Medicare PFFS Plans:
Everything You Need to Know
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Our Medicare Insurance experts will help you find the right Medicare plan, by walking you through
your options and comparing the top Medicare insurance companies.
Get online quote
Best Medicare Insurance Agent
Our Medicare Insurance experts will help you find the right Medicare plan, by walking you through
your options and comparing the top Medicare insurance companies.
Get online quote
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Medicare PFFS Plans:
Everything You Need to Know

Medicare PFFS plans are one of the many types of Medicare Advantage plans. They were created in 2006 as a way to offer more choices to beneficiaries.
PFFS plans are offered by private insurance companies, and they allow you to choose any doctor or hospital that accepts Medicare.
We will discuss what PFFS plans are, how they work, and who should consider them.
Integrity Now Insurance Brokers is a license Medicare insurance agent who can help you decide if a PFFS plan is right for you!

How does a Medicare PFFS plan work?

If you join a Medicare PFFS plan, you agree to pay the plan’s premiums as well as copays and coinsurance for medical services as outlined in the plan.

The thing that makes these plans different from an HMO or PPO is that you are not limited to any certain network of providers.

You can also use doctors and hospitals outside of the United States if they accept Medicare payment!

Who should consider a Medicare PFFS plan?

If you are someone who likes to have the freedom to choose your doctor and hospital, then a Medicare PFFS plan might be right for you. These plans can also be a good option if you travel frequently or if you live in an area with limited provider options.

Two Common Features Of Medicare PFFS Plans Are:

Medicare PFFS plans two most common features are:

  1. You can use any Medicare-participating provider that accepts the plan’s terms and conditions.
  2. The plan pays a percentage of the Medicare-approved amount for covered services.

A separate Part D drug plan is not required if you participate in a Medicare PFFS plan that includes a prescription drug plan as part of the coverage.

You may pick a Medicare PFFS plan that includes a built-in drug plan or one that offers “medical only” coverage and enroll in a different prescription drug plan.

When selecting a Medicare PFFS plan ensure you understand if the plan includes Part D coverage or if you need to obtain a standalone plan. You will also want to compare drug costs for both the built-in drug plan and a standalone Part D plan.

If you are interested in learning more about Medicare PFFS plans, or if you would like help finding a Medicare insurance agent, please contact us today! We would be happy to answer any of your questions. Thanks for reading!

What is Covered Under a Medicare PFFS Plan?

The benefits provided by PFFS must be identical to those offered by Original Medicare Part A and Part B. The way you finance your share of medical expenses is different.

For example, if you need hospitalization, your PFFS payments a daily copay for a specific number of days. Each benefit period has its own deductible under Original Medicare Part A.

Coverage for Part A and B includes:

  • Inpatient care in a hospital or Skilled Nursing Facility (SNF)
  • Short-term SNF care after a qualifying hospital stay
  • Home health care
  • Hospice care (The Part A Hospice Medicare Benefit covers medical care for terminally ill patients.)
  • Outpatient medical services that are essential to cure or diagnose your medical condition
  • Preventive care
  • Durable medical equipment (DME)
  • Ambulance services
  • Clinical research
  • Mental health care

PFFS plans also may include services that Medicare does not cover:

  • Part D Prescription drug coverage
  • Vision, dental, and hearing care
  • Fitness club memberships
  • No cost transportation to doctor’s office
  • Chiropractic care
  • Acupuncture

Advantages of a Medicare Advantage PFFS Plan

  1. Signing up for a primary care doctor may not be required.
  2. You can see a specialist without having to get a referral.
  3. Any Medicare-approved medical practitioner that accepts the plan’s payment conditions may be used anywhere in the country.
  4. You can be treated by any participating providers if the plan has a network.
  5. When you receive treatment, you only have to pay a specified copayment amount. The health care provider charges the plan for the rest of the cost.
  6. You may be eligible for a variety of extra benefits that are not available through Original Medicare Part A and Part B.

Disadvantages of a Medicare Advantage PFFS Plan:

  1. You can only see providers who are compatible with the plan’s payment terms. They may choose not to take the plan at any time, even if they’ve previously treated you unless they’re a member of a network.
  2. Providers can refuse to see you unless it’s an emergency.
  3. If you go outside of the plan’s network, you may face higher copayment and coinsurance costs.
  4. PFFS plans are rarely available as a Medicare advantage option.

Who is eligible for a Medicare PFFS Plan?

To be eligible for a Medicare Advantage PFFS plan, you must fulfill the following conditions:

  • Eligibility and enrollment in Original Medicare Parts A and B are required.
  • You must reside in a region where state-licensed and Medicare-approved HMO plan providers are available for at least six months each year.
  • If a Medicare beneficiary does not live in a covered region for at least six months out of the year, they are not qualified for a Medicare PFFS plan.

How much does a Medicare PFFS Plans cost

The average cost for a Medicare PFFS plan is around $100 per month. This is above and beyond the cost of your Part B monthly premium. You may also incur costs for your Part D prescription drug plan if it is not included within the PFFS plan.

Outside of the monthly premium, you will also incur costs when you use the plan, including:

  • Copays: If you go to a doctor or receive other medical treatments, you may be required to pay copays. This amount is determined by the insurer.
  • Coinsurance: You can pay a proportion of the Medicare-approved service charge after you’ve exhausted your deductible for the year.
  • Deductibles: Before your insurance begins to pay for services, you may be required to pay an annual out-of-pocket cost.
  • Out-of-network charges: If you visit a medical professional outside your plan’s network, you may be charged anything from $350 to $3,800 for an office visit (or higher). These higher fees may be applicable if you go to a doctor out of network.
  • Additional services: Some plans may charge more premiums and a distinct drug deductible if they include vision, dental, or hearing coverage.

The cost of a policy varies by state, so it’s vital to compare the coverage choices accessible in your region for an accurate price range.

What About A Medicare Supplement
Plan ("Medigap Plan")

The best time to sign up for a Medicare supplement plan is during the guaranteed issue period. This is typically when you are about to turn 65 and become Medicare eligible.
If you sign up for a Medicare advantage plan first and you fall outside of the guaranteed issue period, you may be required to go through medical underwriting.
Unlike Medicare advantage plans, Medigap plans are not guaranteed issue plans. This is often why people choose a Medicare PFFS plan as their medical history prevents them from selecting a Medigap plan.
If you fall under the guaranteed issue period or you are healthy, a Medicare supplement Plan G or Plan N could be a better option over a Medicare Advantage PFFS plan.
Depending on the Medigap plan selected, your cost could be substantially lower than a Medicare PFFS plan. This is because Medigap plans cover most of your medical cost and do not add higher cost for seeing out of network doctors.
Medigap plans do not have a medicare provider network, and are considered an open access plan.

How Much Do Medicare Supplement Plans Cost VS Medicare PFFS Plans?

When comparing the monthly premium of a Medicare PFFS plan and a Medicare supplement plan, the costs of these plans change from location to location. The pricing for a Medicare supplement plan may include pricing related to a person’s age.

A Medicare PFFS plan are not age banded, so they will not increase as you become older.

Most Medigap plans are age banded plans, which means as you age the premium may increase. This means the monthly premiums for both plans may be similar today at age 65 but at 75 the Medigap plan may cost more.

Outside of the monthly insurance premiums for a Medigap plan and a Medicare PFFS plan, you will need to factor in the plans copays, deductibles, coinsurance, and max out of pocket cost.

For instance a Medigap Plan G a Medicare beneficiary is only responsible for the Part B annual deductible. All other Medicare eligible cost are covered at 100%.

Where Medicare PFFS plan could change you thousands of dollars as you use the plan for your medical needs.

All costs associated with these plans should be carefully evaluated before making any decisions.

Looking For A Medicare Insurance Agent Specializing In PFFS Plans

Integrity Now Insurance Brokers is a nationwide Medicare insurance agency specializing in Medicare advantage plans and Medicare supplement plans..

Our Medicare insurance agents are licensed and certified through a national organization known as AHIP. They are required to recertify on Medicare annually to ensure they are up to date on any changes.