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What Is a Medicare PFFS Plan?

Medicare Advantage plans are private health insurance plans available to seniors who qualify for Medicare. These plans cover Parts A and B of Medicare insurance and typically also include prescription drug coverage and other services such as hearing and dental that Original Medicare does not cover. Medicare Private Fee-for-Service (PFFS) Plans are one of four common kinds of Medicare Advantage plans. The other three common types are:

A Medicare agent at PBC can help you learn about whether a Medicare PFFS plan is right for you. In this article we’re going to take an overall look at Medicare PFFS Plans and how they work.

How Medicare PFFS Plans work

PFFS Plans may or may not have an established network of doctors and hospitals. Plans without a network can be convenient because members can seek care from any Medicare-approved doctor or hospital that accepts both Medicare and your plan’s terms and conditions. Kupuna who choose a PFFS Plan with an established healthcare network can seek medical care from any network providers who have agreed to always treat plan members.

Though PFFS Plans have a requirement like other Medicare Advantage plans to provide seniors with the same benefits, rights, and protections as Original Medicare, the plan is allowed to determine how much it will pay medical providers and hospitals for services and how much to charge plan members on a monthly basis. PFFS Plans may offer extra benefits, such as vision, dental and hearing aids and you may pay more or less for Medicare-covered services.

Check with a Medicare Agent for individual plan details.

Can I join a Medicare PFFS?

In order to qualify for a Medicare PFFS Plan, you must already be enrolled in Medicare Parts A and B. You must also live in an area where the plan exists and you can not have kidney malfunction at the time of your application.

On a Medicare PFFS do I have to get care within a network?

Some PFFS Plans contract with a network of medical providers who establish an agreement to treat all plan members even if you’ve never seen them before. Know that out-of-network health care providers and hospitals may decide not to treat you even if you were a patient in the past but members are not limited to in-network providers as long as the provider is eligible to receive payment from Medicare and accepts your plan’s terms and conditions. This is why it is important to make sure that the doctor, hospital or other health provider accepts your plan’s payment terms before receiving care. In the case of an emergency such as a heart attack, health care providers must treat you.

Do I need to have a primary care physician if I choose a Medicare PFFS?

PFFS Plans do not require their members to choose a Primary Care Physician (PCP).

Will I need to get a referral to see a specialist?

PFFS Plans do not require their members to get a referral before seeing a specialist.

Will I get prescription drug coverage on a Medicare PFFS?

Prescription drugs may be covered in PFFS Plans. If you decide to join a PFFS Plan that doesn't offer prescription drug coverage, you have the option to join a Medicare drug plan (Part D) to get coverage.

Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.

At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.


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