Medigap Plan N has consistently been a favorite among the Medigap options. Lately, we’ve noticed a surge in queries about Plan N from beneficiaries. Typically, Plan N comes with a more affordable monthly premium compared to Plan G, making it seem like a tempting choice on the surface. But is there a trade-off?
Opting for a plan with a reduced premium usually translates to higher out-of-pocket expenses for the beneficiary. However, if you seldom need medical attention and are comfortable with occasional copays, this might work for you. Broadly speaking, Plan N mirrors Plan G in its offerings. In certain regions, the savings on premiums might render Plan N a more economical choice annually.
The uncertainty surrounding out-of-pocket expenses tied to Plan N frequently arises after visits to healthcare facilities like doctor’s offices or emergency rooms. You might be pondering, ‘Which types of office visits come with a Plan N copay, and which ones don’t? What qualifies as an office visit?’
The answer isn’t always straightforward. Whether you’re required to pay a copay hinges on the specific billing code utilized by the provider. Deciphering this can be intricate unless you’re familiar with the precise code assigned to the claim.
Every medical service you undergo corresponds to a distinct code that informs the insurance company about the procedure conducted. Clients often find themselves perplexed when confronted with copayments. At Boomer Benefits®, we have a comprehensive understanding of these codes due to our daily involvement in addressing claims matters. In this piece, I’ll elucidate this information to equip you with the knowledge needed to navigate your financial obligations confidently.
Medigap Plan N Coverage
Before delving deeper, let’s outline the key features of Medigap Plan N. Much like Plan G, Plan N entails your accountability for the annual Part B deductible. Once this deductible is met, your coverage becomes notably extensive.
Plan N assists in addressing your Part A deductible and related services, Part B coinsurance, and other facets. However, it’s important not to overlook the significance of the copays and potential Part B excess charges that could come into play.
Up to $20 Copay
If you’ve conducted an online search about Plan N, you might have come across phrases like, “You might have a copay of up to $20 under Plan N” or “There’s a possibility of excess charges.” The imprecise, open-ended wording tends to create ambiguity.
Do you pay the deductible first?
You are responsible for the deductible. You must pay this amount first before you have a copay for an office visit. This means that you will pay $226 (in 2023) for your Part B services, such as doctor visits, physical therapy, durable medical equipment, lab work, and more. Once that deductible is met for the year, you can expect copays for certain office visits.
How is the copay determined?
You might have observed that the copay isn’t a fixed figure; instead, it has an upper limit of $20. This is due to the copay being determined by the Medicare-approved amount for the particular service in question. It’s important to note that the Plan N copay can vary, with a maximum of $20, indicating that consistency isn’t guaranteed.
To illustrate, let’s consider an instance where your office visit holds a Medicare-approved amount of $460, and you’ve already met the annual deductible. Medicare covers 80%, which amounts to $368, resulting in a remaining balance of $92 to be paid to the provider. With Plan N, your copay of $20 is applicable, and your plan handles the remaining $72.
However, if the Medicare-approved amount is merely $80, Medicare Part B will cover $64, and the outstanding 20% coinsurance adds up to $16. Here, you’ll pay $16 instead of the maximum $20 copay.
What services are subject to the $20 Plan N copay?
Having covered the potential range of your copay, let’s delve into the types of visits that entail such a fee. Any visit classified as an office visit or evaluation and management visit will be subject to the $20 copay. While this might seem straightforward, there are 15 distinct codes that can trigger up to a $20 copay. If your visit is associated with any of these 15 codes, anticipate a copay.
The intricacy arises from not knowing precisely which visits will correspond to these codes until after the visit concludes. Essentially, your physician will assign the appropriate code after the visit, and the billing department will formulate the claim based on the information provided by the doctor. Subsequently, the claim is sent to Medicare.
After Medicare and your Medigap Plan N process the claim and relay it back to your healthcare provider, you’ll receive the copay bill. Additionally, you should receive an Explanation of Benefits from your Plan N provider before the bill. This document itemizes the expenses and coding associated with a visit. If the code aligns with one of the codes listed below, you’ll be accountable for the copay.
Do telehealth visits apply to the copay?
Traditionally, telehealth services were typically offered as an extra perk with Medicare Advantage plans. However, the landscape has shifted since the pandemic, with more healthcare providers extending telehealth options to patients. This can prove especially convenient for those with hectic schedules or a preference to avoid waiting rooms. If telehealth visits align with your preferences, it’s only natural to inquire whether the Plan N copay applies.
While telehealth visits can encompass virtual office visits, psychotherapy sessions, and consultation services, it’s conceivable that they might correspond to one of the relevant CPT codes. If this is the case, you should anticipate a copay bill. In the event that you ever encounter queries or uncertainties regarding a code or bill received, my team is just a phone call away.
Is the Plan N copay required for physical therapy, lab work, or X-rays?
A frequently raised question among beneficiaries while evaluating Medigap plans is whether the Plan N copay is relevant to particular services like physical therapy or lab work. It’s important to clarify that the copay is exclusively relevant to the office visit itself.
Every service conducted during the visit is assigned its own distinctive code. If these codes don’t align with the relevant copay codes, you won’t encounter a copay for those specific services.
What if you have multiple visits in one day?
If you share my inclination, you might prefer scheduling multiple appointments on the same day for efficiency. However, it’s worth noting that if you follow this approach, a copay will be incurred for each Medicare-approved visit on that particular day, provided it corresponds to one of the relevant codes. This applies regardless of whether your appointments involve various doctors within the same medical practice.
Up to $50 Copay
Recalling the outset of this article, I pointed out the possibility of encountering a copay during an emergency room visit. For such instances, the copay could reach a maximum of $50 for each relevant visit. As illustrated in the chart provided earlier, five distinct ER codes fall within the copay category. Consequently, you should anticipate a copay if your visit corresponds to any of the aforementioned codes.
Much like the office copays, this amount is calculated in relation to the Part B 20% coinsurance. In essence, it’s determined by the Medicare-approved amount designated for that specific service.
What happens if you are admitted as an inpatient?
Transitioning from an emergency room visit to being admitted as an inpatient in the hospital is not only a procedural shift but also brings about a change in your Medicare coverage. While receiving care in the emergency room falls under Part B coverage, being admitted as an inpatient result in Part A coverage governing your inpatient stay. Consequently, if you become an inpatient in the hospital following an ER visit and your care is covered by Part A, your Plan N copay will be waived.
How often do you pay the ER copay?
While the desire to make multiple visits to the emergency room in a single day is minimal, it’s a circumstance that can occur. In such a situation, if you don’t end up being admitted to the hospital as an inpatient, you will be responsible for a copay of up to $50 for each relevant emergency room visit you experience on that particular day.
Is Plan N the right plan for you?
All factors considered, Plan N offers comprehensive coverage tailored to Medicare beneficiaries seeking lower premiums or those who infrequently visit the doctor. However, as time has passed, I’ve encountered numerous individuals raising inquiries about the Plan N copays prior to enrolling. The available information hasn’t always been crystal clear. The truth is, that copayments can accumulate, making it vital to grasp which services necessitate these copays—a crucial aspect impacting one’s decisions concerning Medigap.
Should you find yourself with queries about Plan N and its cost structure, rest assured that my team is equipped with answers. You can reach us at 817-249-8600. Our assistance extends beyond mere enrollment; we’re here to provide guidance if you have concerns about copays or bills. And remember, our services come to you free of charge.
Key Takeaways
- Copays within Plan N are determined by the specific coding assigned to each visit.
- Roughly 15 doctor visits are subject to the office visit copay.
- The copay for emergency room visits is applicable to 5 distinct codes.