Plan N Question

[goillini52]

I have always had the understanding that with Plan N the $20 only applies to doctors visit and not for therapy of any kind

I have a client that is about to begin cardiac therapy Now after some heart Issues, The Therapy place is telling him this is Not true and he will have to pay a $20 copay for each therapy visit.

He did inform them That I told them that this $20 copay should only apply if it is a doctors visit and they told him this is in fact Not true and he will have to pay

Is he responsible for the copay and am I wrong?

If he should not pay a copay, How should he handle this?

Tell them to file with Medicare and find out.

 

[jbage007]

Based on Medicare allowed max for Dr. visit fees? Whatever that is?
If it's say, $70, then 20% is $14.
I've never read it that way. Are you sure? That's the equivalent of paying 20%. Why have a co-pay?

 

[goillini52]

Based on Medicare allowed max for Dr. visit fees? Whatever that is?
If it's say, $70, then 20% is $14.
I've never read it that way. Are you sure? That's the equivalent of paying 20%. Why have a co-pay?

Look at any Outline of Coverage that you leave your new client and under Plan N under You Pay it says, "Up to $20 per Office Visit".

 

[vic120]

Based on Medicare allowed max for Dr. visit fees? Whatever that is?
If it's say, $70, then 20% is $14.
I've never read it that way. Are you sure? That's the equivalent of paying 20%. Why have a co-pay?

Because it is a Medicare supplement, not a PPO or HMO.

With a supplement they only pay out, If Medicare pays 20% They client pays the leftover

If the leftover is over $20 the insurance kicks in and pays

However, if the leftover is only $10 there is nothing more for the client to pay beyond $10 and the INsurance does not take money from the client to put it elsewhere like with a managed plan

 

[Chazm]

Most Clients tell me that their co-pay for an office visit is about $14-$16 For a plan N

 

[Travis Price]

I think it's just easier to say up to $20. Undersell, over-deliver.

 

[somarco]

As others have pointed out, the N copay is not $20, it is the remaining 20% (above the B deductible) up to $20.

Anyone with plan N should NEVER pay a dime until Medicare has adjudicated the claim and sent to the Medigap carrier.

The Medicare MSN will tell if the claim is even payable; the carrier EOB will tell what (if anything) they owe.

There are specific codes (as Travis pointed out) where a copay MAY be required. If someone presses me on this issue I will find and give them the codes.

I NEVER say if a claim is paid or not.

The only sure way is to follow my advice at the top. Wait until AFTER Medicare has adjudicated and approved the claim PLUS the claim has gone to the carrier.

Medical provider staff would know a plan N from a plan T. I never take what they say as gospel.

 

[Travis Price]

I would agree that's the smartest way to do it. At least you have appeal rights at that point.