FHIR Chat · Cost Share Follow-up Question · Da Vinci PDex Drug Formulary

Stream: Da Vinci PDex Drug Formulary

Topic: Cost Share Follow-up Question

Kate Dech (Mar 22 2021 at 17:39):

What is the guidance for populating coinsurance rate (required) when there is only a copayment amount for a tier/pharmacy type? Likewise, what should be populated for copayment money amount when there is only a coinsurance?

There is a coinsurance option of "no charge" but that can be misconstrued as meaning there is no charge to the member. (And the definition of this is that deductible doesn't apply, not that there isn't a value.)

There is a difference between a $0 copayment and null copayment. Likewise, 0% coinsurance could be interpreted as "no patient pay" (and 100% looks like full member pay). Can we use the no data absent extension to explicitly state there is no copayment amount or coinsurance?

Also, have there been any discussions about scenarios where there is both a copayment and coinsurance where comparators are needed for less of/greater of applies?

@Bapi Behera , @Mona O

Saul Kravitz (Mar 22 2021 at 18:36):

@Dave Hill @Corey Spears

Kate Dech (Mar 25 2021 at 13:33):

Here's some additional information to consider..
A coworker sent me a link to public information about Finder.HealthCare.gov and their APIs for rendering health plans available outside the Health Insurance Marketplace (non-qualified plans) but they appear to follow much of the structure of the QHP data dictionary for sending HIOS plans to CMS. https://finder.healthcare.gov/#services/version_3_0
If you look at their last example (getSMGPlanBenefits Samples), they have a plan with (+) copay amounts and no coinsurance. The coinsurance rate is not included and the coinsurance option is 'no charge'. They also have a value for just 'flat copay' (first highlighted example) for a tier that isn't subject to the deductible (while the second tier is).
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Saul Kravitz (Mar 25 2021 at 15:05):

@Corey Spears

Last updated: Apr 12 2022 at 19:14 UTC