Creating a Coverage Policy for Employer Memberships

Creating a coverage policy for employer memberships allows employers to cover part of the costs for procedures and items. Follow these steps to configure an employer coverage policy in SigmaMD.

Setting up coverage for a Hint Connect employer? See Setting Up Hint Connect Members for the setup we recommend.

Step 1: Navigate to Coverage Policies

Go to Billing > Memberships > Coverage Policies.
Click Coverage policy and select Employer.

Step 2: Define the Coverage Policy Rules

Policy Name: Choose a name for the coverage policy.
Select Employer: Choose one employer for this policy.
Membership Plan: Only memberships associated with the selected employer will be displayed. Select one or more plans to include.

Create Rule

Charge Item, Phlebotomy fee or Shipping
- Charge item:
  - Category: Apply coverage to a specific category or select "All categories."
  - Items: Apply coverage to a specific item or select "All items." Each item shows its location, or All locations.
- Phlebotomy fee: Apply coverage to the phlebotomy fee.
- Shipping: Apply coverage to shipping charges.

Price Adjustment

No price adjustment: This rule doesn't change the price, so a broader category or All items rule can still apply.
Discount of: Apply a percentage discount to selected items/categories.
Surcharge of: Add a dollar amount to selected items/categories.
Replace price with: Replace the dollar amount on selected items/categories.

Employer Coverage

No employer coverage: This rule doesn't set employer coverage, so a broader category or All items rule can still apply.
Employer covers up to: The employer will cover costs up to the defined percentage or dollar amount of the selected items.
Employee pays up to: The employee will pay costs up to the defined dollar amount of the selected items.

Step 3: Saving and Viewing Policy Rules

Click Add rule, and the rule appears under All Rules on the right. Each rule needs a price adjustment, employer coverage, or both.
Multiple rules can be created per policy.
When more than one rule could apply to the same item, the most specific rule takes effect: a rule set on an item at a specific location overrides a rule for the same item at all locations, an item rule overrides a category rule, and a category rule overrides a rule set on all items.
This applies no matter which direction the rule moves the price. A surcharge or a replacement price set on a specific item overrides a discount set on that item's category, even though the patient pays more as a result.
When two rules are equally specific, the rule that costs the patient less is applied.

Patient Invoice View

When an item falls under a coverage policy, hovering over the unit price will display the applied policy values.
If the employer covers a portion of the cost, the displayed amount reflects the patient’s portion after employer coverage.

Employer Invoice View

When an invoice is generated for the employer’s billing cycle, a table below the invoice will display:
- Memberships charged to the employer.

Charge items covered by the policy, along with corresponding values.

Creating an employer coverage policy allows seamless cost-sharing between employers and patients. If you need further assistance, contact SigmaMD support.