Plan N Co-pay for Doctor Office Vists

[steveadlman]

Will a person that has a Plan N have to pay a $20 co-pay for a doctor office visit if they live in an assisted living facility and the doctor comes to see them? The doctor comes every Wednesday to the assisted living facility and will see residents that have requested a visit.

 

[DS4]

Will a person that has a Plan N have to pay a $20 co-pay for a doctor office visit if they live in an assisted living facility and the doctor comes to see them? The doctor comes every Wednesday to the assisted living facility and will see residents that have requested a visit.

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

 

[TampaHound]

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

OK...maybe I'm missing something but I don't see the answer to the original question in that. Unless it's coded a certain way and I don't know the code?

 

[MedicareAgent]

The answer is Yes they have up to 20$ copays for every visit.

 

[MBSC]

Facility Visits are not Office Visits

You compare the CPT codes for "office visits" in the Plan N guidance document above to the CPT codes for "facility/home visits" in the SNF/Assisted Living document below.

http://www.sccma-mcms.org/Portals/19/assets/docs/Nursing-Facility-Services-POS.pdf

The codes are not the same. Of course, you are relying on a minimum wage medical billing clerk to correctly code the claim. If there is a coding mistake and a copay charged, the provider should resubmit with the correct facility visit CPT.

Q: One of our Doctors goes to an assisted living place and sees patients there. There is a room there that is like a doctor office and that has a waiting room. He does not go to the patient's individual apartments. Does this get coded as a regular office visit?

A: It doesn't matter if he's seeing the patient in the bathroom at the assisted living facility....that's the place of service. Use codes from the 99324-99337 section of E&M for assisted living facility services provided by a physician.

Pam Brooks, MHA, CPC, PCS, COC
Coding Manager
Wentworth-Douglass Hospital

 

[agentjhc]

With the N co-pays and potential ecxess charges, they still shouldn't add up to the $6700 MOOP on a Med Adv, I wouldn't think.

 

[TampaHound]

With the N co-pays and potential ecxess charges, they still shouldn't add up to the $6700 MOOP on a Med Adv, I wouldn't think.

Yes, but if the charges are going to add up in the future then the G is the way to go.

Of course, by the time their in a nursing home, it's to late for G.

 

[MedicareAgent]

What company are you selling a G with Tampahound

 

[somarco]

if the (xs) charges are going to add up in the future then the G is the way to go.

The percentage of providers taking assignment has been steadily declining over the years to the current level of 96%. Nothing to indicate it will reverse.

Unless you have data to prove otherwise.

8 of the current 10 plans do not pay xs charges and the premium difference in D vs G is nominal.

 

[WCMason]

When my main carrier, Aetna, had a $25 or so premium difference between N and G I did about 50/50 each. Since they dropped the premium on G by 14%, leaving an $11-12 difference between the two, almost no one takes N. The exceptions: spouses of clients who already have N. They have experienced copays that are often less than $20 and if they've seen an excess charge, it's been insignificant. They have discovered that N is usually a better value even when the price difference is that small. But I do get a few of those spouses who take G and the spouse who already has N applies for G, just for the convenience of not dealing with copays for such a small difference. I'm good either way.