Eligibility Estimates: Examples

Yesterday, we talked about what an eligibility estimate is, and what the information within one means. Today we'll walk through some examples of eligibility estimates.

Here are three scenarios: 

Patient #1:

Has no deductible, no out-of-pocket max, and no additional co-payments. The patient is covered at 100%. No preferred care provider referral is required. There are no restrictions for the diagnoses, and there is no maximum visit limit. 

What this means: Your patient is fully covered for nutrition counseling services and the specific diagnosis you provided. He doesn't need to get a physician to refer him and can start seeing you anytime. 

Patient #2: 

Has a deductible of $200, of which $20 has been met. She has an out-of-pocket max of $1,000, of which $450 has been met. After the deductible is met, the patient is covered at 70% with no additional co-pay. After the out-of-pocket max has been met, the patient is covered at 100%. The patient needs a preferred provider referral for services. There are no diagnosis restrictions and no maximum number of visits allowed. 

What this means: The patient won't be covered at all unless she has a referral from her main physician. 

The patient needs to meet a certain amount ($200) before their insurance kicks in - this means she has to still pay $180 herself.

After she meets the $200 deductible, insurance will cover her nutrition counseling sessions for 70% of the cost. The 30% that she will pay herself goes toward her out-of-pocket max until she has paid $550 herself.

After she meets her out-of-pocket max, then insurance will fully cover her counseling sessions.

Patient #3: 

Has a deductible of $500 which has been met. His out-of-pocket max does not apply. After the deductible is met, there's a $20 co-pay each visit, but then the patient is covered 100%. There is no PCP referral required. The patient has diagnosis restrictions for diabetes or obesity. They are allowed 12 visits per contract year.

What this means: Since this patient has met his deductible of $500 already, he just needs to pay $20 each visit and then his insurance covers the rest. He doesn't need to be referred by a primary care physician, but he's only covered for counseling if he's diagnosed with diabetes or obesity. He's only covered for 12 visits each plan year- after he needs to pay out of pocket for any services. 

No matter what scenario you find, remember to ALWAYS get a reference number at the end of the call or make a note of the date and time you called. This can help with denied claims down the road. 


We tried to cover the most common scenarios with these examples. If you come across an unusual case that you think the Healthy Bytes community can learn from, feel free to post it in the comments and we'll do our best to answer.

But remember to follow HIPAA guidelines - PHI is strictly not allowed!