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  1. FHIR Specification Feedback
  2. FHIR-31349

Support for 'deductible-waived' (Medicare)

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    • Change Request
    • Status: Published (View Workflow)
    • Medium
    • Resolution: Persuasive with Modification
    • US Da Vinci Drug Formulary (FHIR)
    • 1.0.1
    • Pharmacy
    • Formulary Drug
    • Hide

      Add code to both http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS and http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS

      Defined as 

      code: deductible-waived
      display: Deductible Waived
      copay definition: The consumer pays the copay with deductible requirement waived.

      coinsurance definition: The consumer pays the coinsurance with deductible requirement waived.

      Show
      Add code to both http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CopayOptionVS  and  http://hl7.org/fhir/us/davinci-drug-formulary/ValueSet/CoinsuranceOptionVS Defined as  code: deductible-waived display: Deductible Waived copay definition: The consumer pays the copay with deductible requirement waived. coinsurance definition: The consumer pays the coinsurance with deductible requirement waived.
    • Corey Spears / Jean Duteau: 12-0-0
    • Enhancement
    • Compatible, substantive

    Description

      Ref:  zulip post from Courtney Bland (Aetna)

      So for example, the deductible is $1000. The consumer is interested in a Preferred Generic drug. That drug tier has the deductible waived and a copay of $10. What that means is that the consumer doesn't have to meet its deductible before paying the copay of $10 and that $10 ends up applying to the deductible. The definition of before deductible is: The consumer first pays the copay, and any net remaining allowed charges accrue to the deductible. That doesn't fit this situation. In this situation, the copay goes towards the deductible. The net remaining doesn't go towards the deductible. 

      Yes, this is an industry standard for Medicare and differs from QHP, I believe. We have the same issue with coinsurance. The deductible can be waived on a tier with coinsurance. The coinsurance will contribute to the deductible in the same way as copay, even when the deductible is waived. I think a deductible waived flag would ideal as opposed to using text because it is not a rare condition for Medicare. Before deductible for the copay option seems to be meant for another scenario in which the customer pays the copay and the remaining charges go to the deductible. Using that option gives people the wrong impression. The coinsurance option value set doesn't really have anything that applies. Alternatively to adding a new option, maybe, the value sets could be made extensible. Thank you.

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              saul_kravitz Saul Kravitz
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                Updated:
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