Procella HelpdeskThe Deductible Method indicates how the deductible will be applied to the member and if the deductible is accumulated on one or more family members.
Edit Name: This is the unique Name for this edit.
Message Group: This allows the addition of a message to be assigned to this edit, triggering each time the edit is used.
Deductible Method:
The Deductible Method indicates how the deductible will be applied to the member and if the deductible is accumulated on one or more family members.
- Individual: The deductible is accumulated and applied to each individual member.
- Family: The deductible is accumulated and applied to each Family unit. All family members contribute to a single deductible.
- Individual & Family: There is a deductible for each member and for the entire Family unit. Once the Family deductible is met by any combination of Family members, no other members are required to pay a deductible amount. Individual members may hit their Individual deductible before the Aggregate (Family) deductible is met.
- Family # to Meet: The number of Family members required to reach their Member deductibles before deductibles are considered satisfied for all Family members. In this method, the number of members to meet their individual deductible must be satisfied as well as the family deductible before the family has no additional deductible to satisfy.
- Coverage Based: The cardholder coverage type is used to determine the deductible. If the coverage type is for only one member (subscriber only, spouse only, one dependent), the Individual/Member deductible is applied. All other coverages (reflecting 2 or more family members) will contribute to meet the Family deductible.
Deductible, Member $: The deductible amount applied to the Member. When the Member reaches this amount, no additional deductible is required for them. This field is active when the Deductible Method is: Member, Member & Family, or # to Meet.
Deductible, Family $: The deductible amount applied to the Family. All Member’s within a Family Unit contribute to the Family deductible. This field is only active when the Deductible Method is Family.
Members to Meet: The minimum number of family members who need to meet their individual deductible before the Family deductible will be considered satisfied. This field is only active when the Deductible Method is # to Meet.
Deductible Period:
Deductible Period Types:
- Rolling: This type of period accumulates for a fixed period (months) and then restarts for another fixed period of the same length. As an example, a deductible may be every 3 months and the date of service is July 11th. The deductible period begins on the Date of Service of the first claim for the member that meets the criteria for the deductible and the accumulation is based on the preceding 3 months (April 11th through July 11th). A Rolling period is only available for an INDIVIDUAL deductible method.
- Fixed: This type of period has a start date and an end date. There is no rolling over. It can be considered a one-time event.
- Term (No Roll Over): The Term period has a defined start date and then a defined number of months.
- Term (Roll Over): The roll over means that any amounts applied to the previous year’s deductible during the last X months may be used in the current period’s deductible IF the deductible was not met. If the deductible for last year was met, no roll over amounts will be credited.
- Term (Restricted Roll Over): Restricted Roll Over means that any roll over amounts are good for only a specified number of months. For instance, the term may be the last 3 months of the last benefit year and is used for the first 4 months (restricted) of the current benefit year. If the deductible for last year was met, no roll over amounts will be credited.
- Lifetime: This type of period has a beginning date and no end date associated with it.
The typical Deductible Period is a TERM (No Roll Over). This type has a start date and a set number of months.
Start Period: The date the deductible period starts. This should not be confused with the start and end date of the EDIT (if implemented). The START period is used for the following Deductible Periods:
- Fixed
- Term (all 3 types)
- Lifetime
End Period: For the FIXED deductible period, this is the specific end date for the deductible.
Duration in Months: The number of months (for all periods except FIXED and Lifetime).
Use Proration: This is a checkbox. The method by which the Proration is used is managed at the Group/Plan level. Before using Proration in production, ensure comprehensive testing ensuring its performance is in line with expectations.
The following are only made available when the Deductible Period is Term/Restricted Roll Over or Term/Roll Over.
- Prior Roll Over Months: The number of months in the prior year that will be considered for the current benefit year deductible due to Roll Over.
- Current Roll Over Months: For Term/Restricted, the number of months from the beginning of the current benefit period the roll over amounts are eligible.
Processing
Default and Advanced Processing allows control over how accumulations, in this case, deductibles, are summed. In most cases, Default Processing will satisfy the business requirements. Advanced Processing allows capturing of data in different buckets. For instance, if Mail and Retail90 In-Network deductibles were needed, this would be defined here.
Best practice is to test the setups in the test environment to ensure outcomes are as expected.
