Medical Expense✓ Verified · outline & fact-checked · Sep 2026Difficulty 2/5
A beneficiary enrolled in a Medicare Advantage Private Fee-for-Service (PFFS) plan schedules a visit with a new doctor who is eligible to participate in Medicare. Under the plan's rules, the services will be covered only if:
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
A PFFS plan determines its own payment amounts through its fee schedule and generally operates without a network. Any Medicare-eligible provider may furnish covered services, but only if that provider affirmatively agrees to accept the plan's terms and conditions of payment; a provider who has not accepted the terms may decline to treat the member. This provider-by-provider acceptance requirement is the practical difference between PFFS plans and network-based MA HMOs, which require members to stay in network with gatekeeper referrals.
Why the other options are wrong
- A) A closed network with referral requirements describes the MA HMO model; PFFS plans generally have no network and require no referrals.
- C) PFFS plans are open to any Medicare beneficiary eligible to enroll; dual eligibles are the target population of D-SNP plans, not PFFS plans.
- D) Paying out of pocket is not a condition of coverage; when the provider accepts the plan's terms, the plan pays the provider according to its own fee schedule.
Memory hook
PFFS = the plan sets its own prices and any willing provider can play — no gatekeeper, no narrow network.