7.3 Benefit Category Plan Design Options
A Benefit Category is a specific area of plan coverage that may include features different from the plan's base options. The Benefit Category Settings screen allows you to customize copay and coinsurance rates, deductible and out-of-pocket maximum settings, and complex plan maximums on a per benefit category basis.
By default, each benefit category uses the base plan options configured under Global Settings. In the example below, we see that the Ambulance, Chiropractic, Diagnostic Testing, and Durable Medical Equipment categories are unchanged from the base plan while Allergy Testing and Disability have been customized:
Each category can be customized for both Network and Non Network usage. This is typically referred to as Preferred and Non Preferred in Summary Plan Design (SPD) documents.
Editing Category Settings
To edit the settings for a specific category, click the category's name in the list. The following screen is displayed:
Category options can be customized for both Network and Non Network use.
Copay - A per charge deductible that must be met by the member before the plan sponsor begins paying coinsurance. Note that configuring a copay value does not imply that the benefit is covered at 100% - the coinsurance value should be adjusted for 100% plan coverage in these cases.
Copay applies to out-of-pocket max - Specifies whether copayment should count toward the member's out-of-pocket expenses. This effects the calculation of the member's out-of-pocket maximum.
Coinsurance - The percentage of eligible charges paid by the plan sponsor after member deductible and copay. Select Not Covered if the plan does not include coverage for the benefit category.
Waive deductible - Specifies that the member's deductible need not be reached for the plan to begin paying coinsurance. This is often used in combination with a copay value or when the plan fully covers a benefit.
Waiving the deductible does not effect the copay value. When the deductible is not waived and a copay is set, the member is required to hit their deductible before copayment begins. When the deductible is waived, copayment begins on the first charge.
Once category settings have been configured, you may edit coverage maximums or save changes and go back to the category list by clicking the Save Benefit Settings button.
Configuring Coverage Maximums
Benefit maximums create limits on the amount a plan sponsor will pay, per family, per plan year, for a specific benefit category. Maximums can be used to limit the plan sponsor's liability or to discourage certain types of activity by creating a payment barrier.
To add a maximum, select a Type, Status, and Amount, and click the Add button:
You can add multiple maximums to each benefit category. When any of the maximums is reached, the coinsurance rate becomes 0% plan sponsor, 100% member.
The Type field specifies what kind of maximum is being set and may be one of the following:
Dollars - Caps the total amount the plan sponsor will pay over the course of a single plan year.
Per Incident - Caps the total amount the plan sponsor will pay for a single charge. The sponsor pays at the configured coinsurance rate up to this limit, at which point the member assumes responsibility for remaining payment.
Days - Limits the combined length of stay to a number of days. Charges that surpass this limit become 100% member responsibility.
Visits - Limits the number of claims for the plan year.
Status specifies whether the maximum should apply to Network activity, Non Network, or All activity.
The Amount is the actual maximum quantity. The pull-down includes basic values as well as a Custom Value option that allows free form input.