Private Fee-for-Service (PFFS) Plan

How PFFS Plans Function in West Virginia

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C)

delivered by a private insurance company. PFFS plans aren’t the same as the Original Medicare Or Medigap. The plan decides how much it will reimburse doctors, other health care providers, and hospitals and how much you must pay when you obtain care. 

Can I obtain my health care from any doctor, other health care provider, or hospital?

Sometimes, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans. Go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care benefits. If you join a PFFS Plan with a contracted network of providers, you can also see any network providers who have always arranged to treat plan members. Your plan may not cover your services, or your costs could be higher.

You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan’s payment terms and agrees to treat you, and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). Not all providers will.

Are prescription drugs covered?

Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn’t offer drug coverage, you can join a separate 

Medicare Drug Plan (Part D)

 To get coverage. Do I need to choose a primary care doctor?

You don’t need to choose a primary care doctor in PFFS Plans. 

Do I have to get a referral to see a specialist?

You don’t have to get a referral to see a specialist in PFFS Plans.

What else do I need to know about this type of plan?

• The plan determines how much you pay for services. The plan will tell you about your cost sharing in the “Annual Notice of Change” and “Evidence of Coverage” documents it sends each year.
• For each service, you get, ensure your doctors, hospitals, and other providers agree to treat you under the plan and accept the plan’s payment terms. 
• Some PFFS Plans contract with a network of providers who always decide to treat you even if you’ve never seen them before.
• Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
• Doctors, hospitals, and other providers must treat you in an emergency.
• Show your plan membership ID card each time you visit a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment. You can’t use your red, white, and blue Medicare card to get health care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to your Original Medicare in the future.
• Check with the plan for more details.