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Back  RFI # 785: Out of Pocket Amt

Formal vs. Informal Help Informal Formal


Diana Sokolowski


What is the intent of the Out of Pocket amount ? Must is be a combination of the deductible and coinsurance ? The example within the 5010 documentation, 1.4.9 Business Usage - Patient Responsibility, Combinations of Patient Responsibility, lists separate amounts. We currently pass Coinsurance Max and Deductible Max separately. Must we combine them into 'Out of Pocket' or can we leave them separate. Please advise. Thanx...

Submitter Assigned Keywords

Out of Pocket


This issue is explicitly addressed in guide 005010X279. Section 1.4.9. defines Out of Pocket (Stop Loss) as different from coinsurance and deductible. It is "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." There may be an individual and a family Out of Pocket maximum under a specific contract. The out of pocket amount may be comprised of other patient responsibility amounts like coinsurance, co-payment and deductible.
Submission 5/15/2009
Status Date 7/9/2009
Status F - Final
Primary References
Document 005010X279
Set ID271
Segment IDEB
Element Position01
Industry NameBenefit Info Code
External Code List1390
Code ValueG