Private Fee For Service

Medicare Private Fee-for-Service plans are a type of Medicare Advantage plans in which the insurance company determines how much it will pay your healthcare provider and how much you pay for a covered health service.

Like all Medicare Advantage plans, they offer additional benefits not provided by Medicare.

 

How do Private Fee for Service plans work?

With a PFFS plan the insurance company decides how much it will pay for your covered health service.

There may or may not be a healthcare provider network. You will have to ask the insurance agent who is offering the plan to be certain. 

However, even if there is a network, you can usually go outside the network. You’ll just have to ask the healthcare provider you wish to visit if they accept your plan. 

And you should do this for every service. Non-network providers can choose to accept a PFFS plan on a case-by-case basis. 

You do not need to choose a primary physician or get a referral to see a specialist with this plan.

Am I eligible for this plan?

To be eligible for a PFFS plan, you have to be enrolled in Medicare Parts A and B and continue paying all applicable premiums.

When to enroll

You can enroll during your initial enrollment period (when you can initially enroll in Medicare). This is a seven-month period that starts three months before the month you turn 65 and ends three months after the month you turn 65.

There is also the annual election period that spans from October 15 through December 7 every year. 

Finally, you may be eligible for a special election period if there have been significant changes in your coverage or income. 

You can find out if you are eligible by speaking with a licensed Medicare agent, but here are some instances where you would be eligible: 

  • You move outside your current plan’s area
  • Suffered unintentional loss of coverage
  • Got married
  • Had a baby

There are many more ways you can become eligible for a special election period. So, again, be sure to ask an insurance agent.

What does it cover?

As with all Medicare Advantage plans, you will receive all benefits Original Medicare comes with along with additional benefits. 

The additional benefits your plan may include are: 

  • Adult day-care services
  • Dental
  • Fitness memberships
  • Hearing
  • Nutrition programs
  • Over-the-counter drugs
  • Services and supports for those with chronic conditions
  • Transportation to doctor visits
  • Vision
  • Wellness programs
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