A Private Fee-for-Service (PFFS) Medicare Advantage plan is characterized by:

Why A is correct

A PFFS plan is a Medicare Advantage type in which the plan sets its own payment rates for providers. Providers who have not contracted with the plan may decide, on a claim-by-claim basis, whether to accept the plan's terms for a given service; if they agree, the plan pays them its fee schedule. PFFS plans generally do not require a primary care gatekeeper or referrals, and members may see any provider willing to accept the plan's payment terms. The plan type is available to all Medicare-eligible beneficiaries, not only those under 65.

Why the other options are wrong

• B) PFFS plans typically do not require a PCP selection or gatekeeper referrals — that is an HMO/POS feature. The PFFS member generally needs no gatekeeper or referral under the plan.
• C) Members may use any provider willing to accept the plan's terms; PFFS is not confined to a small employed-physician network. Any willing provider may bill the plan case by case.
• D) PFFS plans are not restricted to beneficiaries under 65; they are open to all Medicare-eligible beneficiaries. All Medicare-eligible beneficiaries, of any age at all, may enroll in PFFS plans instead.

Memory hook

PFFS = the plan sets the price, and any willing provider can bill it case by case. No gatekeeper, no roster.

Why A is correct

A Private Fee-for-Service (PFFS) plan is a Medicare Advantage product that does not rely on a provider network or a primary care gatekeeper. Instead, the enrollee can visit any Medicare-approved provider who is willing to accept the plan's payment terms and conditions for each service rendered. This open-access, network-free structure is what distinguishes a PFFS plan from an MA HMO, which requires network providers and typically a PCP referral. Option A correctly states the defining access feature of a PFFS plan.

Why the other options are wrong

• B) A narrow network with a primary care gatekeeper describes an HMO, not a PFFS plan, which has no network or gatekeeper requirement. Networks and gatekeepers are HMO features that PFFS plans deliberately lack.
• C) PFFS plans do not employ providers directly; enrollees use independent Medicare-approved providers who accept the plan's payment terms. PFFS enrollees use independent Medicare-approved providers, not plan employees.
• D) No Medicare plan requires a referral from a government agency; PFFS care is obtained directly from willing providers. No government referral is required for any Medicare plan, including PFFS.

Memory hook

PFFS = pay-as-you-go without the fence: any Medicare doctor who accepts the plan's terms.

Why A is correct

A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan that generally has no provider network. The plan sets its own fee schedule and pays Medicare-approved providers at those rates on a fee-for-service basis. Providers may choose whether to treat a PFFS enrollee on a visit-by-visit basis. Because there is no network and no gatekeeper, PFFS plans are distinct from MA HMOs, which require network providers and usually PCP referrals. Like all MA plans, a PFFS plan must cover all Original Medicare benefits.

Why the other options are wrong

• B) A PCP referral system is characteristic of HMO-style plans, not PFFS plans, which generally operate without a gatekeeper or network.
• C) PFFS plans are open to anyone eligible for Medicare Advantage, not only those with employer-sponsored coverage.
• D) Every Medicare Advantage plan, including PFFS, must provide at least all Original Medicare Part A and Part B benefits.

Memory hook

PFFS = no network, pay-as-you-go. Any Medicare-approved doctor can treat, and the plan pays.

Why A is correct

A private fee-for-service (PFFS) plan is a Medicare Advantage product in which the plan sets its own payment rates and terms for providers rather than paying Medicare-approved amounts. Medicare pays the plan a capitated amount, and the plan decides how much it will pay doctors and hospitals; any provider willing to accept the plan's terms can treat a member, but providers are not required to accept the plan and may decline. There is no network and no gatekeeper requirement, but deductibles and copayments still apply. The opt-in provider structure of PFFS is a defining Medicare Advantage type tested in the senior products outline.

Why the other options are wrong

• B) PFFS plans have no gatekeeper; members may see any provider willing to accept the plan's terms.
• C) Providers may decline to accept PFFS plan payment terms; acceptance is voluntary.
• D) Cost-sharing exists under PFFS plans just as under other Medicare Advantage products.

Memory hook

PFFS sets its own price tag; the doctor can take it or leave it.