Medicare PFFS (Private Fee For Service) plans are both similar and different to Medicare HMOs.

Medicare Health Maintenance Organizations (HMOs) are private companies that are paid by the federal government to provide individuals with Medicare-covered health benefits. Some HMOs offer additional benefits such as vision and hearing care.

Like HMOs, PFFS plans:

  • are private companies that contract with Medicare. They change benefits or pull out of Medicare from one year to the next.  
  • have networks of providers who have agreed to see members of the plan. 
  • have yearly limits on out-of-pocket Part A and B costs that can help protect you if you use a lot of medical care or need expensive treatments.
  • may include Part D drug coverage but are not required to include it.
  • may include additional benefits that Medicare does not cover, such a routine vision and dental care.

Unlike a Medicare HMO, Medicare PFFS plans:

  • Cannot require you to see doctors or other healthcare providers in their networks. Most PFFS plans must have networks of doctors. However, PFFS members are not restricted to these networks. You can go to any Medicare-approved doctor or hospital in the U.S. that agrees to treat you after learning that you are in enrolled in the plan (you will typically pay more if you see non-network providers). 
  • Cannot require that you choose a primary care physician (PCP).
  • Cannot require you to get a written referral from your primary care physician to get treatment from a specialist.
  • Cannot require that you get prior approval or contact the plan before getting care.
  • Must provide you with an Evidence of Benefits statement that shows the amount you owe for the deductible, coinsurance/copays and balance billing. Medicare HMO’s do not need to provide this.
  • Allow you to purchase a stand-alone prescription drug plan (PDP) if the plan you are enrolled in does not offer one. You cannot join a PDP if the HMO you are enrolled in does not include Part D coverage.