Domestic Out of Pocket Deductible Credit

Domestic Out of Pocket Deductible Credit

What is Out of Pocket (OOP) Deductible Credit?

Deductible credit and Coinsurance (Out of Pocket) credit applies to calendar-year plans for group-to-group takeover for individuals on the prior group plan, for overlapping benefit periods.

It is the money paid out-of-pocket each year before medical plan coverage begins. Each family member usually has a separate deductible to meet.

A member’s out-of-pocket maximum paid in the same calendar year will be credited to the new plans’ out-of-pocket maximum.


Eligibility and Submission Process

Members of a new group plan that has transferred its coverage from another insurance carrier with no gap in coverage are eligible.

Members who want to receive credit for OOP Deductible and Coinsurance paid under the prior carrier should submit a copy of the Explanation of Benefits (EOBs) to Aetna no later than 90 days after the effective date.

EOBs may be submitted through:

  • The initial submission, with the first claim;
  • Fax to claims at 1-866-474-4040 with the subject, “Deductible/Coinsurance (Out of Pocket) Credit Request - ECHS Category: SFRE” and the Group/Control Number in order to direct the information to the correct area for processing.

To avoid delay, make sure to include the SSN on the EOB or on the deductible credit form.

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