Medicare Plan N Copays: How Much Will I Owe?

Medicare Plan N is not the most comprehensive Medigap plan on the market. And yet, more and more beneficiaries are seeing the value of lower monthly premiums. In fact, we’re seeing the number of people enrolled in Plan N grow at a faster rate than any other Medigap plan.

In many cases, Plan N is more cost-effective than other popular plans like Plan G and Plan F. So, what’s the catch? Lower-premium plans often mean higher out-of-pocket costs. Why would anyone want that? The biggest difference between Plan N versus Plan G or Plan F is the copays. However, if you are someone who rarely visits the doctor or doesn’t mind the occasional copay, Plan N might be a great choice for you.

Before you decide which Medigap plan to choose, it’s important to understand the Plan N copays. There is a lot of confusion about what constitutes an office visit and how much you’ll actually have to pay. Today, we’re going to clear up some of that confusion so you can make an informed decision.

Medicare Plan N Benefits

First, let’s review what Plan N covers. All Medigap plans act as a secondary insurance plan to your benefits with Original Medicare (Part A and Part B). Original Medicare offers great coverage but does leave you with many out-of-pocket costs. Plan N will pick up the majority of those remaining expenses. Plan N covers:

• Part A deductible
• Part A coinsurance costs, with an extra 365 days of coverage
• First 3 pints of blood
• Skilled nursing coinsurance
• Foreign travel emergencies (up to plan limits)

The three things missing from this list are the Part B deductible, Part B excess charges, and Part B copays. Plan N has copays for office visits and emergency room visits.

Office Visit Copays

A copay, or copayment, is a set amount of money you pay for a service. Under Plan N, an office visit copay can cost up to $20 per visit. But what exactly is considered an office visit? And what do the words up to really mean? How will you know if a visit will be less than $20?

The answers to these questions aren’t always so simple, and you may not know for sure until you get the bill from your doctor’s office. However, we’d like to provide you with a little more information that will help you determine when a Plan N copay applies.

Whether or not you will have a copay really depends on what medical code the provider bills for your office visit. This code is what is entered on their claim and sent to the insurance carriers. Each service has a specific code that tells the carrier exactly what was done.

What services apply to the Plan N copay?

Let’s talk about what kinds of office visits will have a copay. Office visits coded as evaluations or health management visits all apply to the Plan N copay. Sounds simple, right? It is, but there are 15 different medical codes that can be used for those two types of services.

Another type of office visit to consider doesn’t happen in the office at all. Telehealth visits, once only covered by Medicare Advantage plans, were made increasingly popular during the COVID-19 pandemic. Now, telehealth visits are included in Original Medicare benefits.

Telehealth visits are convenient for many people, especially if traveling is difficult due to your health or if you live in rural areas. They also require less time since you don’t have to drive to an office, which helps people with busy schedules. Having this easy access to care has been very beneficial.

Providers offer a variety of telehealth services like office visits, consultations, and psychotherapy. Regardless, these services will fall into one of the medical codes that require a Plan N copay.

Another common question we get asked is if the copay applies to lab work, x-rays, or physical therapy. Again, we can’t say yes or no. Those services will have their own codes, so the copay will only apply to the office visit itself. If the provider does not charge an office visit code, you will not have a copay.

If you schedule multiple visits in one day, expect to pay a copay for each office visit. For example, if you see your primary care physician in the morning and then see your specialist later that day, a copay will apply to both visits, even if they practice in the same location.

How is the copay calculated?

Now, let’s address that vague wording of up to $20 and help you understand exactly how the copay is calculated.

First, you’ll need to meet your Part B deductible. The only Medigap plan that covers the Part B deductible is Plan F. If you have Plan G or Plan N, you must pay the Part B deductible before Medicare begins to pay for Part B services. This year (2023), the deductible is $226. You pay 100% of the costs until you meet the deductible.

Once your deductible is met, that’s when the copays kick in. Let’s look at a couple of examples.

Example 1:

It’s your first visit of the year, and you have not paid any of your Part B deductible. The total Medicare-approved charge for the visit is $400. Right off the bat, you’ll owe $226, leaving a balance of $174. Part B then picks up 80% of that balance, leaving a total of $34.80. If you have Plan N, it will cover the difference between that amount and $20, leaving you with just the $20 copay.

Example 2:

You’ve already met your deductible in this example. You had another office visit, but this time, the Medicare-approved about was only $80. Part B pays 80%, leaving the balance at $16. Since $16 is less than $20, you only owe $16 to the provider.

As we mentioned earlier, it’s likely that you won’t know how much your bill will be until you get the invoice from your provider or the Explanation of Benefits from your insurance carrier. The EOB is helpful in explaining what codes were charged and how the payment from Medicare and Plan N was applied.

Emergency Room Copays

Now let’s talk about emergency room copays. Under Plan N, you’ll be responsible for up to $50 for an emergency room visit. As with the office visit copays, there is more than one code that may be charged for an emergency room visit. The five codes you may see for an emergency room visit include the following:

• 99281
• 99282
• 99283
• 99284
• 99285

Copays are calculated just like we did in the office visit copay examples above. It will depend on what the Medicare-approved amount is for a service and whether or not you have met your deductible. However, there are a couple of other tricks to this copay.

What if I’m admitted as an inpatient?

When you are in an emergency room, the services you get are covered under Medicare Part B. However, if you are admitted as an inpatient, your coverage now changes to Medicare Part A. If this happens, you will not be responsible for the emergency room copay. Since you have Plan N, and it picks up all remaining Part A costs, you won’t have to pay for any services that fall under Part A.

And yes, if you have a REALLY bad day and have to go to the emergency room more than once, you’ll have a copay due for each visit. To avoid these larger copays, we recommend going to an urgent care clinic, which would not be billed as an emergency room visit. Of course, only do this if you aren’t experiencing a true medical emergency!

Is Plan N Right for You?

So, what do you think? Are the Plan N copays worth the risk to you? If you’re considering enrolling in Plan N, the copays are the biggest factor in that decision. Ask yourself how often you visit the doctor or the emergency room. Do you expect to have multiple visits per month? Or, are you relatively healthy and rarely visit the doctor?

Ask an independent insurance agent at Bobby Brock Insurance to compare Plan N premiums to other plans in your area. If you can save a significant amount of money by switching to Plan N, it might just be the most cost-effective option for you, even if you include one or two office visits per month.

We love saving our clients’ money. To learn more about Medicare Plan N or to shop for other Medicare plans, chat with one of the experts at Bobby Brock Insurance today.