Medicare Private Fee-for-Service (PFFS) plans

With the advent of Medicare Advantage several years ago, new Medicare plans have been introduced, including a Private Fee-for-Service (PFFS) plan. Unlike the similarly named "Medicare fee-for-service," PFFS plans are created and administered by health plans. PFFS plans combine the benefits of Medicare Parts A and B into one plan (usually with supplemental coverage).

Unlike other Medicare Advantage plans, a PFFS plan generally has no provider network. Members may receive care from any physician or other health care professional who is eligible to be paid under Medicare rules. Typically, services are reimbursed based on Medicare's rates, although a health plan may choose to reimburse at a higher level as an incentive for providers to treat PFFS members.

Provider responsibilities

Since there is no network associated with a PFFS plan, physicians and other health care professionals may decide at each visit whether or not they will provide services to a PFFS member. If a provider chooses to see a PFFS member, he or she is considered "deemed" for that date of service if each of the following criteria is met:

• The provider is aware before rendering service that the patient is enrolled in a PFFS plan.
• The provider accesses or has reasonable access to information about the PFFS plan's terms and conditions of payment. (This information is available by calling the phone number or accessing the Web site listed on the member card. In addition, providers can access the Medicare Advantage PFFS Terms and Conditions Web Finder Tool.)
• The physician subsequently provides service to the patient.

 

Once a provider is considered deemed, he or she must follow the sponsoring health plan's terms and conditions of participation. As a result, the provider may collect only the applicable copayment or coinsurance amounts from the member and may not otherwise charge or bill them, unless balance billing is permitted by the sponsoring health plan. 

In the event that the member needs urgent or emergent care, the treating provider has the option of informing the PFFS plan that he or she does not wish to be considered a deemed provider. The provider will generally receive payment equal to Original Medicare, and the provider may collect only the applicable copayment or coinsurance amounts from the member. 

Identifying members

Although Regence BlueCross BlueShield of Utah (Regence BCBSU) does not offer a PFFS plan, other Blue Cross and/or Blue Shield Plans (Blue Plans) do, and their members may seek services in Utah. The PFFS plan member card features the alpha prefix of the member's Blue Plan and the Medicare Advantage PFFS logo shown below:

 

 

As with other BlueCard members, PFFS claims should be sent to Regence BCBSU. 

 

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