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Back  RFI # 1566: 270/271 - OOP variations

Formal vs. Informal Help Informal Formal

Submitter

Beth Petermann

Description

The 5010 TR3 states that "The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient."

There doesn't appear to be a codifiable way to express when the above isn't true; for example, on policies when copayments also contribute to the out of pocket.

Is it advisable to return on the 271 a message stating which amounts contribute toward the out of pocket (e.g., "Benefit year deductible, coinsurance and copayments contribute to the out-of-pocket" or "Only coinsurance contributes to the out-of-pocket")

Submitter Assigned Keywords

OOP, Out of pocket, pocket

Response

Section 1.4.9 defines Out of Pocket (Stop Loss) as follows:
“Out of Pocket (Stop Loss) represents the maximum amount of the patient's portion of responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the individual patient and a higher amount for the entire family. The Out of Pocket (Stop Loss) amount is represented as a dollar amount in EB07. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in EB07. Negative numbers are prohibited.”

The description for Out of Pocket (Stop Loss) only indicates that this “typically represents the combined total amount of deductible and co-insurance payments made by the patient” but does not prohibit it from including other amounts such as co-payments (see RFI 785). Since co-payment amounts would likely only make up a very small portion of the OOP, not indicating that OOP includes co-payments would have minimal impact. Use of message text is not necessary to clarify what is and isn’t included in OOP.

If the OOP maximum has been met and the patient is no longer subject to co-payments (which would be the case if co-payments were part of the OOP), it would be appropriate to return 0 as the co-payment amount.

In the example where only co-insurance contributes to the out of pocket (OOP) maximum, it is unclear if the patient does or doesn’t have a separate deductible which would also have to be met in addition to the co-insurance maximum dollar amount is met. If there is no deductible at all, you would report 0 deductible and report the co-insurance maximum as the OOP amount. If there is a separate deductible and a separate co-insurance amount, you would report the deductible amount and you would add both deductible and co-insurance maximum amounts together and report this as the OOP maximum.

Recommendation

If you are returning OOP, you should be identifying the amount of OOP remaining, which has much greater value to the provider and patient than just the baseline OOP amount.
Submission 4/16/2012
Status Date 6/29/2012
Status F - Final
Primary References
Document 005010X279
Section1.4.9
Page35