Medicare Copay question

[bizlady]

DH starts Medicare early next year and we are evaluating plans. We have never had copays.

The plan we will choose will have no deductibles, including the Medicare deductibles.

If we choose a plan with a copay:
1. Is that payable at the time of the appointment?
2. Generally, would we expect a bill for some additional amount in addition to the copay? Or only if that service in the plan specifically calls for co-insurance?

So for example, physician services in and out of network are copay $15- no coinsurance, and diagnostic tests and labs are 0 copay no coinsurance.
That's it then is the $15?

We understand we have to copay for any prescriptions at pickup.

 

[MissMolly]

It has been my experience that co-pays are due at the time of service, generally before you ever see the doctor. I do not have additional amounts due for ordinary doctor appointments - surgeries are of course a different ballgame.

 

[Koolau]

On MC for several years now but NOT a MC expert.

There's always a sign at the doc's office that "co-pays are due at time of service." However, I've never been asked for money at time of service. Any co-pays, etc. are billed at end of billing cycle. No fuss, no muss. Generally, with a decent supplement, your monthly OOP may not amount to too much though I can't offer anything other than my own experience. I wouldn't be too concerned about it unless you are living hand to mouth/pay check to pay check, etc. As usual YMMV so ask your provider.

 

[audreyh1]

Hopefully ReWahoo will answer. But he indicated that he was always billed later for any Medicare copays.

I think the copay up front thing is more of a feature of pre-Medicare insurance.

 

[CRLLS]

From my understanding, a "copay" is a set rate you pay for prescriptions, doctor visits, and other types of care. "Co-insurance" is the percentage of costs you pay after you've met your deductible.

Any Medicare Part A and Part B EOB's that I've seen do not use either term. I know that some, but not all Medicare Supplements may have copays and/or coinsurance (to be paid by the individual". I have never had any insurance with a copay, that is, having to pay a fixed dollar amount for a Dr's office visit. I believe it is for the office visit itself, any services performed beyond the "normal" are billed above and beyond the base billed rate.

I'm not sure what terminology the Medicare Advantage plans use. It is unclear if the OP is using one of these.

 

[Katsmeow]

It sounds like you are planning to get a Medicare Advantage plan rather than having traditional medicare plus a supplement. I do know the answer to your question, but would urge you to research carefully on making that decision. You may have already done that, but just in case I did want to mention that.

 

[MBSC]

Generally, with a decent supplement, your monthly OOP may not amount to too much...

You may have missed the "in and out of network" phrase in the OP. They are asking about Medicare Advantage, not original Medicare. Providers can collect MA copays upfront at the appointment unless the member is dual eligible and also has Medicaid.

With original Medicare, participating providers cannot collect cost sharing upfront. Non-participating providers not accepting claim assignment have the option of collecting the full amount (115% of 95% limiting charge) upfront since Medicare and supplements send non-assigned payment to the member.

2. Generally, would we expect a bill for some additional amount in addition to the copay?

Network providers never balance bill additional amounts for covered services. What is different about Medicare Advantage is that out-of-network (non-contracted) providers cannot balance bill PPO members. For covered services, members are only responsible for the copays and coinsurance.

Medicare Managed Care Manual
Ch.4 - Benefits and Beneficiary Protections
Section 50.1 – Guidance on Acceptable Cost-sharing

Maximum Out-of-Pocket (MOOP) and Combined (Catastrophic) Limits on cost-sharing:

PPO plans are required to have a combined limit on cost-sharing that is inclusive of both in- and out-of-network cost-sharing for all Part A and Part B services.

Section 50.5 – Guidance on Other Enrollee Out-of-Pocket Liability

No balance billing: As indicated in section 170 below, an enrollee is responsible for paying non-contracted providers only the plan-allowed cost-sharing for covered services. The MA plan, not the enrollee, is obligated to pay balance billing when it is allowed under Medicare rules. Furthermore, if an enrollee inadvertently paid balance billing which is the plan’s responsibility, the plan must refund the balance billing amount to the enrollee.

Section 170 – Balance Billing

The guidance in this section applies to HMOs (Health Maintenance Organizations), HMOPOS (HMO Point of Service), PPOs (Preferred Provider Organizations), and RPPOs (Regional PPOs).

When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing. Providers who are permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost-sharing (the balance) for services, directly from the MAO and not from the enrollee.

Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf

If your doctor, provider, or supplier doesn't accept [original Medicare] assignment:

- You might have to pay the entire charge at the time of service.

Reference: https://www.medicare.gov/your-medicare-costs/part-a-costs/lower-costs-with-assignment

 

[bizlady]

You may have missed the "in and out of network" phrase in the OP. They are asking about Medicare Advantage, not original Medicare. Providers can collect MA copays upfront at the appointment unless the member is dual eligible and also has Medicaid.

With original Medicare, participating providers cannot collect cost sharing upfront. Non-participating providers not accepting claim assignment have the option of collecting the full amount (115% of 95% limiting charge) upfront since Medicare and supplements send non-assigned payment to the member.


Network providers never balance bill additional amounts for covered services. What is different about Medicare Advantage is that out-of-network (non-contracted) providers cannot balance bill PPO members. For covered services, members are only responsible for the copays and coinsurance.

SUPER HELPFUL- thank you. The advantage plans we are considering are PPO plans and part of DH union retiree plans, so quite competitive. I think I now have a better understanding of how this will work with this and the answers of others. Who knew that learning about Medicare was going to be so confusing (to us at least).

 

[audreyh1]

Medicare is confusing, though no more confusing than other health insurance options.

 

[ivinsfan]

Well two large providers in my area MN have announced they are leaving the Medica MA plans in the state. This will impact 10K people in the state,, MN..

The one and only acceptable provider in my area, that operates all the clinics and hospitals in a 75 mile area is one that has left. They say the problem wasn't the rates they pay it was the "ongoing issues getting Medica to approve legitimate claims."

I'm still hanging with my too pricey Medicare supplement.

 

[REWahoo]

Medicare is confusing, though no more confusing than other health insurance options.

+1

It might reduce some of the confusion, at least on this thread, if one of the mods changed the title to "Medicare Advantage copay question".

 

[REWahoo]

Hopefully ReWahoo will answer. But he indicated that he was always billed later for any Medicare copays.

I have a Plan N supplement which charges a $20 copay for Dr. visits and $50 for emergency room visits. Don't know what happens on emergency room billing but I've only been asked to pay the $20 up front at a Dr. visit on one occasion. What usually happens is whatever amount the supplement pays is reduced by $20.

 

[ivinsfan]

SUPER HELPFUL- thank you. The advantage plans we are considering are PPO plans and part of DH union retiree plans, so quite competitive. I think I now have a better understanding of how this will work with this and the answers of others. Who knew that learning about Medicare was going to be so confusing (to us at least).

When you say competitive are you talking price or the size of the PPO...?

 

[CRLLS]

While traditional Medicare does not have any in-network and out-of-network services, some Supplement (aka Medigap) plans do. They are generally called "Select" like "Plan G Select" or "Plan F Select" These Select plans do use networks in order to offer a lower cost versions of the more traditional "Plan F" or "Plan G" with the same coverage.

 

[bizlady]

When you say competitive are you talking price or the size of the PPO...?

The price and services included. I have reviewed what is available in our county both for supplements, and advantage plans. The plans thru DH retiree plans are reasonable priced, have no deductibles, and good copays. More important coverage for nearly everything we can think of or might need, now or in the future seems comprehensive. We just did not understand if we had to pay copays and 20%, or just copays. Max out of pocket is $3400 and we can absorb that if ever needed.

 

[MissMolly]

The price and services included. I have reviewed what is available in our county both for supplements, and advantage plans. The plans thru DH retiree plans are reasonable priced, have no deductibles, and good copays. More important coverage for nearly everything we can think of or might need, now or in the future seems comprehensive. We just did not understand if we had to pay copays and 20%, or just copays. Max out of pocket is $3400 and we can absorb that if ever needed.

These MA Employee Retirement plans will vary from employer to employer. We are on my employer provided MA retirement plan. It is a Medicare Advantage PPO plan. We have a $15 copay for regular doctors, a $25 copay for specialists, a $500 deductible and a MOOP of $1,200.

My husband had surgery this year. We had to pay the deductible of $500. Then we paid 4% of other charges associated with the surgery as well as $25 for each PT session he had. We then reached our MOOP of $1,200 for him, so now all remaining doctor appointments, PT session or (God forbid) any additional surgeries this year will be at zero cost to us. Everything resets on Jan 1 of each year.

My coverage under this plan is at no cost (retiree benefit). The monthly cost for my husband is $77.

Everything associated with this surgery went smooth as silk. We paid exactly what I expected we would pay. The insurance paid exactly what I expected they would pay. I have no complaints with my MA PPO plan.