Medigap -- Is "Plan N the new Plan G"?

[REWahoo]

In my reading I thought the Plan N copay is just for Office Visits.

Correct. From Medicare.gov:

Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don't result in inpatient admission.

I'm in a state with no excess charges billing.

Unless you travel out of state frequently I don't see where plan G offers anything other than higher premiums.

 

[REWahoo]

What is the difference between G and N? Seems like G covers more. Is the price differential really that much?

Plan N allows a co-pay (see my post above) and does not pay for Part B excess charges (if any). That's the only difference between the two.

In our case plan N premiums are about $20/month per person less than plan G . Plus, there are some who think plan N premiums will not increase as much as plan G premiums in the future.

 

[H2ODude]

ReWahoo: regarding ...Unless you travel out of state frequently I don't see where plan G offers anything other than higher premiums.

What specifically is the disadvantage of N out of state? I've just always looked at the traditional Medigap plans without network requirements to be sort of travel neutral. And when we go overseas I just hope for the best; may start looking into a travel supplement for that.

 

[REWahoo]

ReWahoo: regarding ...Unless you travel out of state frequently I don't see where plan G offers anything other than higher premiums.

What specifically is the disadvantage of N out of state? I've just always looked at the traditional Medigap plans without network requirements to be sort of travel neutral. And when we go overseas I just hope for the best; may start looking into a travel supplement for that.

Sue J said she lived in a state that doesn't permit excess charges, which means N and G are the same other than the N co-payments. Having N, traveling to a state allowing excess charges and needing medical care MIGHT mean she would have to pay that 15%. But I think the odds of that happening are very small.

N offers 80% "foreign travel emergency" coverage, the same as F and G.

 

[wmc1000]

The Plan N copays don't kick in until your $185 deductible is met for the year. That is why they don't ask for your copay at the time of treatment. Once your deductible is met the copays kick in for Dr visits, ER visits, Lab tests, PT, etc.

This is the website that stated Plan N copays were not limited to Dr. and ER visits... Don't know if this is totally correct or not - he might be a misinformed insurance agent although he states he has been in the business for over 30 years.

How does an Office Visit Copay work? - JohnConner.com

 

[MBSC]

The Plan N copays don't kick in until your $185 deductible is met for the year. That is why they don't ask for your copay at the time of treatment. Once your deductible is met the copays kick in for Dr visits, ER visits, Lab tests, PT, etc.

Lab and PT services are not subject to the Plan N office visit copay.

Q2. Under Plan N, what constitutes an "office visit" for purposes of determining whether the subscriber is subject to the Part B coinsurance or copayment of up to $20?

Services coded as office visits or evaluation and management visits and billed on Part B professional claim forms (CMS-1500 or ASC X12N 837 professional) would be considered “office visits” for purposes of determining whether the subscriber is subject to the Plan N Part B coinsurance or copayment of up to $20. These include CPT-4 codes 99201 – 99205 and 99211 – 99215, as well as 92002, 92004, 92012, and 92014 (ophthalmology) and 90805 (psychotherapy).

Q3. When applying the Plan N physician office copayment or coinsurance, should the amount be applied only to the office visit charge and not to other charges such as laboratory, x-ray or durable medical equipment (DME)?

The coinsurance or copayment should be applied only to CPT-4 codes 99201 – 99205 and 99211 – 99215, which are codes used to bill an office visit.

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

This is the website that stated Plan N copays were not limited to Dr. and ER visits...

The agent is misinformed.

 

[wmc1000]

Also if feeling ill and you have plan N you can avoid a copay if you have met your deductible by going to an Urgent Care Facility as opposed to your doctor:

12. Is the Plan N ER or office visit coinsurance or copayment applicable to Urgent Care
facilities?
No. Since a visit to an Urgent Care facility is not coded as either an office visit or an ER visit
and has a unique code, the Plan N copayment or coinsurance for either the office visit or ER
visit does not apply to visits to an Urgent Care facility.

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

 

[MBSC]

Now, I'm confused. I thought that when someone loses employer group coverage (e.g. by retiring at an age greater than 65), that person effectively enters the open enrollment period regardless of his age and would be eligible to join any Medigap plan offered in his state without underwriting; that is to say, he would be treated as if he were just turning 65.

If the person has a large group plan, it is primary to Medicare and they can delay Part B enrollment. When they finally do enroll in Part B, the Medigap OEP clock starts and they can choose any Medigap plan.

The Medigap OEP is tied to the Part B enrollment date. For those in a small group plan with under 20 employees, Medicare is primary requiring Part B enrollment at 65. For those choosing to keep the small group plan as secondary coverage, their Medigap OEP window has closed by the time they retire and want a Medigap plan.

They can still buy any Medigap if they are healthy enough to pass underwriting. The unhealthy are given the GI right to buy certain Medigap plan letters under federal rules. Some states have additional regulations requiring all Medigaps be available when group coverage is lost. Some carriers let them choose any plan when they see the loss of group coverage letter.

 

[MBSC]

Also if feeling ill and you have plan N you can avoid a copay if you have met your deductible by going to an Urgent Care Facility as opposed to your doctor:

12. Is the Plan N ER or office visit coinsurance or copayment applicable to Urgent Care facilities?
No. Since a visit to an Urgent Care facility is not coded as either an office visit or an ER visit and has a unique code, the Plan N copayment or coinsurance for either the office visit or ER visit does not apply to visits to an Urgent Care facility.

My area has several walk-in clinics with medical doctors that use "urgent care" in their name but are not a UCF. They bill the office visit codes since they are clinics. We do have one true UCF that is owned by a hospital. There is no copay if it's a true UCF.

 

[audreyh1]

If the person has a large group plan, it is primary to Medicare and they can delay Part B enrollment. When they finally do enroll in Part B, the Medigap OEP clock starts and they can choose any Medigap plan.

The Medigap OEP is tied to the Part B enrollment date. For those in a small group plan with under 20 employees, Medicare is primary requiring Part B enrollment at 65. For those choosing to keep the small group plan as secondary coverage, their Medigap OEP window has closed by the time they retire and want a Medigap plan.

They can still buy any Medigap if they are healthy enough to pass underwriting. The unhealthy are given the GI right to buy certain Medigap plan letters under federal rules. Some states have additional regulations requiring all Medigaps be available when group coverage is lost. Some carriers let them choose any plan when they see the loss of group coverage letter.

Thanks for those clarifications. So someone coming off a large group plan has the full Medicare open enrollment privileges even if they are well past 65.

 

[ncbill]

Thanks for those clarifications. So someone coming off a large group plan has the full Medicare open enrollment privileges even if they are well past 65.

Also if they haven't yet signed up for Part B...because of finances my relative didn't until they were in their early 70s & starting to have significant back pain (got them signed up for Plan G as well)

 

[REWahoo]

Also if they haven't yet signed up for Part B...because of finances my relative didn't until they were in their early 70s & starting to have significant back pain (got them signed up for Plan G as well)

Weren't they required to pay a late enrollment penalty?

In most cases, if you don't sign up for Part B when you're first eligible, you'll have to pay a late enrollment penalty. You'll have to pay this penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it.

https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty

 

[ivinsfan]

Weren't they required to pay a late enrollment penalty?



https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty

It does say there are some special exemptions but doesn't clearly say what they are.. early 70's could be 10% penalty for each year ..80% higher perhaps.

 

[ncbill]

It does say there are some special exemptions but doesn't clearly say what they are.. early 70's could be 10% penalty for each year ..80% higher perhaps.

IDK...but keep in mind it was less than a year from the time Part B coverage/drug plan kicked in & when they died.

Not something I'm going to worry about at this point.