Medicare Advantage PFFS Plans 2025

Are you exploring the flexibility of Medicare Advantage PFFS Plans for 2025 and wondering if one is right for you?

These plans provide a unique option for Medicare beneficiaries who value choice over constraints, allowing you to see any Medicare-approved provider without needing a referral network.

However, understanding the implications of PFFS flexibility – such as provider acceptance and individual cost-sharing – is crucial before making an informed decision. This article unpacks the essentials of PFFS plans, from how they operate and eligibility, to costs, and important enrollment information.


Key Takeaways



  • While PFFS plans may provide greater freedom in selecting healthcare providers and do not necessitate referrals, they can come with higher premiums, limited provider acceptance, and varying costs for out-of-network care.

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Understanding Medicare Advantage PFFS Plans


Medicare Advantage PFFS Plans, Understanding Medicare Advantage PFFS Plans


Medicare Advantage PFFS plans constitute a unique category within the Medicare Advantage Plan framework. These plans set their payment rates for healthcare providers, a stark contrast to Original Medicare or Medigap.

The most captivating element of a PFFS plan is the flexibility it offers to the beneficiaries. They can seek services from any Medicare-eligible provider, making it a practical choice for those who value freedom in their healthcare decisions.

However, it’s important to acknowledge that this freedom of choice comes with certain conditions. A Medicare Advantage PFFS plan does not employ specific cost-controlling measures such as mandating referrals or prior authorization.

This means that beneficiaries have more flexibility in selecting their healthcare providers and accessing their Medicare benefits.

But at the same time, beneficiaries may have to cover any disparity between the plan’s payment and the actual cost charged by the provider.


Key Components of PFFS Plans

A Medicare Advantage PFFS plan is characterized by its unique payment arrangement. The plan establishes terms and conditions of payment which determine the rates for plan-covered items and services.

This implies that the plan commits to reimbursing medical providers at predetermined rates for various healthcare services. This is a departure from a Medicare Advantage PPO plan, which typically has a network of providers and allows for out-of-network care at a higher cost.

When it comes to PFFS plans, the provider network usually refers to the network of healthcare providers under contract with the plan. However, it’s worth noting that PFFS plans generally do not have a plan-specific provider network.

This sets them apart from other types of plans that do have distinct provider networks. This implies that beneficiaries can choose any primary care doctor or specialist who agrees to the plan’s payment terms.


How PFFS Plans Work

Medicare Advantage PFFS plans are considered a type of Medicare Advantage plan, distinct from Medicare Advantage HMO options.

They offer the following benefits:

  • Flexibility to choose any Medicare-approved doctor or hospital


  • Ability to seek care from any provider authorized to receive payments from Medicare


  • Reimbursement rates for healthcare providers are set by the plan


  • Expenses for services are outlined in the Annual Notice of Change and Evidence of Coverage, which is disclosed to beneficiaries.


Beneficiaries can access healthcare services under a PFFS plan by presenting their plan membership ID card at each visit to a healthcare provider. Providers have full authority to decide whether they accept the plan’s payment terms and conditions during each visit.

The beauty of PFFS plans is that referrals are not necessary for patients to schedule appointments with specialists, providing an added layer of convenience.

Eligibility and Enrollment in Medicare PFFS Plans


Medicare Advantage PFFS Plans, Eligibility and Enrollment in Medicare PFFS Plans


For eligibility in Medicare PFFS Plans, individuals need to be enrolled in both Parts A and B of Medicare. This offers a straightforward eligibility criterion that simplifies the process for potential beneficiaries.

After confirming eligibility, the next step to enroll in a Medicare PFFS Plan involves directly reaching out to Medicare or the plan.

It’s advisable to communicate with a plan representative to ensure the receipt of all essential information and to make a well-informed decision. This process is possible even for those with a pre-existing condition, except for End-Stage Renal Disease (ESRD).


When to Enroll

The Annual Enrollment Period for Medicare PFFS plans occurs from October 15th to December 7th annually. This period offers a window of opportunity for beneficiaries to join a PFFS plan of their choice.

There are also Special Enrollment Periods that allow Medicare beneficiaries to enroll in a Medicare PFFS plan outside the standard enrollment periods.

However, it is recommended to reach out to Medicare or the plan directly, potentially by engaging in a conversation with a plan representative during these periods.

Failing to meet the enrollment deadline for a Medicare PFFS plan may result in a penalty of 10% of your monthly premium for each year of delayed enrollment.

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Costs Associated with Medicare PFFS Plans


Medicare Advantage PFFS Plans, Costs Associated with Medicare PFFS Plans


The cost of a Medicare PFFS Plan is an important consideration for potential beneficiaries. These plans encompass an average monthly cost of $80 if they include prescription drug coverage.

The maximum out-of-pocket cost can reach $8,850 in 2024, although plans may establish lower limits. This gives you a clear picture of the expenses you may incur as part of your healthcare.

The monthly premium for a Medicare PFFS Plan, also known as a private fee for service plan, includes a predetermined fixed monthly fee that individuals pay for coverage, irrespective of the level of services utilized.

The cost of Medicare PFFS Plans can vary based on:

  • Your geographical location


  • The plan’s terms of payment


  • Coverage options


  • Cost-sharing arrangements.


Comparing PFFS Plan Costs

When comparing premium costs of various PFFS Plans, examine the monthly plan premium costs established by each plan and consider any additional cost-sharing expenses that may be applicable.

This way, you can make a comprehensive comparison and select a plan that suits your financial capacity.

It’s important to remember the out-of-pocket costs, which are subject to an annual limit. For instance, in 2024, the maximum out-of-pocket for PFFS plans is $8,850, although certain plans may provide lower limits.

Accounting for these costs will help you make a well-informed decision, ensuring that you are not caught off guard by unexpected expenses.

Provider Acceptance and Network Limitations


Medicare Advantage PFFS Plans, Provider Acceptance and Network Limitations


One of the key distinguishing factors of Medicare Advantage PFFS plans is their flexibility in provider choice. Unlike other Medicare Advantage plans like HMOs or PPOs, PFFS plans offer the following benefits:

  • No predetermined provider network


  • Payment rates for doctors and healthcare providers are determined independently by the insurance company


  • Members have the liberty to choose any provider who accepts the plan’s payment terms.


However, this liberty of choice comes with its unique challenges. Beneficiaries must identify healthcare providers that accept their PFFS plan.

Members can utilize the Medicare Care Compare tool on the official Medicare website, review their plan’s website, or reach out to plan representatives for details on Medicare-approved providers, ensuring they select a Medicare-approved provider

. But it’s worth noting that Medicare PFFS Plans only constitute 1% of Medicare Advantage plans, suggesting a comparatively lower acceptance rate.


Finding Providers that Accept PFFS Plans

To locate healthcare providers that accept PFFS plans, you can consult online directories and resources, visit the plan’s website, or contact plan representatives.

Some websites like CMS and specific provider directories such as Humana provide such information. Being proactive in this aspect can ensure that you have a smooth healthcare experience.

Your insurance company plays a significant part in convincing healthcare providers to accept your PFFS plan. They are responsible for convincing providers to accept the rates as listed by the plan. Prior to enrollment, it is important to confirm if the healthcare provider is affiliated with a network that has committed to providing care to members of the PFFS plan.

Additionally, for out-of-network doctors, they must agree to the terms of the plan on a per-visit basis. In such cases, the out-of-network provider must be willing to accept the PFFS plan’s conditions.

Weighing the Pros and Cons of Medicare PFFS Plans

Apprehending the advantages and disadvantages of Medicare PFFS Plans is vital for determining their compatibility with your healthcare needs and preferences.

While they offer a multitude of benefits like flexibility in provider choice and not requiring referrals or prior authorization, they also come with their own set of challenges.

Higher premiums compared to original Medicare, elevated copayments and coinsurance for out-of-network services, and restricted acceptance by providers are some of the drawbacks that you need to consider.

Additionally, compared to other Medicare Advantage plans, Medicare PFFS Plans offer a broader range of provider choices. They empower plan holders to establish rates for various healthcare services.

However, it’s crucial to consider both the positive and negative aspects of Medicare PFFS Plans to make an informed decision that aligns with your healthcare needs and ensures that your expectations are fulfilled.


Is a PFFS Plan Right for You?

The choice of a healthcare plan is a personal matter, largely influenced by your individual healthcare needs and preferences.

When selecting a Medicare PFFS plan, it is crucial to consider the coverage options provided by the plan, including its reimbursement rates for doctors, healthcare providers, and hospitals. Additionally, it is important to consider any supplementary benefits available, such as vision and hearing care.

A fee for service PFFS plan provides significant flexibility as it allows members to consult any doctor or provider who agrees to the plan’s payment terms and conditions. PFFS plans to establish their own reimbursement rates for providers.

Prescription Drug Coverage and Medicare PFFS Plans


Medicare Advantage PFFS Plans, Prescription Drug Coverage and Medicare PFFS Plans


Medicare PFFS Plans may cover prescription drugs. However, if the plan does not include drug coverage, individuals have the option to enroll in a separate Medicare drug plan (Part D) to obtain the necessary coverage.

This offers beneficiaries a comprehensive healthcare package that caters to all their needs.

The rates for prescription drugs within a Medicare PFFS Plan are determined by the plan itself. This allows the plan to cater to the specific needs of its members and offer them a tailored healthcare experience.

On the other hand, these rates can significantly vary between different plans, hence thorough research before selecting a plan is imperative.


Adding a Part D Plan

A Medicare Part D plan is a voluntary outpatient prescription drug benefit available for individuals with Medicare. It is designed to assist in covering the cost of prescription drugs, potentially reducing overall expenses, and providing protection against higher costs.

If a PFFS plan does not provide drug coverage, you have the option to enroll in a distinct Medicare Part D plan to obtain drug coverage.

Incorporating a Part D plan into a Medicare PFFS plan may lead to supplementary monthly premiums, the amount of which may differ based on the specific plan.

Typically, it can amount to approximately $80 per month for a PFFS Medicare Advantage plan inclusive of prescription drug coverage. This is a crucial consideration to keep in mind while choosing a PFFS plan.


Medicare Advantage PFFS plans offer a unique approach to healthcare by providing beneficiaries with flexibility in provider choice and the ability to establish rates for various healthcare services.

From understanding the key components of these plans to weighing their pros and cons, it’s crucial to make an informed decision that aligns with your healthcare needs.

Considering the costs associated with these plans, finding providers that accept PFFS plans, or adding a Part D plan for comprehensive coverage, each step plays a pivotal role in shaping your healthcare experience.


Frequently Asked Questions


→  What is Medicare Advantage PFFS?

Medicare Advantage PFFS, or Private Fee-for-Service, plans are offered by private companies and are paid by the federal government to administer Medicare benefits. They are not the same as Original Medicare or Medigap.


  What is the difference between a PPO and a PFFS plan?

The main difference between a PPO and a PFFS plan lies in the provider network and cost coverage.

PPO plans offer the flexibility to seek care outside the network with potentially higher costs, while PFFS plans allow out-of-network care based on the provider’s acceptance of payment terms.


  Do PFFS plans require a network?

PFFS plans do not always require a network of providers, as some plans may offer full, partial, or no networks at all.

If you plan to receive care from an out-of-network provider, you may incur higher costs and can request an advance organization determination from your plan.


→  Can you enroll in a PFFS and a stand-alone drug plan?

Yes, you can enroll in a PFFS plan and a stand-alone Part D drug plan if your PFFS plan does not offer Part D coverage.

This will allow you to ensure you have comprehensive coverage for both medical services and prescription drugs.


 How can I enroll in a Medicare PFFS Plan?

You can enroll in a Medicare PFFS Plan by calling us today at 1-833-641-4938.

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.