CENTERS FOR MEDICARE & MEDICAID SERVICES

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Marketing Rules for Medicare

Private Fee-for-Service Plans 

A Medicare Private Fee-for-Service (PFFS) Plan is a type of Medicare

Advantage Plan (like an HMO or PPO) offered by a private company. In a

Medicare PFFS Plan, you can go to any doctor or hospital you could go to

if you had Original Medicare if the doctor or hospital agrees to accept the

plan’s terms and conditions of payment, or otherwise agrees to treat you.

Your doctor or hospital doesn’t have to accept the plan’s terms and

conditions, and may choose not to treat you, except for emergencies. Your

doctor or hospital can decide if they will accept the terms of the plan, and

whether or not to treat you, each time they see you. This is why you must

show your plan ID card every time you visit a doctor or hospital.

The plan determines how much it will pay doctors and hospitals, and how

much you must pay when you get care. A Medicare PFFS Plan works

differently than Original Medicare and Medigap (Medicare Supplement

Insurance) policies. You must follow the plan rules carefully when you go

for health care services. When you are in a Medicare PFFS Plan, you may

pay more, or less, for Medicare-covered services than in Original Medicare.

You may have extra benefits that Original Medicare doesn’t cover.

All people representing Medicare PFFS Plans must follow certain rules

when giving you information about their plan. These rules also apply to

independent agents and brokers working with Medicare PFFS Plans.
Medicare PFFS Plans MUST do the following:

• Give you written information with a complete description of how the plan works

• Make clear that there is no guarantee that your doctor or hospital will agree to

accept the plan’s terms and conditions or provide you with treatment if you

join the plan 

• Call you after you join to make sure that you wanted to join and that you

understand how the plan works

• Send you a letter if they can’t reach you by telephone with instructions on how

to disenroll if you change your mind

• Have people available to answer any questions you have about the plan

• Have people available to answer your doctor’s or other providers’ questions

Like all Medicare Advantage Plans, Medicare

PFFS Plans CAN’T do the following:

• Ask for your personal information (like your Social Security, bank account, or

credit card numbers) over the telephone.

• Come to your home uninvited to sell or endorse any Medicare-related product.

• Plans can’t call you unless you are already a member of the plan. If you are a

member, the agent who helped you join can call you.

• Require you to speak to a sales agent to get information about the plan.

• Offer you cash to join their plan or give you free meals while marketing a plan

to you.

• Enroll you into a plan, in general, over the telephone unless you call them and

ask to enroll.

• Ask you for payment over the telephone or web. The plan must send you a bill.

• Tell you that they are Medigap (Medicare Supplement Insurance) policies.

• Sell you a non-health related product, like an annuity or life insurance policy,

during a sales pitch for a Medicare health or drug plan.

• Make an appointment to tell you about their plan unless you agree in writing or

through a recorded telephone discussion to the products being discussed.

During the appointment, they can only try to sell you the products you agreed

to hear about.

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Like all Medicare Advantage Plans, Medicare PFFS

Plans CAN’T do the following: (continued)

• Talk to you about their plan in areas where you get health care like an exam

room, hospital patient room, or at a pharmacy counter.

• Market their plans or enroll you during an educational event like a health fair

or conference.

If Plans use independent agents and brokers to sell their plans, they must be licensed

by the state and the plan must tell the state which agents are selling their plans.

If you believe you have been misled by a Medicare PFFS Plan, call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For More Information

For more information about Medicare PFFS Plans, visit www.medicare.gov on the

web, and select “Find a Medicare Publication” to read or print a copy of the booklet

“Your Guide to Medicare Private Fee-for-Service Plans.” You can also call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. For

information about your Medicare plan choices, look at your “Medicare & You”

handbook.

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CMS Publication No. 11327 

Revised September 2008

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