Information You Need to Know: Medicare Private Fee for Service Plans

June 22, 2009


A Medicare Advantage Private Fee for Service Plan (PFFS) is a particular product in which the rules for participation are defined by Medicare. It is a Medicare Advantage (MA) health plan, offered by a state-licensed, risk-bearing entity (sometimes a private insurance company). Such a plan maintains a yearly contract with the Centers for Medicare and Medicaid Services (CMS) to provide beneficiaries with all their Medicare benefits plus any additional benefits the company decides to provide. Because insurance companies can decide where they will do business, these plans may only be offered in some parts of the country.

One major difference between a PFFS Medicare Advantage Organization (MAO) and other MAOs is that, in most cases, people who join a PFFS MAO are not required to use a network of providers. Beneficiaries can see any provider who is eligible to receive payment from Medicare and agrees to accept payment from the PFFS MAO. Beneficiaries are to present their plan membership ID card every time they visit a health care provider so that the physician may decide whether to accept the terms and conditions of payment for the PFFS plan before treating the patient. Also, by treating the patient, providers accept the terms and conditions of the plan.

Physicians may decide on a case-by-case basis to accept patients enrolled in a PFFS plan, or they may join the network.

Learn about Medicare PFFS plans on the CMS website

Read the Medicare PFFS Plan Model Terms and Conditions of Payment

Review the Beneficiary Guide to Medicare PFFS plans