How does an Office Visit Copay work?

Office visit copays work differently depending on the type of plan you have.  An office visit copay works differently for a Medicare PPO plan than a Medicare HMO plan.  And the Medicare Supplement Plan N copay is also different then the previous two plans.

Medicare Supplement Plan N … Plan N has a copay of $20 per visit.  Plan N also has an annual outpatient deductible of $233 which first needs to be paid before the copays commence.  Once the copays start, you are responsible for the $20 copay for each Dr visit, lab, x-ray, outpatient surgery, physical therapy, etc.  The Plan N hospital benefit is 100% coverage.

HMO … Typically when you receive services from your HMO primary care physician or a specialist, whatever services or procedures and costs you receive during the visit, all are included in your Plan co-pay.  For example; you schedule a visit because your knee hurts from your day of hiking.  The doctor who sees you discusses your knee issue, examines your knee, has you walk down the hall for an X-Ray, then gives you a cortisone shot.  If your HMO plan has a $30 copay, that is all you would pay for this days visit.

PPO … PPO’s will work a bit differently than a HMO plan.  With a PPO when you see the doctor for the same situation; your copay would pay for the consultation.  The X-Ray costs and cortisone shot fee would all go towards your annual deductible.  PPO copays typically only pay for the consultation.  If a visit is considered “preventive care,” an annual physical, screenings, colonoscopy, etc. If the visit is “medically necessary” the doctor would not consider it “preventive,” and the insurance company would charge you accordingly, which would most likely go towards your annual deductible.

Preventive Care … If your visit is for an annual physical.  Your doctor usually charges $150 for an appointment, but in this case the charge is covered at 100%, no copays or out of pocket costs.  During the physical your doctor says you should get your cholesterol checked from the lab withing the same building, this is still considered Preventive and is covered by insurance.

Some PPO’s (Preferred Provider Organization) offer plans with unlimited office visit co-pays, other plans have a limited number of co-pays per year, such as three or five, after they are used you simple pay the cost of the visit.  And others offer no office visit co-pays.

Value for your money.  There are so many plans and companies available today, I understand how comparing plans can be a chore.  I’m here to help.  Within a few minutes I will be able to narrow down the list of plans to just a few for your review.  Making the comparison process much more manageable.  So feel free to call anytime with your question or comments.  I look forward to hearing from you.

Have questions or would like more details, please contact me anytime.

John Conner

Medicare Plan Options ... Medicare Supplement, Medicare Advantage, Medicare Part D Rx