A Medicare Advantage Private Fee-for-Service (MA PFFS) plan is a plan in which the member may go to any Medicare-approved doctor, ancillary provider, or hospital that accepts the plan’s terms and conditions of participation. Acceptance is “deemed” to occur where the provider is aware, in advance of furnishing services, that the member is enrolled in a PFFS product and when the provider has reasonable access to the Terms and Conditions of participation.

The Medicare Advantage organization, rather than the Medicare program, pays physicians and providers on a fee-for-services basis for services rendered to such members. Members are responsible for cost-sharing, as specified in the plan, and balance billing of members will not be permitted. Medicare Advantage PFFS varies from the other Blue products in the following ways:

• You can see and treat any MA PFFS member without having a contract with Blue Cross and Blue Shield.
• If you do provide services, you will do so under the Terms and Conditions of that member’s Blue Plan.
• You may choose to render services to a MA PFFS member on an episode of care (claim-by-claim) basis. Please refer to the back of the member’s ID card for information on accessing his/her plan’s Terms and Conditions.
• Your reimbursement will be based on original Medicare rates.
• You can submit your MA PFFS claims to your local Blue Cross and/or Blue Shield plan.