Charge Amount (Cost Share) Business Logic

PPO (Non-HSA) Subscriptions 

The copay is always charged to the participant for initial visits until the out of pocket (OOP) max is met.

When the participant has not met their OOP max:

• The participant pays 100% of the copay amount, up until the OOP max is met. Once the OOP max is met, the participant pays 0.

• If the remaining OOP Max is greater than 0 but less than the Copay amount, the participant pays an amount that equals the remaining OOP max (e.g lesser of two $$ values).

HSA Subscriptions

This section contains the 98point6 ContractedRate + Deductible Awareness check.

If the deductible is met, the participant pays a contracted rate * coinsurance %, up to a maximum out of pocket cost:

• Participant pays 100% of the 98point6 contracted rate until the deductible is met.

• If the remaining deductible is greater than 0 but less than the contracted rate, the participant pays the (remaining deductible) + (contracted rate - remaining deductible)*Coinsurance %.

• If the remaining deductible = 0, the participant pays the (contracted rate)*Coinsurance %.

• All spend is subject to the OOP max. If the remaining OOP max = 0, the patient pays 0. 

• If the remaining OOP max is greater than 0 but less than the (calculated patient cost), the patient pays the (remaining OOP max).