Devil in the Details: Do Patients Pay a Copay on the Very Day Their DED is Met???

[jesseroads]

Hi all,
New member here. I've built a collections estimate calculator in excel as part of my job. We do intake for a number of treatment centers around the country and would like to accurately quote a caller on how much treatment will cost them, and the particular treatment center on how much they can expect to collect from insurance.

I'm stuck on one technical point. Let's say that a client's DED will be met part of the way through a particular service on a particular day. 32 minutes into receiving group therapy on a Tuesday, suddenly that client's DED is met! So, Does the client also pay a copay on that day? What if the DED is met after only 3 minutes in group therapy on that day... the client's payment for that day won't even meet the amount of the copay!

It's possible that different insurance companies handle this situation differently, but I'm hoping that there's a general rule, as I don't want to code that much into excel! Thanks to any replies!!!

 

[FLM2]

Hi all,
New member here. I've built a collections estimate calculator in excel as part of my job. We do intake for a number of treatment centers around the country and would like to accurately quote a caller on how much treatment will cost them, and the particular treatment center on how much they can expect to collect from insurance.

I'm stuck on one technical point. Let's say that a client's DED will be met part of the way through a particular service on a particular day. 32 minutes into receiving group therapy on a Tuesday, suddenly that client's DED is met! So, Does the client also pay a copay on that day? What if the DED is met after only 3 minutes in group therapy on that day... the client's payment for that day won't even meet the amount of the copay!

It's possible that different insurance companies handle this situation differently, but I'm hoping that there's a general rule, as I don't want to code that much into excel! Thanks to any replies!!!

Copays are generally paid before any deductible is met so isn't relevant to this.

Coinsurance is paid after the deductible is met. Once the deductible is met, any excess over the deductible is paid at the cost sharing rate. As an example, if the deductible was $2,000 and the patient had reached $1980 before a $75 outpatient treatment, the patient would pay the first $20 to reach the deductible and then the cost sharing would take over-if it were 80/20, the plan would pay 80% of the remaining $55 and the patient the other 20%.

 

[jesseroads]

Copays are generally paid before any deductible is met so isn't relevant to this.

Thanks, that was my thought too, but I've seen policies that require the DED to be met and then the client is required to pay copays until the OOP max is met. These aren't for "office visits" but for facility admits providing Intensive Outpatient Therapy (IOP) and above. Since IOP is 3 hours per session, 3-5 days per week, it's understandable that the insurance company wouldn't want to do it for just a $35 copay.

(a variation on this is that some "copays" are as much as 1k, now, for Residential treatment center services. Obviously this isn't per day or per session. Really this is more of an admit fee.)

 

[FLM2]

Thanks, that was my thought too, but I've seen policies that require the DED to be met and then the client is required to pay copays until the OOP max is met. These aren't for "office visits" but for facility admits providing Intensive Outpatient Therapy (IOP) and above. Since IOP is 3 hours per session, 3-5 days per week, it's understandable that the insurance company wouldn't want to do it for just a $35 copay.

(a variation on this is that some "copays" are as much as 1k, now, for Residential treatment center services. Obviously this isn't per day or per session. Really this is more of an admit fee.)

Call the insurance company that offers the plan, if you call three times you will get three different answers.

 

[Ann H]

FLM2 answered your question quite well. However, I think your real issue is with the out-of-pocket maximum rather than the deductible. Under the new ACA-compliant plans, the out-of-pocket maximum includes the deductible, co-insurance and copays. Under older pre-ACA plans, the out-of-pocket maximum most often does not include the deductible or copays, but instead refers to the end of your co-insurance. So, if a patient comes into your office and meets the deductible half-way through the day, but has not met the out-of-pocket maximum, they could still have to pay a copay or co-insurance percentage. Conversely, If they have meet the out-of-pocket maximum, AND if they have an ACA-compliant plan, their share of the costs for covered services ends at that point. For the remainder of the calendar year. Unless there are out-of-network charges, too. Or unless they have a grandfathered plan. Or a "grandmothered" pre-ACA plan that they are allowed to keep. Or certain large-group MEC plans that play by different rules.

Good luck with your Excel Spreadsheet. I've been a health insurance agent for 34 years, and my brain is fried over these details!