Private Fee-for-Service (PFFS) Plans
Private Fee-for-Service (PFFS) plans are a type of Medicare Advantage plan structure offered by private insurers approved by Medicare. Unlike HMO and PPO plans, PFFS plans do not always operate with a defined provider network.
How PFFS Plans Work
Under a PFFS plan, the plan establishes payment terms for covered services. Healthcare providers may choose whether to accept the plan’s payment terms for each service. If a provider agrees to the plan’s terms and conditions, the service may be covered under the plan’s rules.
Provider Participation
Because PFFS plans may not use traditional provider networks, it is important for members to confirm that a provider agrees to accept the plan’s terms before receiving non-emergency services. Emergency services are covered regardless of provider participation status.
Cost Structure
PFFS plans typically include defined cost-sharing requirements such as copayments or coinsurance. Cost-sharing details are outlined in the plan’s Evidence of Coverage (EOC) and may vary by service type.
Out-of-Pocket Maximum
Like all Medicare Advantage plans, PFFS plans include an annual maximum out-of-pocket limit for Part A and Part B covered services. Once this limit is reached, the plan pays 100% of covered services for the remainder of the plan year.
Disclaimer: This information is provided for educational purposes only and is based on publicly available guidance from the Centers for Medicare & Medicaid Services (CMS). It has not been reviewed or endorsed by Medicare, CMS, or any federal agency. This content does not constitute plan-specific advice. For individual coverage questions, please consult a licensed insurance professional.