PFFS costs and coverage

Medicare Private Fee-for-Service (PFFS) plans

Medicare Private Fee-for-Service (PFFS) plans must provide you with the same benefits as Original Medicare but may do so with different rules, restrictions, and costs. PFFS plans can also offer additional benefits. Below is a list of general cost and coverage rules for Medicare PFFS plans. Remember to speak to a plan representative to learn the details about any plan you are considering.

Costs

  • Many plans charge a monthly premium in addition to the Part B premium. Plans may charge a higher premium if you also have Part D coverage.
  • Plans may set their own deductibles, copayments, and other cost-sharing for services.
  • All plans must set an annual limit on your out-of-pocket costs. This limit may protect you from excessive costs if you need a lot of care or expensive treatments. The maximum out-of-pocket for PFFS plans in 2024 is $8,850, but plans may set lower limits.

Providers

  • You are not required to select a primary care provider (PCP).
  • You can see a specialist without a referral.
  • PFFS plans cover your care if you visit an out-of-network provider or facility, but you may pay a higher amount for out-of-network services.
  • PFFS plans cannot charge more than Original Medicare charges for certain kinds of care, including chemotherapy, dialysis, and skilled nursing facility (SNF) care. However, plans can charge higher copays for other services, including home health, durable medical equipment (DME), and inpatient hospital care.

Benefits

  • Your plan may offer additional benefits, such as vision, hearing, or dental care. Check with the plan directly to learn about coverage rules and restrictions for any added benefits.