when using in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. providers or facilities. All PFFS plans also must cover out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. care, but you may pay a higher cost.
If you plan to receive care from an out-of-network provider See Health Care Provider. , you or your provider can request an advance organization determination (also called an advance coverage determination) from your plan. An advance organization determination is a request for your plan to confirm that a service is medically necessary Medically necessary refers to procedures, services, or equipment that meet accepted medical standards and are necessary for the diagnosis and treatment of a medical condition. and will be covered. If you plan to receive a costly service from an out-of-network provider, requesting an advance organization determination can help you avoid unexpected denials. Contact your plan for information about requesting an advance organization determination.
Medicare PFFS plans are not available everywhere. Call 1-800-MEDICARE (633-4227) or your State Health Insurance Assistance Program (SHIP) to find out if there is a PFFS plan available in your area. To enroll in a PFFS plan, call Medicare or the plan directly. Be sure to make an informed decision by contacting a plan representative to ask questions before enrolling.