Co-payment is a type of payor program that is used when a client shares the cost of their care with another payor. Co-payment works well in many split billing scenarios where government funding or another type of coverage will cover up to a certain amount of the client’s care, and the client/guarantor is responsible for the rest of the cost.
In co-payment, the set of rules added to a program is referred to as a contract. Only one contract can be added to a program (in other words, sequencing multiple contracts so that different rule sets are in effect at the same time is not possible). However, you can still create different versions of the contract rules with different effective dates.
The benefit rules on contracts for co-payment programs are created using a term and, if necessary, a limit. The term represents the base rule for determining how much of a service’s cost should be billed to the payor. For co-payment , the term represents the fixed amount over a given frequency that will be covered by the payor on the contract. The limit imposes a cap on the term amount based on a set frequency. The possible limit types are amount, hours, or number of visits, all of which must be combined with a limit frequency.
The funder type of the guarantor can be client individual or funder individual for co-payment programs.
Creating a co-payment payor program for a client
Payor programs are set up at the client level.
You must be in a role configured with the View payor program and Manage payor program ACLs in Settings>Roles and permissions to view, add, and edit payor programs for clients.
To add a new program, go to Accounting>Payor programs on the client’s profile and select +Add program.
In the Add payor program dialogue, enter the Name of the payor program and select Co-Payment as the type.
Select a client individual or funder individual type funder to serve as the Guarantor.
If you select a funder of type client individual, you will also need to choose a Billing contact.
Check the box next to Apply taxes to guarantor if applicable. This setting will determine if taxes set at the bill code level should be applied to items billed to the guarantor. Note that you will only see this field if taxes have been enabled for this program type in your environment by your AlayaCare client services team.
Finally, select a Billing frequency for the program. In payor invoicing, the billing periods are determined by the billing frequency. The available frequencies are 1 week, 2 weeks, 4 weeks, and Calendar month. When you have finished, click Save.
The program will open as a new screen. Select Edit to make changes to the program details.
Adding a contract to the program
Once you have created a program, you can add a contract. The contract specifies the benefit rules that will be used to determine how billable items linked to the program are invoiced. To add a contract to the program, select +Add contract.
In the Add contract dialogue, complete the required fields.
Under Contract Details, select a funder to represent the Payor. You can select any enabled funder individual or client individual funders available to the branch that the client belongs to. If necessary, enter the Contract Number, Coverage Start and End Date, Reference Number, and Claim Number and fill out the Contact Details section. Use the Apply Taxes checkbox if you wish to apply taxes set at the bill code level to items covered by this contract.
Under Contract Rules, Amount will be pre-selected as the term Type. Select a term Frequency and enter the term Amount. The available frequencies are Per Hour, Per Day, Per Week, Per Calendar Month, Per Calendar Year, and Per Benefit Year. If you select Per Week as the frequency, you must also select a day for Start of Week.
If you select Per Benefit Year as the Frequency, you must also select the Month and Day of the Month on which the benefit year begins.
Example scenario for terms in amount: the amount specifies the maximum amount that the payor on the contract will cover for the length of time specified by the frequency. So if $400 is entered as the Amount and Per Week is selected as the frequency, when generating invoices for a week in which 3 visits valued at $200 each occurred, the payor will be invoiced $400 for the first two visits and the next payor or the guarantor will be invoiced $200 for the last visit.
After adding the term details, you can also add a limit to the contract. The limit can be an amount or a number of hours or visits over a specific frequency.
Note that when Amount is selected as the limit Type, the limit Frequency must always be larger than the term Frequency (Per Day < Per Week < Per Calendar Month < Per Calendar Year/Benefit Year). If the term has the maximum frequency selected (Per Calendar Year or Per Benefit Year), then you will not be able to select Amount as the limit Type.
Example scenario for limit in amount: The term amount is $50 per day and the limit is $100 per week, and the following visits occurred in one week (Monday visit: $120 and visit #2 cost $100). The payor will be invoiced $100 (because the total cost of both visits is over the weekly limit). The guarantor will be billed $120, the total remaining from both visits.
For limits in Hours, the frequencies Per Day, Per Week, and Per Calendar Month will be available to select.
Example scenario with a limit in hours: there are two visits in one week; visit #1 lasted 3 hours and cost $150 and visit #2 lasted 2 hours and cost $100. If the term is a fixed amount of $60 per hour, and the limit is 2 hours per week, the payor will be invoiced $120 for the first visit ($60 x 2h), and the guarantor will be billed the remaining amount of $130.
For limits in Visits, the frequencies Per Week, Per Calendar Month, Per Calendar Year, and Per Benefit Year will be available to select.
Example scenario with a limit in visits: The term is a fixed amount of $200/week and the limit is 2 visits/week, and there are two visits in one week (one on Monday charged at $120 and one on Wednesday charged at $100). The payor will be invoiced $120 for the first visit, and the guarantor will be invoiced $100 for the second visit, since the limit on the term has been reached.
If Per Week is selected as the limit Frequency, you will also need to specify a day as the Start of Week.
To set a deductible or elimination period on the contract, select an option from the Deductible applies dropdown.
To set an elimination period, select either Elimination by calendar days or Elimination by service days and then enter the number of days in the period.
To enter an amount, select Deductible amount and enter the value of the deductible.
In the Select Premiums field, click the + button to select one or more billing premiums configured in Accounting>Accounting settings>Premiums that should be fully covered by the payor on the contract. Note that premiums must be fully covered by either the payor or the guarantor (in other words, the cost of premiums cannot be split between two bill-parties if using a co-payment payor program).
When you have completed on required fields, click Save.
The program page will open with the contract details listed under Contract configuration. To make changes, select the Edit button.
If the contract has never been used to generate invoices, you will be able to edit all the informational fields.
If any draft or sent invoices exist against the contract, certain fields will be disabled for editing (Payor, Contract Number, and Coverage Start Date).
Adding a new version of a contract
If you need to change the benefit rules for a contract, you can create a new version of the contract. Note that versions cannot have any gaps or overlaps in terms of dates.
To create a version, click the +Add version button.
In the Add version dialogue, enter the effective Date on which the changes to the contract will apply. This date must be past the Coverage Start Date by at least one day. You will not be able to modify the term or limit Type, but you can make changes to the term Amount, term Frequency, limit value (Amount or Number of hours/visits) and limit Frequency or attach more premiums.
If more than one version of a contract exists, you will not be permitted to modify the Coverage Start Date. If Per Calendar Month is selected as the term frequency, note that the Coverage Start Date must be the first day of a month.
When you have finished, click Save to create the new version.
To edit or delete a version, select the downward arrow next to view and select Edit or Delete.
You will not be able to make changes if invoices have been generated for the version.
Note that having more than one version will lock the Coverage Start Date field for editing regardless of whether invoices exist against the contract.