Medicare Advantage plans are available in four main types: Private Fee-for-Service (PFFS), Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Special Needs Plans (SNP). Each offers different levels of flexibility, cost, and provider access, depending on your healthcare needs and preferences.


PFFS Medicare Advantage plans, are a type of Medicare Advantage plan (Part C) offered by private insurance companies, PFFS plans are required to provide the same coverage as Original Medicare (Parts A and B). Unlike Medicare Supplements, each PFFS plan sets its own payment terms, including what you pay for services. These plans may also include extra benefits not offered by Original Medicare.

How Does a Medicare Private Fee-for-Service (PFFS) Plan Work?

With a PFFS Medicare Advantage plan, you don’t need to choose a primary care doctor or get referrals to see specialists. You can visit any provider who accepts the plan’s payment terms, also known as Medicare Assignment. However, not all providers are required to accept it.


Here’s how it works:

- Some PFFS plans may have a provider network. Even with a network, you can often go out-of-network if the provider agrees to your plan’s terms.

- Always check in advance — providers can choose to accept or decline your plan on a visit-by-visit basis. Just because a provider accepted your plan once doesn’t mean they’ll accept it again.

- In an emergency, all providers are required by law to treat you, even if they don’t normally accept your plan.

- Unlike HMO or PPO plans, PFFS plans let the insurance company — not Medicare — decide how much it pays the provider and what you pay for each service.

PFFS Plan Costs

Some Medicare Advantage PFFS plans offer no monthly premiums, though others may charge a separate plan premium in addition to your standard Medicare Part B premium.

To enroll in a Medicare Advantage plan, you must live in a service area where the plan is offered. Each insurance company sets its own rates, so costs can vary. It’s always best to consult a licensed Medicare insurance agent to compare options in your area.


In some cases, providers may charge up to 15% more than the plan’s approved rate. However, if the provider accepts your plan’s terms, you can visit in-network or out-of-network doctors without paying extra.

PFFS Plan Coverage


Medicare Advantage PFFS plans must offer at least the same coverage as Original Medicare Parts A and B, including:

In addition, many PFFS plans provide extra benefits, such as:

- Dental, vision, and hearing care

- Fitness memberships (e.g., SilverSneakers)

- Transportation to medical appointments

- Over-the-counter allowances

- Wellness programs and chronic condition support

Each plan varies, so it’s important to check with your provider or agent for available benefits in your area.

PFFS, PPO vs. HMO — What’s the Difference?

The biggest difference with a PFFS (Private Fee-for-Service) Medicare Advantage plan is that the insurance company — not Medicare — sets the rates. That means your plan decides how much it will pay the provider and what you’ll pay for covered services. In most other Medicare Advantage plans, Medicare controls these rates.


Here’s how PFFS plans compare to other types of Medicare Advantage plans:


- PFFS plans usually don’t have a provider network. You can see any doctor or hospital that agrees to the plan’s payment terms.

- If a service isn’t covered but is medically necessary, you can request an “advance coverage decision” before receiving it.

- Most PFFS plans include prescription drug coverage. If not, you can add a stand-alone Part D plan — something not allowed with HMO or PPO plans that don’t include drug coverage.

- You may need to check with the provider before each visit to confirm they’ll accept your plan.

- HMO plans require referrals from your primary care doctor to see specialists, while PFFS and PPO plans do not.

How to choose between PPFS, HMO, and PPO?

Every Medicare Advantage plan has its pros and cons, so the best choice depends on your health needs, budget, and location. Not all plans are available everywhere, and not every doctor accepts every plan. That’s why it’s important to speak with a licensed Medicare insurance agent.

PFFS Plan Eligibility

If you qualify for Medicare Part A and B, you’re also eligible for a Medicare Advantage PFFS plan. Most people become eligible for Medicare at age 65 if they are a U.S. citizen or lawful permanent resident and have lived in the United States continuously for at least

five years.


If you’re under 65, you may still qualify if you:


- Have End-Stage Renal Disease (ESRD)

- Have Amyotrophic Lateral Sclerosis (ALS)

- Have received Social Security disability benefits for 24 months

Enrollment in a Medicare Advantage PFFS plan is limited to specific windows:


- Initial Coverage Election Period (ICEP): This 7-month window starts 3 months before the month you turn 65 and ends 3 months after your birth month.

- Annual Enrollment Period (AEP): Takes place from October 15 to December 7 each year, allowing you to enroll, switch, or drop - Medicare Advantage plans.

- Medicare Advantage Open Enrollment Period (MA OEP): Runs from January 1 to March 31, during which you can switch Medicare Advantage plans or return to Original Medicare.

- Special Enrollment Period (SEP): Certain life changes — like moving to a new area, losing current coverage, or qualifying for Extra Help — may allow you to enroll or switch plans outside of standard windows. It’s best to consult a licensed Medicare advisor to understand your specific options.

Let us simplify Medicare and Health

Insurance for you—at no cost!

Navigating healthcare and Medicare

doesn’t have to be stressful. At Cole Insure,

we specialize in offering tailored solutions

to meet your unique needs, ensuring you feel

supported and covered every step of the way.

Located in Kansas City, Missouri!

We are not connected with or endorsed by the United States government or the federal Medicare program. Health Insurance

sold on www.coleinsure.com is processed through the licensed entity: Cole Insure LLC

Copyright © 2024 Cole Insure. All Rights Reserved.