What Is a PFFS Medicare Plan?
A Medicare Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan that pays doctors a set rate for services.
PFFS plans are often advertised as giving you flexible coverage because you can use PFFS plans at any doctor that will accept the plan's terms. However, PFFS enrollees have said that it can be difficult to find doctors outside of the plan's network who will take the insurance.
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Pros and cons of PFFS plans
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Doesn't require referrals or preauthorization.
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No primary care doctor needed.
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Can add prescription coverage through Medicare Part D.
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Out-of-network medical doctors can refuse service.
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PFFS plans are expensive.
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Your doctor can charge you up to 15% extra per procedure.
Alternatives to PFFS plans
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Choose a PPO plan if you want coverage for a wide selection of doctors.
PPOs are cheaper than PFFS plans, on average, and they don't have the same issues of doctors choosing not to accept a plan's terms.
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Choose an HMO plan if you're willing to only use doctors in a plan's network.
HMOs cost about half as much as PFFS plans, making them a good deal. However, you'll have some extra hassle with an HMO plan because you'll need a referral from your regular doctor before you can see a specialist.
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What is a PFFS plan?
With a PFFS Medicare Advantage plan, a private insurance company agrees to pay set amounts for each type of medical treatment. This is called a fee-for-service model.
Depending on your plan, you may have to pay for the service up front and then ask for your company to pay you back later. Other plans will pay out directly to your doctor.
Where can you use a PFFS plan?
- You can use a PFFS plan at any doctor or hospital that's in the plan's network. However, there are a few cases where some PFFS plans won't have a network of providers that agree to accept the plan.
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You can also use your PFFS plan at any other doctor or hospital that will accept it. If you want to see a doctor who's not in the plan's network, you can ask if they'll accept your insurance. Keep in mind that a doctor may approve your insurance for one procedure, but decline it for another.
Even if a doctor accepts your PFFS coverage, they may ask for a higher payment amount than your plan will pay. In that case, you would need to pay the difference between those two amounts.
Ways that a PFFS plan makes it easier to get medical care
- Can get medical care without checking with your insurance beforehand: PFFS plans don't require that you get approval from your insurance company before you get a certain service or prescription drug, called preauthorization. That's a big advantage over other plan types like HMOs and PPOs, which often have prior authorization requirements.
- Can see a specialist without a referral: PFFS plans are similar to PPO (preferred provider organization) plans because they don't require you to get a referral before you see a specialist. However, you may have to call ahead to confirm that a doctor will accept your plan if you want to go out of network.
A PFFS Medicare Advantage plan works like Original Medicare (Parts A and B). Both are fee-for-service plans. However, Original Medicare is run directly by the government, while private companies sell and run PFFS plans.
It's important to remember that a PFFS Medicare Advantage plan isn't the same as Original Medicare or Medigap. You'll have to pay a separate monthly rate to your PFFS company.
PFFS plans vs. HMO and PPO
HMO | Local PPO | PFFS | |
|---|---|---|---|
| Monthly cost | $16 | $28 | $32 |
| In-network coverage | |||
| Out-of-network coverage | |||
| Specialist visits allowed without a referral | |||
| Can get medical care without prior approval from insurance |
Average rates for 2025 Medicare Advantage plans that cover prescription drugs. All plans will cover out-of-network medical care in an emergency.
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Cost of PFFS vs. PPO and HMO
PFFS Medicare Advantage plans usually cost more than other types of plans.
A PFFS Medicare Advantage plan with prescription drug coverage costs an average of $32 per month. That's higher than typical HMO or PPO plans. However, rates can vary widely by state.
Free PFFS plans are available in Georgia, Kentucky, Pennsylvania, South Carolina and West Virginia. PFFS plans cost an average of more than $50 per month in Kansas, Montana, New York and Wyoming.
State | Average monthly cost |
|---|---|
| Arkansas | $48 |
| Colorado | $12 |
| Georgia | $0 |
| Illinois | $38 |
| Indiana | $48 |
PFFS plans aren't common and aren't available in every state. Just 1% of Medicare Advantage plans are PFFS plans.
When shopping for coverage, you can choose to add a separate Medicare Part D prescription drug plan to a PFFS plan. This isn't possible with most Medicare Advantage plan types.
Cost of medical care with PFFS plans
With a PFFS plan, you won't typically save money when it comes to paying out-of-pocket costs, such as your copay. Compared to an HMO or PPO plan, PFFS plans have a more expensive monthly rate and similar costs when you get medical care.
Some PFFS plans let your doctor charge you up to an extra 15% on top of what your procedure costs, called balance billing.
Similarities between PFFS and other Medicare Advantage plans
- Your coverage is bundled: Like all other Medicare Advantage plans, PFFS plans bundle your coverage to include basic medical services. Plans also often cover prescriptions, dental, vision and fitness programs.
- Emergency care is guaranteed: During an emergency, hospitals and doctors across the country must treat you no matter what type of Medicare plan you have.
Which company has the best PFFS Medicare Advantage plan?
Humana has the best PFFS Medicare Advantage plans because of its good prices, high plan quality and wider availability.
Company |
Quality rating
| Monthly cost | |
|---|---|---|---|
| Humana | $25 | |
| Arkansas Blue Medicare | $48 | |
| Wellcare | $79 | |
| AARP/UHC | $82 | |
Plan quality is the average star rating for PFFS plans on Medicare.gov. Monthly cost is the average rate for a PFFS plan that includes prescription coverage.
Only four companies sell PFFS Medicare Advantage plans, and Humana is the best overall option.
- AARP/UnitedHealthcare is the worst-rated company for PFFS plans, with only three out of five stars.
- Arkansas Blue Medicare has expensive rates for PFFS plans, averaging $48 per month for a plan that includes prescription coverage.
- Wellcare's rates for PFFS plans are even higher, averaging $79 per month for a plan that includes prescription coverage.
Frequently asked questions
What is a PFFS Medicare plan?
A Private Fee-for-Service (PFFS) Medicare Advantage plan agrees to pay doctors set rates for different services. PFFS plans tend to cost more than other Medicare Advantage plan types, like HMOs and PPOs. That's in part because PFFS plans don't require permission before you get certain services or procedures, called preauthorization.
How do Medicare Advantage PFFS plans compare to Original Medicare?
PFFS is a type of Medicare Advantage plan that's run by a private company, and that offers bundled coverage with extras like prescription drug benefits, dental and vision. Original Medicare (Parts A and B) is run directly by the government and limits you to basic medical and hospital care.
What is the difference between a PPO and a PFFS?
Private Fee-for-Service (PFFS) plans are the only type of plan that doesn't require you to get permission from your insurance company for certain procedures, called preauthorization. PPOs may require preauthorization for some services, but they typically cost less and you may have an easier time getting out-of-network care.
Methodology and sources
Medicare Advantage cost and rating data was taken from the Centers for Medicare & Medicaid Services (CMS) public use files.
Information on rules regarding PFFS and other Medicare Advantage plan types came from Medicare.gov and the Centers for Medicare & Medicaid Services (CMS).
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