Medicare Advantage Plans (Part C)
Medicare Advantage plans may combine all Medicare-covered benefits with additional services, depending on the plan.
Understanding Private Fee-for-Service (PFFS) Plans
What is a PFFS Plan?
A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage Plan offered by private insurance companies. It works differently from other Medicare plans.
With a PFFS plan, you can usually go to any doctor, hospital, or other healthcare provider — as long as they accept the plan’s terms and agree to treat you
Key Features of PFFS Plans
1
Freedom to Choose Providers
You are not limited to a network. You can visit any Medicare-approved provider who accepts the plan’s payment terms
2
No Need for a Primary Doctor or Referrals
You do not need to choose a primary care physician (PCP), and referrals are not required to see specialists.
3
Pre-Set Costs
The plan sets how much it pays providers and what your share of the cost is. These amounts may be different from other plans.
4
Emergency and Urgent Care may be Covered
Whether you are in or out of the plan’s service area, emergency and urgent care services may be covered.
5
Additional Benefits May Be Included
Some PFFS plans may include benefits like vision, dental, hearing, or wellness programs.
How a PFFS Plan Works
- You receive a plan ID card to use when receiving services.
- Before each visit, your provider must agree to treat you and accept the plan’s payment terms.
- Some plans may include a provider network. If they do, using in-network providers may save you money.
Things to Keep in Mind
- Providers can choose on a visit-by-visit basis whether to accept your plan.
- You may be responsible for cost-sharing amounts like copayments or coinsurance.
- Monthly premiums, deductibles, and service areas vary by plan.
Is a PFFS Plan Right for You?
A PFFS plan may be a good fit if you:
- Want more freedom to choose your doctors and hospitals.
- Prefer not to have a primary care doctor or need referrals.
- Are looking for plans that may include extra benefits beyond Original Medicare.
Learn More, Choose Confidently
Explore all your Medicare coverage options and make the choice that’s best for your health and budget.
Have questions about your Medicare coverage options? Speak To a Licensed Sales Agent can explain how PFFS plans work and help you find one that fits your needs.
When are you eligible for a Medicare Advantage plan?
- If you’re 65 or older
- If you have other Medicare coverage, you can change to Medicare Advantage during annual open enrollment
- You may also qualify under other exceptions, such as an eligible disability or chronic condition
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We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
[[Senior Healthcare Advisors, LLC, ], [in California – SCH Insurance Agency]] represents Medicare Advantage [HMO, PPO and PFFS] organizations [and stand-alone PDP prescription drug plans that have a Medicare contract. Members may receive a monthly or quarterly allowance benefit in the form of a prepaid card to pay for a wide range of approved [healthy groceries] [and] [utilities]. Unused amounts will expire at the end of the month or quarter. Enrollment depends on the plan’s contract renewal.
Eligibility is based on clinical criteria established by the plan. The benefits mentioned in this material may be available as part of a Special Supplemental Benefit for the Chronically Ill (SSBCI) for members with certain chronic conditions. Not all members qualify.
Not all plans offer all of these benefits. Availability and amount of these benefits vary by carrier, plan, location and service area. Not all plans offer SSBCI benefits. Limitations and exclusions may apply. [[Senior Healthcare Advisors, LLC,], [in California – SCH Insurance Agency]] not connected/endorsed by a government entity. You also agree to the Privacy Policy.
SSBCI benefits are available only to qualifying enrollees who meet the criteria for one or more of the following chronic conditions, which may include but are not limited to: congestive heart failure, diabetes, cardiovascular disorders, chronic obstructive pulmonary disease (COPD), and autoimmune disorders.
Enrollment in a plan may be limited to certain times of the year unless you qualify for a Special Enrollment Period or you are in your Medicare Initial Enrollment Period. Enrollment in a Medicare Advantage plan depends on contract renewal.