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Patient responsibility

Some benefits require the patient to pay a portion of the cost of care, also known as patient responsibility. For example, a patient may have a co-payment for in-office visits.

Response shapes

Stedi returns one of two response shapes, depending on the endpoint you called. Both contain the same benefits information, organized differently. You can identify them by the top-level array that organizes the patient's benefits information - either plans or benefitsInformation.

Top-level arrayEndpoints
plansReal-Time Eligibility Check JSON
benefitsInformationBatch Eligibility Check, Insurance Discovery, Real-Time Eligibility Check Raw X12, Real-Time Eligibility Check JSON - Legacy

Every section on this page covers both response shapes, labeled plans and benefitsInformation. Select the label that matches the endpoint you called, and the page applies your selection to every section.

Where can I find patient responsibility?

Patient responsibility appears in the benefit entries for co-insurance, co-payments, deductibles, limitations, out of pocket, and spend down. These entries almost always include either an amount or a percentage that indicates what the patient owes.

Read the named arrays under plans[].benefits: coInsurance, coPayment, costContainment, deductible, limitations, outOfPocket, and spendDown. Each entry's amount or percent property contains the patient's responsibility.

The following example shows three different types of patient responsibility:

  • Co-payment: The coPayment entry shows that the patient's co-payment for pharmacy services is $10 for in-network providers.
  • Deductible: The deductible entry shows that the patient's deductible for general medical services is $1,000 per calendar year for in-network providers.
  • Co-insurance: The coInsurance entry shows that the patient's co-insurance for out-of-network dental care is 0% for CDT procedure code D0150 (comprehensive oral evaluation).
"plans": [
  {
    "benefits": {
      "coPayment": [
        {
          "amount": "10",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "88",
            "definition": "Pharmacy"
          },
          "network": { "indicator": "IN_NETWORK" }
        }
      ],
      "deductible": [
        {
          "amount": "1000",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "30",
            "definition": "Health Benefit Plan Coverage"
          },
          "network": { "indicator": "IN_NETWORK" },
          "timePeriod": "CALENDAR_YEAR"
        }
      ],
      "coInsurance": [
        {
          "percent": "0",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "CDT",
            "value": "D0150"
          },
          "network": { "indicator": "OUT_OF_NETWORK" },
          "dates": {
            "latestVisit": { "start": "2024-04-04" }
          }
        }
      ]
    }
  }
]

Service history

Some benefits have frequency limits. For example, "one visit every 6 months" or "two cleanings per year." Others depend on when the patient last received the service. If the patient has already reached the allowed frequency, the next visit may not be covered. In that case, they may owe the full amount.

Frequency limits show up in responses for dental, vision, and Medicaid. They also apply to some medical services, like annual wellness visits or therapy sessions.

Some plans, especially dental, apply shared frequency limits across a group of procedures. For example, a plan can allow one X-ray series per year, regardless of the procedure code used later in the claim. When the plan has already paid a claim for one of the codes in the group, it can deny later claims for the others.

To estimate patient cost for these types of benefits, you need two additional pieces of information from the benefit entry:

  • When the service was last performed.
  • How often the plan allows the service, such as once every 6 months or twice per year. Many payers don't populate this and instead return the information as free text in the payer's freeform messages.
  • The last date of service is in dates.latestVisit.
  • The allowed frequency is in serviceLimits. Each object sets an ageMinimum, an ageMaximum, or a delivery object containing the quantity, frequency, and period. When a payer sends the information as free text instead, it appears in the benefit entry's messages array.

The following example shows a co-insurance entry for a dental exam. The plan allows one visit every six months, and their last visit was on April 4, 2024.

"plans": [
  {
    "benefits": {
      "coInsurance": [
        {
          "percent": "0",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "CDT",
            "value": "D0150"
          },
          "dates": {
            "latestVisit": { "start": "2024-04-04" }
          },
          "serviceLimits": [
            {
              "delivery": {
                "quantity": { "qualifier": "VISITS", "value": "1" },
                "period": { "qualifier": "MONTH", "value": 6 }
              }
            }
          ]
        }
      ]
    }
  }
]

Types of patient responsibility

The following types of benefits indicate patient financial responsibility for care. Payers sometimes send a zero in the amount or percentage property when the patient has no responsibility.

If a particular benefit category isn't applicable to a plan, the payer often sends nothing for that category rather than explicitly sending a zero benefit. For example, if a health plan has 20% co-insurance for STC 98 but no co-payment, the response typically contains no co-payment entry for that STC at all.

Co-Insurance

Co-insurance represents the percentage of a benefit patients are responsible for covering themselves. For example, if a patient has met their annual deductible and their co-insurance is 20%, they would pay $20 for a treatment that costs $100. The amount of co-insurance can differ depending on whether a provider is in-network with the health plan.

Co-insurance appears in the plans[].benefits.coInsurance array. Entries always include a value in percent.

The following example shows 20% co-insurance for in-network emergency services.

{
  "coverageLevel": "EMPLOYEE_ONLY",
  "network": {
    "indicator": "IN_NETWORK"
  },
  "service": {
    "value": "86",
    "definition": "Emergency Services",
    "system": "STC"
  },
  "messages": ["Emergency Room"],
  "percent": "0.2"
}

Co-Payment

A co-payment is a fixed dollar amount a patient must pay for a benefit. For example, a patient may have a $10 co-payment for a physician office visit. The amount of co-payment can differ depending on whether the provider is in-network with the health plan.

Co-payments appear in the plans[].benefits.coPayment array. Entries always include a value in amount.

The following example shows a $25 co-payment for in-network chiropractic care.

{
  "coverageLevel": "EMPLOYEE_ONLY",
  "network": {
    "indicator": "IN_NETWORK"
  },
  "service": {
    "value": "33",
    "definition": "Chiropractic",
    "system": "STC"
  },
  "messages": ["Chiropractic"],
  "amount": "25"
}

Cost Containment

Cost containment refers to rules a health plan has in place to control the cost of care. Payers typically include it in the eligibility response when the patient has Medicaid coverage. The amount represents the total the patient must pay out of their own pocket before their benefits begin.

Cost containment appears in the plans[].benefits.costContainment array. Entries always include a value in amount.

Deductible

A deductible represents the total amount the patient will have to pay out of their own pocket before their benefits begin. For example, if a patient's deductible is $1,000, they will have to pay $1,000 for covered services before the health plan will start to pay. Then, the patient will typically pay part of the cost of services (such as co-payments) until they reach their out-of-pocket maximum.

Though behavior can vary by payer, the deductible entry is often included twice in the response for a given coverage level, service type, and network status. One reports a time period like calendar year, meaning the value is the patient's total annual deductible. The other reports a remaining time period, meaning the value is the patient's remaining deductible (annual deductible minus what they've already spent for the calendar year).

Deductibles appear in the plans[].benefits.deductible array. Entries always include a value in amount, and the time period is in timePeriod.

The following example shows a $700 in-network deductible for the calendar year.

{
  "coverageLevel": "INDIVIDUAL",
  "network": {
    "indicator": "IN_NETWORK"
  },
  "service": {
    "value": "30",
    "definition": "Health Benefit Plan Coverage",
    "system": "STC"
  },
  "messages": ["Benefit does apply to member's out-of-pocket maximum"],
  "timePeriod": "CALENDAR_YEAR",
  "amount": "700"
}

No deductible for specific benefits

Some health plans list an annual deductible amount while offering a subset of benefits with a zero deductible. The most common case is preventive care benefits, which the Affordable Care Act usually requires health plans to cover with no deductible or co-payment. For example, a High Deductible Health Plan (HDHP) may have a $3,000 annual deductible, but cover an annual wellness visit at no cost.

For benefits with a zero deductible, the patient isn't required to pay any amount out of pocket before coverage begins, regardless of whether they've met their annual deductible amount. Note that a zero deductible doesn't necessarily mean that the patient pays nothing - their health plan may still require a co-payment or co-insurance for the benefit type.

Payers may indicate that a specific benefit has a zero deductible by including a deductible entry with the amount set to 0. Alternatively, they may send a message indicating that the patient has no deductible: in the entry's messages array for the plans shape, or in benefitsInformation[].additionalInformation[].description for the benefitsInformation shape.

No annual deductible

If the payer doesn't include a deductible entry at all, you can generally assume that the patient has no annual deductible. This behavior is common with group HMO plans, which sometimes rely only on co-insurance or co-payment for cost control, but it can also occur with other types of health plans.

Medical payers are required to return deductible information for service type code 30 (Health Benefit Plan Coverage), so if the first eligibility response for another service type code doesn't include deductible information and you suspect that a deductible may still apply, then we recommend running another eligibility check for service type code 30.

Example

In the following example, one entry shows that the patient has $500 remaining to meet their annual deductible, and the other shows that their annual deductible is $1,000.

In the following example:

  • The first entry shows that the patient has $500 remaining to meet their annual deductible (timePeriod = REMAINING).
  • The second entry shows that the patient's annual deductible is $1,000 (timePeriod = CALENDAR_YEAR).
"plans": [
  {
    "benefits": {
      "deductible": [
        {
          "amount": "500",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "30",
            "definition": "Health Benefit Plan Coverage"
          },
          "network": { "indicator": "IN_NETWORK" },
          "timePeriod": "REMAINING"
        },
        {
          "amount": "1000",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "30",
            "definition": "Health Benefit Plan Coverage"
          },
          "network": { "indicator": "IN_NETWORK" },
          "timePeriod": "CALENDAR_YEAR"
        }
      ]
    }
  }
]

Limitations

Dental and vision plans often use this benefit type to specify an annual maximum benefit amount.

The Affordable Care Act prevents most commercial health plans from imposing limits on annual or lifetime benefit amounts. This generally doesn't apply to government health plans, and some commercial health plans are exempt, so we recommend checking for limitations across all plan types: medical, dental, and vision.

Limitations appear in the plans[].benefits.limitations array.

The following example shows a $2,000 annual maximum benefit amount.

{
  "coverageLevel": "INDIVIDUAL",
  "network": {
    "indicator": "IN_AND_OUT_OF_NETWORK"
  },
  "service": {
    "value": "30",
    "definition": "Health Benefit Plan Coverage",
    "system": "STC"
  },
  "timePeriod": "CALENDAR_YEAR",
  "amount": "2000"
}

When present, limitations can include an amount that indicates the maximum benefit allocated to the patient. The payer often (but not always) includes a message like "ANNUAL MAXIMUM".

The following example shows a sample response from a dental payer. The patient has an annual maximum benefit for dental care of $2,500.

"plans": [
  {
    "benefits": {
      "limitations": [
        {
          "amount": "2500",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "35",
            "definition": "Dental Care"
          },
          "network": { "indicator": "IN_NETWORK" },
          "timePeriod": "CALENDAR_YEAR",
          "messages": ["ANNUAL MAXIMUM"]
        }
      ]
    }
  }
]

Out of Pocket (Stop Loss)

This benefits type doesn't apply to most dental plans.

Out of pocket, also called stop loss, represents the maximum amount a patient can pay per year. Once the patient reaches this limit, the health plan pays 100% of the allowed amount for covered services unless some other coverage limitation applies, such as a limitation. For example, if a health plan has a limit of 12 covered mental health visits per year, the patient may still be responsible for covering 100% of visits beyond that limit even if they have met their out-of-pocket maximum.

Most health plans are required to set an out-of-pocket maximum, but health plans with provider networks can have unlimited patient responsibility for out-of-network care. When the response contains no out-of-pocket entry at all, the payer indicates that the out-of-pocket maximum is unlimited.

Out-of-pocket maximums appear in the plans[].benefits.outOfPocket array. Entries always include a value in amount.

The following example shows a $3,000 in-network out-of-pocket maximum for the calendar year.

{
  "coverageLevel": "INDIVIDUAL",
  "network": {
    "indicator": "IN_NETWORK"
  },
  "service": {
    "value": "30",
    "definition": "Health Benefit Plan Coverage",
    "system": "STC"
  },
  "timePeriod": "CALENDAR_YEAR",
  "amount": "3000"
}

Spend Down

Spend down is a process that allows individuals with high medical expenses to qualify for Medicaid even if their income is above the Medicaid income limit. The spend down amount represents the total the patient must pay out of their own pocket before they can receive Medicaid benefits.

Spend down appears in the plans[].benefits.spendDown array. Entries always include a value in amount.

When do payers return patient responsibility?

Not all service type codes (STCs) require payers to return patient responsibility information. For example, health plans are required to support inquiries for the following STCs, but aren't required to return patient responsibility information for them.

  • 1 - Medical Care
  • 30 - Health Plan Benefit Coverage
  • 35 - Dental Care
  • 88 - Pharmacy
  • AL - Vision (Optometry)
  • MH - Mental Health

However, health plans regulated under HIPAA must return any applicable patient co-insurance, co-payment, or deductible amounts for the following service type codes.

  • 33 - Chiropractic
  • 47 - Hospital
  • 48 - Hospital Inpatient
  • 50 - Hospital Outpatient
  • 86 - Emergency Services
  • 98 - Professional (Physician) Visit – Office
  • UC - Urgent Care

These lists don't necessarily extend to dental or vision plans. Some payers may support returning patient responsibility information for additional STCs.

How much is left (accumulators)?

Benefit types, such as deductibles, usually include accumulator data, which indicates the amount of the benefit remaining for the calendar year. In fact, the federally mandated Phase II CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule requires HIPAA-covered health plans to return remaining deductible amounts for many commonly used service type codes (STCs), including 30 (Health Benefit Plan Coverage).

When present, accumulator information arrives as a separate benefit entry that reports the remaining amount rather than the full benefit.

The entry's timePeriod property is set to REMAINING.

The following example shows a deductible entry for health benefit plan coverage (STC 30). The timePeriod of REMAINING indicates that this is the remaining amount, and the amount of 0 indicates that the patient has already met their deductible for the year. The network.indicator of IN_AND_OUT_OF_NETWORK indicates that this benefit isn't specific to in-network or out-of-network providers.

"plans": [
  {
    "benefits": {
      "deductible": [
        {
          "amount": "0",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "30",
            "definition": "Health Benefit Plan Coverage"
          },
          "network": { "indicator": "IN_AND_OUT_OF_NETWORK" },
          "timePeriod": "REMAINING"
        }
      ]
    }
  }
]

No Surprises Act

The No Surprises Act is a federal law that protects patients from surprise medical bills — especially in emergency situations or when they unknowingly receive care from out-of-network providers. Under NSA, patients also have the right to a good faith estimate for non-emergency care if they're uninsured or self-pay.

The No Surprises Act bans surprise billing (also known as balance billing) in these situations:

  • Emergency Services: Even if patients go to an out-of-network hospital or ER, they only have to pay in-network cost-sharing. This includes services at freestanding ERs and urgent care centers licensed to provide emergency care.
  • Non-Emergency Services at In-Network Facilities: If patients go to an in-network hospital or surgery center, but an out-of-network provider (like an anesthesiologist or radiologist) treats them, they can't be charged more than their in-network rate.
  • Air Ambulance Services: Patients are only responsible for their in-network rate.

Does the NSA apply?

Payers don't typically note when the NSA applies to a patient's plan in the eligibility response. However, the NSA applies to most health plans, including fully insured and self-funded employer plans. It doesn't apply to:

  • Ground ambulance services
  • Medicare, Medicaid, TRICARE, or VA patients because these programs already have their own strong balance billing protections
  • Some people with health care sharing ministries or short-term limited-duration plans
  • Some unlicensed or unregulated providers

Balance Billing Protection Act

The Balance Billing Protection Act (BBPA) is a Washington state law that protects patients from unexpected medical bills (also known as balance billing) when they receive care from out-of-network providers. It's similar to the No Surprises Act, but it applies specifically to Washington residents with state-regulated plans. It doesn't apply to self-funded employer plans unless they opt in.

The BBPA protects patients from balance billing in the following situations:

  • Emergency services, even if patients are treated by an out-of-network provider or at an out-of-network facility.
  • Non-emergency services at an in-network hospital or ambulatory surgical center when patients are unknowingly treated by an out-of-network provider (like an anesthesiologist or radiologist).

In these cases, the patient only pays their normal in-network cost-share (deductible, co-payment, co-insurance), and the provider must work out the rest with their insurer.

Does the BBPA apply?

When the BBPA applies to a patient's health plan, payers are required to note this on coverage status entries. In the plans shape, these are entries in plans[].benefits.statuses. In the benefitsInformation shape, they're objects with a benefitsInformation[].code of:

  • 1 (Active Coverage)
  • 2 (Active - Full Risk Capitation)
  • 3 (Active - Services Capitated)
  • 4 (Active - Services Capitated to Primary Care Physician)
  • 5 (Active - Pending Investigation)
  • 6 (Inactive)
  • 7 (Inactive - Pending Eligibility Update)
  • 8 (Inactive - Pending Investigation)

In these cases, you see one of the following messages. The plans shape returns it in the entry's messages array, and the benefitsInformation shape in benefitsInformation[].additionalInformation[].description.

Services provided to this patient are subject to the Balance Billing Protection Act. Please see RCW 48.49.020 for details.

Services provided to this patient are subject to the No Surprises Act. Please see RCW 48.49.020 for details.

The following example shows a coverage status entry with the BBPA message included.

"plans": [
  {
    "benefits": {
      "statuses": [
        {
          "status": "ACTIVE_COVERAGE",
          "coverageLevel": "INDIVIDUAL",
          "service": {
            "system": "STC",
            "value": "30",
            "definition": "Health Benefit Plan Coverage"
          },
          "planCoverageDescription": "Open Access Plus",
          "messages": [
            "Complete Care Management",
            "Services provided to this patient are subject to the Balance Billing Protection Act. Please see RCW 48.49.020 for details."
          ]
        }
      ]
    }
  }
]
Provider network status, authorizations, referrals
STCs and procedure codes

On this page

Response shapesWhere can I find patient responsibility?Service historyTypes of patient responsibilityCo-InsuranceCo-PaymentCost ContainmentDeductibleNo deductible for specific benefitsNo annual deductibleExampleLimitationsOut of Pocket (Stop Loss)Spend DownWhen do payers return patient responsibility?How much is left (accumulators)?No Surprises ActDoes the NSA apply?Balance Billing Protection ActDoes the BBPA apply?