Section title: Requests for Interpretation
270/271 Ou of Pocket

Section 1.4.9 defines Out of Pocket as the maximum amount of the patient's portion of responsibility before a benefit if covered with no additional payments from the patient up to the maximum covered by the health plan. Additionally, it indicates out of pocket is typically the combined total of deductible and co-insurance payments made by the patient. If a payer offers a product which has a deductible of $xxx and 80/20 co-insurance with no max, how would a payer represent out of pocket? Additionally, it appears the concept of out of pocket is misleading. It does not appear to include co-payment amounts or dollar amounts a patient may owe if there is a benefit limitation.


In answer to the first question for “a product which has a deductible of $xxx and 80/20 co-insurance with no max”, no Out of Pocket would be reported in this case. Out of pocket is only reported when a maximum has been set by the plan. When the Out of Pocket maximum is returned, it should identify the period of time that the maximum applies to. The period of time could be identified with EB06 = 23 (calendar year), 22 (service year), etc. or with a DTP segment within the Out of Pocket 2110 EB loop. As noted in the guide, the description identifies the typical scenario used by most health plans when using Out of Pocket. The 5010 TR3 states “The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient”, it does not however exclude co-payment or other amounts not listed. This was previously addressed in HIR 785.

RFI Recommendation

Regardless of how a health plan calculates an Out Of Pocket amount, it is highly advised that the health plan also return the amount remaining for the Out of Pocket amount. Like all patient financial responsibility amounts, the remaining amount the patient is responsible for is much more important to the provider and patient than initial amount.

The remaining amount for Out Of Pocket would be returned as follows:

EB*G**30**GOLD 123*29*75~

This represents the patient's Out Of Pocket amount for the Health Benefit Plan Coverage in the Gold 123 plan remaining amount is $75.