8.3 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 Allergy Testing, Ambulance, Diagnostic Testing, Disability, Durable Medical Equipment, ER Emergency, ER Routine, and Home Healthcare categories are unchanged from the base plan while Chiropractic has 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.
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 affects 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 affect 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.
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 maximum type in the drop down box.
The Maximum Type field specifies what kind of maximum is being applied, the amount set and the network tier it affects: the following:
Amount Paid by Plan - Caps the total amount the plan sponsor will pay over the course of a single plan year.
Length of Stay (Days) - Limits the combined length of stay to a number of days. Charges that surpass this limit become 100% member responsibility.
Number of Visits - Limits the number of claims or visits for the plan year.
The Network/Provider Tier specifies whether the maximum should apply to Network, Non Network, or All activity.
The Amount is the actual maximum quantity.
Click Add Maximum
NOTE: You can add multiple maximums to each benefit category. When any of the maximums are reached, the coinsurance rate becomes 0% plan sponsor, 100% member.
- To remove a Coverage Maximum, click the trash can to the right of the maximum.
Coverage Settings when Maximum Exceeded
This section allows for continued benefits after the maximum levels are exceeded. If "Not Covered" is checked, no more benefits are considered. If unchecked, it will allow for further copays, out of pocket maximums, coinsurances and whether dollars should apply to deductible once any of the maximums have been met.
This section allows you to either not cover or apply additional copays and whether they apply to out of pocket maximums, coinsurances, and whether dollars should apply to deductibles once any of the maximums have been met.
Once all changes to the benefit have been made, click Save Benefit Setting for the changes to be recorded.