Medigap Plan N Copays: How Much Will I Owe?

While it may not be the most exhaustive Medicare Supplement (Medigap) plan available, Medicare Plan N is increasingly being perceived as a valuable option due to its lower monthly premiums. Interestingly, we're noticing that Plan N's enrollment rate is outpacing other Medigap plans.

Plan N is often more budget-friendly than other popular plans such as Plan G and Plan F. But, is there a downside? Typically, plans with lower premiums imply higher out-of-pocket expenses. It might make you wonder why anyone would opt for that. The primary contrast between Plan N and plans like Plan G or Plan F lies in the copays. That said, if you seldom require a doctor's visit or are comfortable with the occasional copay, Plan N could be an excellent fit for you.

Before finalizing any Medigap plan, it's crucial to fully comprehend the copays associated with Plan N. There is often a misunderstanding about what falls under an office visit and the exact amount one might need to shell out. Therefore, we aim to dispel these misconceptions today to help you make a well-informed decision.

Medigap Plan N Benefits

First, let's recap what Plan N entails. All Medigap plans function as supplementary insurance to your Original Medicare benefits (Part A and Part B). While Original Medicare provides substantial coverage, it does leave you with several out-of-pocket expenses. This is where Plan N comes into play, absorbing the majority of these remaining costs. Specifically, Plan N covers:

• The deductible for Part A

• Coinsurance costs for Part A, including an additional 365 days of coverage

• The first three pints of blood

• Coinsurance for skilled nursing care

• Foreign travel emergencies (up to the plan's specified limits)

However, there are three elements that aren't covered by Plan N: the Part B deductible, Part B excess charges, and Part B copays. It's also worth noting that Plan N includes copays for routine doctor visits and emergency room visits.

Office Visit Copays

A copay, also known as a copayment, is a fixed sum that you're required to pay for a specific service. With Plan N, a copayment for an office visit could amount to a maximum of $20 per visit. But what qualifies as an office visit? What does the phrase "up to" signify? How can you be certain that a visit will cost less than $20?

These questions might not always have straightforward answers, and the exact cost might only become clear once you receive your doctor’s bill. Nonetheless, we aim to provide additional insights that should help you discern when a Plan N copay might apply.

Whether you'll have to make a copay largely hinges on the medical code that your healthcare provider uses to bill your office visit. This code is inputted into their claim and dispatched to the insurance companies. Each service is designated with a specific code that informs the insurer precisely what service was rendered.

What services apply to the Plan N copay?

Let's delve into which types of office visits entail a copay. Office visits that are coded as evaluations or health management appointments all fall under the purview of the Plan N copay. Sounds straightforward, doesn’t it? Generally, it is, but keep in mind there are 15 distinct medical codes that might be assigned for these two service types.

An additional category of an office visit that merits consideration doesn't take place in a traditional office setting at all: Telehealth visits. Once only included in Medicare Advantage plans, their popularity surged during the COVID-19 pandemic. Presently, telehealth visits are part of the benefits offered by Original Medicare.

Telehealth visits are an accessible solution for many, especially if health issues make travel challenging or if one resides in remote areas. Besides, they save time as there's no need for a commute, benefiting those with tight schedules. This ease of access to healthcare has proven to be extremely advantageous.

Healthcare providers deliver an array of telehealth services, encompassing office visits, consultations, and psychotherapy. However, all these services fall within one of the medical codes that necessitate a Plan N copay.

A frequently asked question is whether the copay applies to lab work, x-rays, or physical therapy. The answer isn't a simple yes or no. These services have unique codes, so the copay will only be applied to the office visit itself. If no office visit code is charged by the provider, there will be no copay.

If you book multiple appointments on a single day, prepare to pay a copay for each office visit. For instance, if you meet with your primary care physician in the morning and then consult a specialist later in the day, a copay will be applicable to both visits, even if they occur in the same facility.

How is the copay calculated?

Now, let's clarify the somewhat ambiguous phrase "up to $20" and help you understand how the copay is computed.

Initially, you'll need to satisfy your Part B deductible. The only Medigap plan that takes care of the Part B deductible is Plan F. If you're enrolled in Plan G or Plan N, the Part B deductible must be paid out-of-pocket before Medicare commences coverage of Part B services. For this year (2023), the deductible stands at $226. You bear the full cost until the deductible is met.

Once you've reached your deductible, that's when the copay system starts to operate. Let's illustrate with a couple of scenarios.

Example 1

For your first visit of the year, none of your Part B deductible has been paid. The total Medicare-approved charge for the visit amounts to $400. Right from the get-go, you'll owe $226, which leaves a balance of $174. Part B then covers 80% of that balance, resulting in a total of $34.80. If you're on Plan N, it takes care of the gap between that sum and $20, leaving you with only the $20 copay.

Example 2

In this case, you've already covered your deductible. During another office visit, the Medicare-approved charge is merely $80. Part B covers 80%, resulting in a balance of $16. Since $16 is lower than $20, your obligation to the provider is just $16.

As stated earlier, it's probable that the final amount of your bill will only become apparent once you receive the invoice from your provider or the Explanation of Benefits from your insurance carrier. The EOB is particularly useful, as it details the codes that were charged and how the payments from Medicare and Plan N were allocated.

Emergency Room Copays

Let's now turn our attention to copays applicable for emergency room visits. Under Plan N, you could be charged up to $50 for a visit to the emergency room. Similar to office visit copays, multiple codes could be used to bill an emergency room visit. The five codes that you might encounter for an emergency room visit include:

• 99281

• 99282

• 99283

• 99284

• 99285

The calculation of copays follows the same principle as we demonstrated in the examples of office visit copays earlier. It will hinge on the Medicare-approved cost for a service and whether you've met your deductible or not. However, there are a few more intricacies involved with this particular copay.

What if I’m admitted as an inpatient?

When you visit an emergency room, the services provided fall under the coverage of Medicare Part B. However, if you're admitted as an inpatient, your coverage switches over to Medicare Part A. You're not liable for the emergency room copay in such a case. Given that you're enrolled in Plan N, which takes care of all remaining Part A expenses, you won't be required to pay for any services categorized under Part A.

Indeed, if you have to visit the emergency room more than once in a single day, you'll incur a copay for each visit. To evade these substantial copays, we suggest opting for an urgent care clinic, as their visits won't be billed as emergency room visits. Naturally, this advice only applies if you're not facing a genuine medical emergency!

Is Plan N Right for You?

So, what's your verdict? Do you find the copays under Plan N worth the potential risk? If you're contemplating joining Plan N, the copays are the most crucial aspect to weigh. Consider your regularity of doctor or emergency room visits. Are you anticipating multiple visits each month? Or, do you generally enjoy good health and seldom need to see a doctor?

Consult with an independent insurance agent at Local Medicare Specialists to compare Plan N premiums with other plans available in your region. If switching to Plan N can yield substantial savings, it could well be the most economically viable option for you, even with a couple of office visits each month factored in.

At Local Medicare Specialists, we take pride in helping our clients save money. To gain more insights about Medicare Plan N or to explore other Medicare plans, engage with one of our knowledgeable experts today.