You’ve been paying toward your health plan deductible all year. Then your employer changes insurance carriers. Do you have to start over? Not necessarily. A deductible credit may allow the new plan to recognize eligible amounts already applied to your previous plan’s deductible.
Here’s how deductible credit forms work, when to ask for one, and what employers and employees should know before changing coverage.
What is a deductible credit?
A deductible credit is an adjustment that applies eligible deductible amounts from a previous health plan toward the deductible on a new plan. It is not a payment or refund. It changes how much of the new plan’s deductible has been satisfied.
Example: Your employer switches carriers on July 1. You have $1,200 applied to your old plan’s deductible, and the new plan has a $2,000 deductible. If the new carrier approves a $1,200 credit, you would generally have $800 left to meet under the new plan, before any new eligible claims. Actual results depend on the plan’s rules and how the carrier applies the credit.
When might a credit be available?
A common situation is an employer changing insurance carriers during the year while continuing to offer coverage to the same group. Depending on the new carrier and plan, credits may also be available in other transitions. Changing employers, moving from individual coverage, or joining a plan as a new hire may be treated differently.
Ask before assuming. A credit is not automatic in every transition. Eligibility, approved amounts, deadlines and whether individual or group submissions are accepted depend on the carrier, plan, funding arrangement, state and circumstances. Check the new plan’s deductible accumulation period too: a January 1 effective date may coincide with a reset, but plan-year and calendar-year rules vary.
Does the out-of-pocket maximum transfer too?
Sometimes. The deductible and out-of-pocket maximum are separate accumulators. Some plans will consider credit for both; others may credit the deductible only or apply different rules to medical and prescription costs. A deductible credit does not automatically mean the same amount will be credited toward the out-of-pocket maximum.
Eligible copays and coinsurance can count toward an out-of-pocket maximum even when they do not count toward the deductible. Premiums generally do not count toward either. Ask how in-network and out-of-network amounts and any separate pharmacy deductible will be handled.
How to request a credit
- Confirm eligibility. Ask the new carrier, employer or Sapper Insurance whether credit is available, which accumulators qualify and what deadline applies.
- Get the new carrier’s instructions. It may accept a group report from the prior carrier, an individual form, or another documented process. Do not assume enrollment alone starts the transfer.
- Gather documentation. Request a deductible and out-of-pocket accumulator report or an explanation of benefits (EOB) from the prior carrier showing the amounts applied during the relevant period. The new carrier may need separate figures for each covered family member.
- Submit securely. Use the new carrier’s approved portal, secure upload, mail or other specified method. These documents may contain sensitive health information.
- Verify the credit. Check the new carrier’s member portal or call member services. If a claim was processed before the credit was applied, ask whether it should be reviewed or reprocessed.
Claims from the old plan may still be processing after the switch. Ask the prior carrier for updated totals once those claims are finalized, and ask the new carrier how to submit any additional eligible amounts before its deadline.
What about family coverage?
Family plans may track both individual and family deductibles or out-of-pocket limits. The new plan may use a different structure from the old one. Obtain each covered person’s totals when available, and ask the new carrier how it will apply them to the new plan’s individual and family limits. Do not simply assume the old family total will transfer dollar for dollar.
Premera and Kaiser deductible credit forms
Premera: Use the Premera deductible and out-of-pocket credit form to provide information for the employee and covered family members, together with an EOB or qualifying report from the prior carrier.
Kaiser Permanente Washington small group: Use the Kaiser deductible and out-of-pocket crediting form. The form requests the latest prior-carrier EOB showing amounts for each covered family member and states that it must be returned within 60 days of the group’s effective date.
Confirm with the new carrier that the form and submission instructions are current and appropriate for your specific plan.
Regence and UnitedHealthcare
For Regence and UnitedHealthcare (UHC), members submit an explanation of benefits (EOB) from the prior carrier to request deductible credit; a separate deductible credit form is not required. Ask the new carrier for its current submission instructions, deadline, eligibility requirements and whether out-of-pocket credit is available for your specific plan. The EOB should show the applicable amounts for each covered family member.
A few questions worth asking
- Does our change qualify, and is the credit automatic or by request?
- Will the new plan credit both deductible and out-of-pocket amounts, including prescriptions?
- Is a group accumulator report available, or must each family submit documentation?
- What is the deadline, and what happens to claims that arrive before credit is posted?
- How will late claims and individual versus family amounts be handled?
Changing plans is complicated enough. Sapper Insurance can help you understand the transition and identify the right carrier process. Contact our team or call 425-363-4300.
This article is general information. Credit is subject to the receiving plan’s terms, carrier procedures and applicable law; confirm your specific situation with the new carrier or plan administrator.