> ## Documentation Index
> Fetch the complete documentation index at: https://docs.getsolum.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Benefit Terms

> Deductibles, out-of-pocket maximums, and the 'applies' flags captured during a verification of benefits — what each field means and how it affects patient cost

# Benefit Terms

When Solum verifies a patient's coverage — through an eligibility check (270/271 transaction) or a verification of benefits (VOB) — the results reach the patient's payor record once the check is matched to a patient. Automatic eligibility checks perform that match on their own; a manually run check stores its extracted result first, and the payor is created or updated when you use **Match to Patient**. This page defines the benefit terms behind those fields and explains how each one changes what the patient actually pays.

Deductible, OOP max, copay, and coinsurance — along with the per-service flags below — are captured separately for **in-network** and **out-of-network** benefits. Only the deductible and OOP max carry both a **total** for the plan period and a **remaining** balance; copay and coinsurance are single values. The two plan-level flags described below cover the whole plan and have no separate in-network and out-of-network settings.

***

## Core amounts

| Term            | Definition                                                                                                                                                                                                                                                                                                       |
| --------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Deductible**  | What the patient pays before the plan starts sharing costs. Until it's met, the patient pays the full allowed (contracted) amount for services that are subject to it.                                                                                                                                           |
| **OOP Max**     | The out-of-pocket maximum — the cap on what the patient pays in a plan year. Once met, the plan pays 100% of covered services for the rest of the year/contract — with one exception: a copay that doesn't apply to the OOP max keeps being charged (see [Copay Applies to OOP Max](#copay-applies-to-oop-max)). |
| **Copay**       | A fixed dollar amount the patient pays per visit or service (e.g., \$30 per session).                                                                                                                                                                                                                            |
| **Coinsurance** | A percentage of the allowed amount the patient pays after the deductible is met (e.g., 20%).                                                                                                                                                                                                                     |

Deductibles and OOP maxes each come in **Individual** and **Family** variants. Both reset every plan year, and premiums never count toward either.

***

## Per-service flags: Deductible Apply and OOP Apply

These two flags appear in the service rates table, per service and service location. They answer: *does this rule touch this specific service?*

### Deductible Apply

* **True** — for this service, the patient pays the full allowed amount until the deductible is met; only then does cost-sharing (copay/coinsurance) kick in.
* **False** — benefits start from visit one, typically with just a copay.

True generally means higher upfront cost for the patient; false means the plan helps from day one.

### OOP Apply

* **True** — this service's costs count toward the OOP max and stop once it's met.
* **False** — this service lives outside the OOP system. Any patient charges for it never cap, even after the patient hits the plan's OOP max through other services.

When the service carries ongoing cost sharing (a copay or coinsurance), False is the worse outcome for the patient: those charges have no ceiling over the year. False is *not* a bad sign on its own — a service with no copay and no coinsurance, where neither the deductible nor the OOP max applies, is simply covered at 100% with no cost share, so there is nothing to accumulate.

***

## Plan-level flags: what feeds the OOP max

These two flags appear under **Plan Coverage Details** on the payor record. They answer a different question: *which payments accumulate toward the OOP max?*

### Deductible Applies to OOP MAX

* **True** — every dollar paid toward the deductible also counts toward the OOP max.
* **False** — the deductible fills up separately, and the OOP max can only be met with copays and coinsurance.

<Note>
  **Example** — plan with a \$1,000 deductible and a \$2,000 OOP max, 20% coinsurance after deductible:

  * If **True**: after the patient pays the \$1,000 deductible, only \$1,000 of OOP max remains.
  * If **False**: after paying the same \$1,000 deductible, the full \$2,000 OOP max still remains — it can only be chipped away with copays and coinsurance.

  True is better for the patient; false makes the cap real but harder to reach.
</Note>

### Copay Applies to OOP Max

* **True** — copays count toward meeting the OOP max.
* **False** — copays live outside the OOP system: they don't help meet the max, and in practice they keep being charged even after the OOP max is met.

<Warning>
  A copay that doesn't apply to the OOP max is the exception to "OOP met = everything free." Deductible and coinsurance stop once the max is reached, but that copay continues every visit, all year.
</Warning>

***

## Why these four flags aren't redundant

The per-service flags and the plan-level flags are independent:

* **Deductible Apply / OOP Apply** say whether a rule touches *this service*.
* **Deductible Applies to OOP MAX / Copay Applies to OOP Max** say what *feeds the OOP counter*.

A plan can require the deductible for a service (Deductible Apply = True) while that deductible money does **not** accumulate toward the OOP max (Deductible Applies to OOP MAX = False). Both questions have to be verified separately.

***

## Notes

* **Blank means not verified.** All four flags are three-state: Yes, No, or blank. Blank means the question wasn't confirmed during the verification — Solum never assumes a flag "applies," because the answer significantly changes the patient-cost math.
* **Automatically populated where possible.** Eligibility responses fill in the amounts (deductible, OOP max, copay, coinsurance, remaining balances); the "applies" flags typically come from the verification of benefits.
* **Manually editable.** Every field can be set or corrected from the patient's payor record.