Procella Helpdesk

EDIT - Member Out of Pocket

The Member Out of Pocket is the accumulator to capture the totals that the member paid.  Many of the options will be consistent with other accumulation edits such as deductible.  There are some additional options, though, that enable certain data to be included or excluded from the MOOP accumulations.

Edit Name is the unique name for the edit.

Message Group is the assigned Message group to be captured each time the edit is used.

Claim Type

All, POS, DMR

Override Global Settings

Below are the standard financials that the Patient Pay Amount may include.  Some of the amounts, though, may not be considered part of the out of pocket accumulations for specific business reasons.  For instance, if the member selected a Brand when a Generic was available, there may be an amount attributable to the DAW (Product Selection/Brand Drug) that should not be considered towards the OOP.  Here is where excluding the DAW Penalty from the OOP setting is established.  


With the switch on for Product Select/Brand Drug, those amounts will be excluded from accumulating in the Member Out of Pocket amount.


Maximum Accumulation

Accumulation Method

  • Individual:  The Member Out of Pocket Maximum is accumulated and applied to each individual member.
  • Family:  The Member Out of Pocket Maximum is accumulated and applied to each Family unit.
  • Individual & Family:  There is a Member Out of Pocket Maximum for each member and for the entire Family unit.  Once the Family Member Out of Pocket Maximum is met by any combination of Family members, no other members are required to pay a Member Out of Pocket Maximum amount.  Individual members may hit their Individual Member Out of Pocket Maximum before the Aggregate (Family) Member Out of Pocket Maximum is met.
  • Family # to Meet:  The number of Family members required to reach their Member Out of Pocket Maximum before Member Out of Pocket Maximum is considered satisfied for all Family members.
    • # to Meet:  The minimum number of family members who need to meet their Member Out of Pocket Maximum before the Family Member Out of Pocket can be considered satisfied.  This field is only active when the Accumulation Method is # to Meet.

 

Maximum, Member:  The Out of Pocket Maximum for the Individual 

Maximum, Family:  The Out of Pocket Maximum for the Family.

Members to Meet:  The number of individuals within the Family that must meet their Out of Pocket before the Family Maximum can be considered met.

Maximum Period

  • Period Type:
    • Term:  The Term period has a defined start date and then a defined number of months.
    • Rolling:  This type of period accumulates for a fixed period (months) and then restarts for another fixed period of the same length.  The maximum accumulation period begins on the Date of Service of the first claim for the member that meets the criteria for the EDIT.
    • Lifetime:  This type of period has a beginning date (Start) and no end date associated with it.
  • Proration: Check Box.  This indicates that the Proration rules in the Group/Plan setup should be used.

The other Proration settings are set at the Group/Plan level.  The Group/Plan settings will identify if the Proration is setup for the Plan or the Member and if it is Plan, the Start Date.  For Member, the start date will be the Subscriber’s coverage effective date.

  • Start Date:  The date a maximum accumulator starts.  Only for Term and Lifetime.
  • Duration, Length:  The length associated with the Period Type for the maximum accumulation.  This field reflects the number of months.  Only available for Term and Rolling.
  • Rollover Option: (only available for Period Type of TERM and Accumulation Method is Individual or Aggregate) Max, No Max.
    • Rollover Percent: (only if Rollover Option is Max or No Max) This reflects the percentage of the Periodic maximum (does not apply to Lifetime) that is eligible for Rollover. 
    • Rollover $ Max: (only for Rollover Option is Max) This reflects the maximum amount that is available for Rollover. When there is a value in both the Percent and $ Max, the $ maximum is compared to the Rollover Percent of the benefit Maximum.  If the Percent calculation is less than the maximum, the percent amount is rolled over.  If the Percent calculation is greater than the $ maximum, the $ maximum amount is rolled over.

Processing

  • Default (check boxes)
    • Include in Plan Accumulation
    • Use Plan Accumulation
  • Advanced
    • Include in Plan Accumulation (check box)
    • Use Plan Accumulation (check box)
    • Use Accumulation (check box)
    • Network Classification: All, In Network, Out of Network
    • Network Type: All, Retail, Retail 90, Mail, Specialty (multi select)

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