Is emergency care covered in a PFFS plan irrespective of whether the provider agrees to the plan's payment?

In a Private Fee-For-Service (PFFS) plan, emergency care is covered even if the provider does not agree to the payment terms of the plan. This means that beneficiaries can seek emergency medical services without worrying whether the hospital or the doctor is contracted with the PFFS plan. The critical aspect of emergency care is that it is considered essential for immediate health needs, and under Medicare regulations, all plans, including PFFS, must cover emergency services without prior authorization or network restrictions.

This provision serves to protect the individual’s health and ensure timely access to necessary medical care, especially in urgent situations where delays could lead to worsening health outcomes. Consequently, the flexibility to obtain emergency services from non-contracted providers is a significant feature of PFFS plans that differentiates them from other types of Medicare Advantage plans, where network restrictions may apply.