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Private Fee-for-Service Plans

Private fee-for-service (PFFS) plans are a different Medicare Advantage option available in Texas. Private insurance companies under contract with Medicare offer these plans.

PFFS plans differ from managed care plans, such as Medicare HMOs or PPOs, in several important ways:

  • PFFS members may go to any doctor, hospital, or other provider that agrees to accept the private fee-for-service plan's terms of payment and is eligible to be paid by Medicare. 
  • Members don't have a primary care physician to oversee their care, so they don't need a referral to go to a specialist.
  • Although members must live in the plan's service area to be eligible, they can receive treatment anywhere in the United States, as long as the provider is willing to accept the plan's terms of payment. Similar to Medicare HMOs and PPOs, the PFFS plan may require prior approval before obtaining some specific services.

As with Medicare HMOs, PFFS members are eligible to join a Medicare Advantage plan if they have both Medicare Part A and Part B and do not have end-stage renal disease. The PFFS plan's contract with Medicare is for one year. Each year, the PFFS plan decides whether to stay in or leave Medicare. If the plan leaves Medicare, members must either return to original Medicare or join another Medicare Advantage plan.

Several companies are approved by the Centers for Medicare & Medicaid Services to offer a private fee-for-service plan in Texas.

Private Fee-for-Service Plan Costs and Benefits

Benefits cover all required Medicare services and may include some enhancements. Most PFFS plans do not include the Medicare Prescription Drug benefit. If you decide to join a PFFS plan and you need the prescription drug benefit, you can get a stand-alone drug plan.

Before you join a plan, understand the expenses associated with the PFFS plan. The following is a list of expenses that could be associated with PFFS plans:

  • monthly premium
  • copayment for primary care physician and specialist physician visits 
  • copayment for ER visits
  • copayment per day for hospital admission
  • copayment per day for skilled nursing facility admission
  • copayment per day for non-notification of planned inpatient admission

Providers should only collect from members the cost sharing allowed by the PFFS plan. If a provider does not want to participate with the PFFS plan, you must seek another provider willing to work with the plan. Because you generally enroll in a Medicare Advantage plan for one year, it is important to confirm that your providers accept the PFFS plan before enrolling in a plan.

Find out if the PFFS plan covers emergency health care while traveling out of the United States or other services not covered by Medicare. Also ask what the cost sharing is for those added benefits.

Notes

  • The process for filing a complaint or grievance, as well as an appeal for services the plan denies or limits, is outlined in the member handbook you received from the plan. You also have the right for a 72-hour expedited appeal. All complaints or appeals should be filed with the plan.
  • If you have other insurance that pays the Medicare copayments or deductibles -- such as a group retirement plan, military health benefits, or Medicaid -- ask both your other insurance carrier and the PFFS plan how they will coordinate claims.

For Additional Information

The Texas Department of Insurance (TDI), Texas Department of Aging and Disability Services (DADS), the Texas Legal Services Center, and local Area Agencies on Aging are partners in the State Health Insurance Assistance Program (SHIP) for Texas. The Texas SHIP is known as HICAP (Health Information, Counseling and Advocacy Program).

View the Medicare Supplement Insurance Handbook and Rate Guide.

To get free one-on-one counseling in your community from a benefits counselor familiar with programs in your area, call DADS or visit its website

1-800-252-9240
www.dads.state.tx.us/

For information about your legal rights and public assistance programs, call the Legal Hotline for Texans or visit the website at

1-800-622-2520
www.tlsc.org

For more information contact:



Last updated: 11/17/2011



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Translation by WorldLingo