Plan N and Outpatient Rehab

[Chazm]

I always assumed that with Plan N you would be responsible for up to a $20 copay for outpatient rehab, which we know in some instances could be multiple visits per week.

But a couple of years ago I was reading on this very forum that outpatient rehab is actually covered at 100% under plan n and a few concurred while no one objected. So I assumed it to be true.

Fast forward to today, I watched a video made by someone on this forum stating that outpatient rehab could cost up to $20 (after ded) per visit. Adding up to potentially high bills.

Which is true?!

 

[TwoCents]

I always assumed that with Plan N you would be responsible for up to a $20 copay for outpatient rehab, which we know in some instances could be multiple visits per week.

But a couple of years ago I was reading on this very forum that outpatient rehab is actually covered at 100% under plan n and a few concurred while no one objected. So I assumed it to be true.

Fast forward to today, I watched a video made by someone on this forum stating that outpatient rehab could cost up to $20 (after ded) per visit. Adding up to potentially high bills.

Which is true?!

You mean this discussion? http://www.insurance-forums.net/for...an-n-no-20-copay-physical-therapy-t24466.html Seems like a lot of indecision to me.

 

[GreenSky]

The only time there is a copay is for an office visit. Therapy does not include a charge for an office visit.

Rick

 

[LostDollar]

https://www.cms.gov/Medicare/Health-Plans/Medigap/Downloads/Plan_N_Guidance2.pdf

That document suggests, that at least in 2010, wcmason's comments about billing codes, in the referenced thread, were/are the appropriate decision criteria for whether or not there is a co-payment or co-insurance due from the beneficiary.

 

[somarco]

You need to be a bit selective when watching agent produced video's. Sometimes they state conjecture and speculation as fact. The more important thing is, have you personally had a client on N that incurred copay's for rehab, therapy, etc?

Was that video available to the public or a private training video?

 

[LostDollar]

I am hesitant to post a link because I don't know that this is the video and a thread involving this group was recently removed from the site.

In a discussion of Plan N characteristics, discussion of the $20 co-pay for a doctor or a provider is followed by an example of a hip or knee replacement which also has a hypothetical need for 7 rehab visits, every day or every other day.

I listened to this 5 times while writing-I think I got it right:
"You could, on Plan N, hit that co-payment amount, every single time you're visiting rehab."

The person presenting has no uncertainty in their presentation and has an aura of authority that make this sound like fact.

 

[MBSC]

Prior to 1/1/17, the PT evaluation codes were 97001-97004. Effective 1/1/17, the PT evaluation codes are 97161-97168. None of these codes are subject to the Plan N copay.

The physician office visit evaluation codes that are subject to the Plan N copay cannot be billed by Physical Therapists.

In rare cases, a physician will bill PT "incident to" an office visit. This occurs when the beneficiary is seen by both a physician and a physical therapist on the physician's staff during the same visit. The claim is filed with both the office visit evaluation (99201-99215) and PT code. The Plan N copay is applied to the office visit charge on the claim and should not surprise the beneficiary since they scheduled a "doctor's appointment" and not a "PT appointment". Follow-up PT sessions should not require a physician evaluation. The "possibility" of this occurring should not influence a person's Medigap decision. A lightning strike is also a possibility.

 

[GreenSky]

I just watched the video in question. It's a shame the speaker hasn't a clue about how Plan N integrates with physical therapy.

Rick

 

[FLM2]

Prior to 1/1/17, the PT evaluation codes were 97001-97004. Effective 1/1/17, the PT evaluation codes are 97161-97168. None of these codes are subject to the Plan N copay.

The physician office visit evaluation codes that are subject to the Plan N copay cannot be billed by Physical Therapists.

In rare cases, a physician will bill PT "incident to" an office visit. This occurs when the beneficiary is seen by both a physician and a physical therapist on the physician's staff during the same visit. The claim is filed with both the office visit evaluation (99201-99215) and PT code. The Plan N copay is applied to the office visit charge on the claim and should not surprise the beneficiary since they scheduled a "doctor's appointment" and not a "PT appointment". Follow-up PT sessions should not require a physician evaluation. The "possibility" of this occurring should not influence a person's Medigap decision. A lightning strike is also a possibility.

Thanks, this is really good information and will be very helpful should this situation come up with one of my clients

 

[Chazm]

You need to be a bit selective when watching agent produced video's. Sometimes they state conjecture and speculation as fact. The more important thing is, have you personally had a client on N that incurred copay's for rehab, therapy, etc?

Was that video available to the public or a private training video?

I have not personally, but I only have around 50 people on plan N and I don't ask each one of them what they have been charged for.

Even in this thread, there seems to be some uncertainty but MBSC's post was invaluable. I made a screen shot of it but I'll probably tell my clients that you should not be charged for PT. But there have been cases where they can bill it as an office visit.

It's a public video