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Medicare Advantage PFFS Plans
What are Medicare Advantage PFFS Plans ?
Medicare Advantage PFFS Plans, or Private Fee-for-Service Plans, are a type of Medicare health insurance option that allows individuals to receive their Medicare benefits through a private insurance company.
With a PFFS plan, individuals are not required to choose a primary care physician or obtain referrals for specialist care.
This flexibility allows individuals to see any healthcare provider that accepts the plan's payment terms and conditions.
Medicare Advantage PFFS Plans may offer additional benefits beyond what is covered by Original Medicare, such as prescription drug coverage, dental, vision, and hearing services.
These plans also have a set schedule of costs for services, including copayments and coinsurance.
However, it is important to note that not all healthcare providers may accept PFFS plans, so it is crucial to verify if a provider is willing to accept the plan's terms before seeking care.
Medicare Advantage PFFS Plans offer individuals the freedom to choose their healthcare providers while still receiving the benefits of Medicare coverage.
Eligibility for Medicare Advantage PFFS Plans
To be eligible for Medicare Advantage PFFS Plans, individuals must meet certain requirements. First and foremost, individuals must be enrolled in both Medicare Part A (hospital insurance) and Part B (medical insurance).
This means that individuals must be at least 65 years old or have a qualifying disability. Additionally, individuals must reside in the service area of the PFFS plan they wish to enroll in.
Unlike other types of Medicare Advantage plans, PFFS plans are not required to have a network of healthcare providers. However, it is important to note that not all healthcare providers may accept PFFS plans, so individuals should verify if their preferred providers are willing to accept the plan's terms.
It is also worth mentioning that individuals with end-stage renal disease (ESRD) usually cannot enroll in Medicare Advantage PFFS Plans, although there are some exceptions. Meeting the eligibility criteria for Medicare Part A and Part B, along with residing in the plan's service area, are the primary requirements for enrolling in a Medicare Advantage PFFS Plan.
Enrollment period for Medicare Advantage PFFS Plans
Medicare has defined several enrollment periods during which you can sign up for, change, or disenroll from these plans:
Initial Enrollment Period (IEP): This is the seven-month period when you first become eligible for Medicare. It starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you're eligible for Medicare due to disability, your IEP starts 3 months before your 25th month of disability and ends 3 months after your 25th month of disability. During this time, you can join a Medicare Advantage Plan.
Annual Election Period (AEP): Also known as Open Enrollment, it occurs from October 15 to December 7 every year. During this period, you can change from Original Medicare to a Medicare Advantage Plan, switch from one Medicare Advantage Plan to another, or switch back to Original Medicare. If you’re enrolled in a Medicare Advantage Plan, you can also switch to a new Medicare Advantage Plan during this period.
Medicare Advantage Open Enrollment Period (MA OEP): This occurs from January 1 to March 31 each year. During this time, if you're already enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch back to Original Medicare. If you switch to Original Medicare during this period, you'll have an opportunity to also join a Medicare Prescription Drug Plan.
Special Enrollment Periods (SEPs): You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or lose other insurance coverage. These chances to make changes are called Special Enrollment Periods. Rules about when you can make changes and the type of changes you can make are different for each SEP.