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Medicare Advantage Private Fee-for-Service

Private sign on a gate, referring to the way Private Fee-for-Service Plans work.

There are several types of Medicare Advantage Plans. Private insurance companies offer PFFS (Private Fee-for-Service) plans.

Like other Medicare Advantage plans, they offer the same coverage as Medicare Parts A and B but offer additional benefits.

How does a Medicare Advantage Private Fee-for-Service Plan work?

PFFS insurance carriers will determine how much they will reimburse your provider and how much you will need to pay out-of-pocket. (The Medicare program sets the rates for all other plans.)

Some PFFS (Private Fee-for-Service) plans have a network of providers, but most do not. Even the network plans will likely still offer coverage out-of-network but at a lesser reimbursement rate. You will want to check with your provider to be sure, as providers can choose to accept the fees of a PFFS on a case-by-case basis.

None of these plans require their members to choose a Primary Care Physician (PCP) or require a referral for specialist care.

What does a Private Fee-for-Service Plan cover?

Medicare Advantage plans offer additional benefits not covered in Original Medicare. These additional benefits apply to Medicare Advantage PPFS plans.

  • dental care
  • hearing exams
  • hearing aids
  • vision exams
  • glasses or contact lenses
  • gym memberships
  • wellness and nutrition programs
  • over-the-counter drugs
  • prescription drugs
  • adult daycare
  • transportation to doctor visits
  • services for chronic conditions

The specific benefits and coverage levels for services like these will vary by plan.

What is the difference between PFFs, HMO, and PPO?

PFFS (Private Fee-for-Service) plans are the only plans that determine how much to pay providers and how much to charge their members. The Medicare program itself sets all other plan reimbursements and is allowable. This is the biggest difference between the PFFS plans and the HMO and PPO plans.

Unlike PPO and HMO plans, PFFS (Private Fee-for-Service) plans usually do not have a provider network. Instead, they offer coverage from any provider who accepts the plan’s payment terms. You should ask your provider if they accept these payment terms.

More often than not, PFFS plans include prescription drug coverage. If the specific plan does not provide this, members can obtain a separate Part D plan. Members who have PPO or HMO plans that do not include prescription drug coverage cannot enroll in a separate Part D plan.

Assortment of capsules vitamins or prescription drugs used for a Private Fee-for-Service plans.
More often than not, PFFS plans include prescription drug coverage.

When can I enroll in PFFs (Private Fee-for-Service)?

Once you are enrolled in both Medicare Parts A and B, you can also enroll in a Medicare Advantage plan. There are specific enrollment periods that apply to Medicare Advantage plans.

Initial Election Period

Each individual has their own Initial Election Period. This period begins 3 months prior to your 65th birthday and extends 3 months after your 65th birthday, for a total period of seven months.

If you are receiving disability benefits from Social Security, you are eligible for Medicare after receiving disability benefits for 24 months. You may apply for an MA plan three months prior to your eligibility date (which would begin on the 25th month of your disability benefits). This enrollment period extends to three months after your eligibility date.

Special Election Period

To qualify for a Special Election Period, you must meet certain requirements. The most common way individuals qualify is if they postpone enrollment into Original Medicare because they have other creditable insurance coverage. Once the individual enrolls in Original Medicare, they are also eligible to enroll in Medicare Advantage.

Other qualifying events include moving outside your plan’s coverage area, your plan getting terminated for reasons outside of your control, or you qualify for Extra Help.

To find out if you qualify for a Special Election Period, give Senior Benefit Solutions a call!

Annual Election Period

The Annual Election Period (AEP) occurs each fall from October 15 through December 7. During this time, you can choose to change or drop your current Part C plan. Your new coverage will begin on January 1.

Medicare Advantage Open Enrollment Period

This is often confused with AEP. However, there are additional things you can do during the Open Enrollment Period, which runs from January 1 through March 31 each year.

During Open Enrollment, you may disenroll in your current MA plan and switch back to Original Medicare. The opposite is also true – you may switch from Original Medicare to Medicare Advantage.

You may also switch MA plans, disenroll from your Part D prescription drug plan, and switch from your current Part D plan to another Part D plan.

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