Defining Eligibility Rules

This chapter provides overviews of eligibility rules and how changes in job data affect eligibility and discusses how to:

• Set up eligibility rules.

• Set up geographic location eligibility rules.

Understanding Eligibility Rules

You use eligibility rules to:

• Determine the benefit program for which each employee is eligible.

• Determine eligibility for each plan option within a benefit program.

• Set up the system so that a participant can be eligible for only one benefit program at a time.

• Define eligibility based on a wide range of personal and job information, as well as geographic location.

After you define the eligibility rule, attach it to your benefit program at the program or plan option level using the Benefit Program table.

Note. For federal users: For Thrift Savings Plans (TSPs), if you want to link an eligibility rule to a TSP option, create a separate eligibility rule to be used exclusively for TSPs.

Never attach the same eligibility rule and geographic eligibility table combination to the program level of more than one benefit program; otherwise, employees will be eligible for more than one benefit program.

For an employee to be deemed eligible for participation in a plan or program covered by an eligibility rule, the employee must meet all of the parameters set for that rule. When defining an eligibility rule, you define the criteria, as well as an indicator that tells the system whether meeting the criteria makes the employee eligible or ineligible.

If you want to define an eligibility rule for a program that is available to employees in the 48 contiguous states but not Hawaii or Alaska, you can select the state criteria to set up the parameter. The system looks at each employee's home address, and makes the employee eligible for the benefit program if he or she lives in one of the 48 contiguous states. A faster way to define this same rule is to say that if the employee lives in Hawaii or Alaska, he or she is ineligible for the benefit program.

The PeopleSoft Benefits Administration software provides 27 different criteria fields (plus two federal-specific fields) that you can use to determine employee benefit eligibility. Nine of these criteria fields can be user-defined to meet the organization's needs. In addition to the Location field, these other criteria fields are available:

• Age

• Benefit Status

• Eligibility Config 1− 9

• EmplID Override

• Employee Class

• Employee Type

• FEHB Indicator (federal employee health benefits)

• FLSA Status (Fair Labor Standards Act)

• FTE (full-time equivalency)

• Full/Part Time

• Medicare

• Officer Code

• Pay Group

• Regular and Temporary

• Regulatory Region

• Retirement Plan (Federal)

• Salary Grade

• Service Months

• Standard Hours

• State

• Union Code

As you work with PeopleSoft Enterprise Benefits Administration, times will occur when eligibility rules are improperly configured. You can troubleshoot eligibility problems by using the Benefit Administration Eligibility Debugging tool, which shows you exactly where an individual employee fails and passes program and plan option eligibility checks during the Benefits Administration process.

See Also

Understanding the Benefits Administration Process

Understanding How Changes in Job Data Affect Eligibility

Actions occur that change an employee's job status and can affect his or her benefits eligibility, such as taking Family Medical Leave Act (FMLA) leave, being terminated, or changing from full-time to part-time employment.

When employee actions occur, two employee status values can be affected: Employee Status and Benefits Status. PeopleSoft Enterprise Human Resources (HR) and PeopleSoft Enterprise Payroll use Employee Status for a variety of functions. Benefits Status, on the other hand, is used only by Benefits Administration and does not conflict with HR and Payroll (North American) operations. This enables you to define employee status in benefits terms without being constrained by HR or Payroll (North American) requirements.

Use the Action Reason table to tell the system how to set Benefits Status by means of the Benefits Employee Status field. The Action Reason table provides the freedom to determine which status values you need and which action changes will trigger a change to benefits status values. Once you've defined your Benefits Employee Status values, you can use Benefits Status on the Eligibility Rules table. You can also change the available Benefits Status values directly through the Translate table.

The following diagram illustrates how the system sets Benefits Employee Status by matching the action and action reason on the Job row to the action and action reason in the Action Reason table. If the Job row does not have an action reason, the system matches the reason to the entry in the Action Reason table that has a matching action and the lowest action reason value within that action.

Process flow for how the system sets Benefits Employee Status by matching the entry in the Action Reason table

The system carries Benefits Employee Status forward from the preceding Job row if the Benefits Employee Status field on the Action Reason table is blank or if no entries are in the Action Reason table that match the action on the Job row. Thus, certain action values and action reason values, such as Hire, Terminate, and Leave of Absence can explicitly affect the Benefits Employee Status while others, such as Transfer, Job Reclassification, and Demotion might not.

See Also

Defining Personnel Actions and Reasons

Setting Up Eligibility Rules

To set up eligibility rules, use the Base Eligibility Rules (BAS_ELIG_RULES_GBL) component.

This section discusses how to:

• Define Benefits Administration eligibility parameters.

• Use modified eligibility parameters.

• Change eligibility flags.

Pages Used to Set Up Eligibility Rules

Defining Benefits Administration Eligibility Parameters

Access the Eligibility Rules Table page (Set Up HRMS, Product Related, Automated Benefits, Eligibility and Event Rules, Eligibility Rules Table, Eligibility Rules Table).

This page contains an Eligibility Field group box from which you can select specific eligibility fields to maintain. When you select the View icon from the Eligibility Field group box for a field, another group box appears with a list of all eligibility fields available that can make up this eligibility rule.

If the check box to the right of a field in the Eligibility Field group box is selected, it indicates that the field is currently being used by the eligibility rule.

The fields in the following list are common to many of the group boxes that appear.

Age

Use this group box to how the system is to calculate the employee's age during eligibility processing.

Benefits Status

Eligibility Config 1 − 9

EmplID Override

Employee Class

Use this group box to define an employee's benefit eligibility based on the employee's employee class. Add more than one classification by inserting a row.

Employee Type

Use this group box to define an employee's benefit eligibility based on whether the employee is salaried or hourly. You can add more than one by inserting a row.

FLSA (Fair Labor Standards Act) Status

Use this group box to define an employee's benefit eligibility based the employee's FLSA Status. Select the status from the list. You can add more than one by inserting a row.

FTE (Full-Time Equivalency)

Full/Part Time

Use this group box to determine an employee's benefit eligibility based on the employee's full-time or part-time status.

Location

Use this group box to define an employee's benefit eligibility based on the location of the employee's home or office. Enter more than one setID and location code by adding a row.

Medicare

Use this group box to define an employee's benefit eligibility based on the employee's medicare status. Enter more than one medicare code by adding a row.

Officer Code

Use this group box to define an employee's benefit eligibility based on the employee's position within the organization. Enter more than one officer code by adding a row.

Pay Group

Regular and Temporary

Use this group box to define an employee's benefit eligibility based on whether the employee is a regular or temporary employee.

Regulatory Region

Use this group box to define an employee's benefit eligibility based on the regulatory region associated with the employee. Enter more than one region by inserting a row.

Salary Grade

Use this group box to define benefit eligibility based on the employee's salary grade. Enter more than one salary grade by adding a row.

Service Months

Use this group box to define employee benefit eligibility based on the employee's months of service. Select how the system is to calculate years of service during eligibility processing. The starting date is the employee's Service Date, as defined on the Job Data - Employment Information page.

Standard Hours

State

Union Code

Use this group box to define an employee's benefit eligibility based on the union to which the employee belongs. You can enter more than one code.

Using Modified Eligibility Parameters

You can add modified eligibility parameters for your company. PeopleSoft Benefits Administration offers nine configurable fields for your use. These fields are delivered blank. Set them up by using PeopleTools and PeopleCode.

The following sections provide examples of ways to use the eligibility configuration fields.

Grandfathering In Coverage

A company signs a new contract with the union. Under the new agreement, existing employees can continue their benefits at the existing rates. New employees hired after the signing date will pay higher premiums.

Start by copying the existing benefit program to create a program for the new employees. Put the new, higher rates on the new program. Existing employees will stay in the old program, and new employees will be in the new program. You could use months of service for eligibility, but you would have to keep adjusting the eligibility rules every month.

To solve this problem, make Eligibility Config Field 1 the grandfather setting. Set it to Y for all existing employees. New hires have the value set to N. You can use the default on the record definition to make this work automatically.

You then set eligibility in the old benefit program to include only employees with Y in Eligibility Configuration Field 1. Set the new benefit program to include only employees with N in Eligibility Config Field 1. This enables you to segregate the populations and keep them separate going forward.

Handling Mergers

Company X buys companies A, B, and C and merges the common departments. To make the merger easier on the newly merged employees, company X enables them to retain their old benefits for the first three years.

Set up separate benefit programs that emulate the different companies' benefit offerings, and place the employees into the appropriate benefit programs. To differentiate between employees, make Eligibility Configuration Field 1 the company setting and set it to A for former company A employees, B for former company B employees, and C for former company C employees. Also set Eligibility Configuration Field 1 to X (or some other value) for all existing company X employees, and make the default X for all future employees. The final step is to change the program eligibility for employees to fall into the appropriate benefit programs.

Configuring Eligibility Based on Values of a Single Field

This example illustrates situations in which the eligibility configuration field emulates data that is not currently part of delivered eligibility.

A manufacturing company wants to use shift assignment in the determination of short-term disability (STD) eligibility. People on the company's third shift do plant maintenance work that is more hazardous than the assembly work performed by employees on the first and second shifts. The company wants to offer third-shift workers a plan with higher benefits.

Unfortunately, shift assignment is not part of the delivered eligibility process. You can solve this problem by setting Eligibility Configuration Field 1 equal to the Shift value. Keep the fields synchronized using Field Change PeopleCode. Anytime the Shift field value changes, the PeopleCode moves the new Shift value to Eligibility Configuration Field 1. Now the Shift value can participate in eligibility.

Configuring Eligibility Based on the Values of Multiple Fields

This example illustrates situations in which the eligibility configuration field emulates data that is not currently part of delivered eligibility.

A company determines long-term disability (LTD) eligibility using a combination of salary plan, grade, and shift assignment. The calculation is complex, because the values of salary plan and shift influence what grades qualify for benefits. Even if you could get the fields into the eligibility process, you would then have to change the COBOL programs to evaluate the three fields together.

Instead, use PeopleCode to perform the evaluation. The PeopleCode that you design looks at the three fields and places a Y in Eligibility Configuration Field 1 if the employee should have LTD. It places N in Eligibility Configuration Field 1 if the employee should not have LTD. Set the eligibility table for LTD to include only employees with Y in Eligibility Configuration Field 1. Now you have a complex eligibility formula in an easily maintained place with no changes to the COBOL programs.

Using Existing Fields to Reduce the Number of Values

A convenience store chain bases dental eligibility on an employee's location, but they have hundreds of locations across the country.

You can use PeopleCode to parse the location code and place the two relevant characters into Eligibility Configuration Field 1. Then base dental eligibility using Eligibility Configuration Field 1, not Location. This reduces the number of entries in the eligibility table. It also simplifies maintenance of the tables because new locations will automatically fit right into the eligibility scheme.

Using Existing Eligibility Fields to Delay Job Data Changes

An organization uses both location and home postal code to determine medical eligibility. An employee transfers from one location to another in February, but does not want to move the family until summer, when school is out. During this time the employee wants to keep the old medical coverage. The organization permits this and does not change the employee's home address until the summer, but the organization cannot delay the change of location, and changing the location makes the employee ineligible for the old coverage.

To solve this situation, perform these steps:

1. Add a new field to the Job table called Manual Location Override. Put it on the Job pages near the Location field.

2. Add Save Edit PeopleCode to the Location field. The PeopleCode copies the value of Location to Eligibility Configuration Field 1 when Manual Location Override is N. It leaves the value in Eligibility Configuration Field 1 alone when Manual Location Override is Y. Then set eligibility to use Eligibility Configuration Field 1 instead of Location.

3. Change the location code to the new location and select the Manual Location Override option. The PeopleCode leaves Eligibility Configuration Field 1 alone, and the employee can remain in the old coverage.

4. When the employee finally moves the family, the user inserts a new row and deselects the Manual Location Override check box. The PeopleCode copies the location to Eligibility Configuration Field 1. This changes eligibility and the system solicits the employee for the medical plans at the new location.

If you leave a field blank, the system assumes that all possible categories are eligible for that field and does not allow Ineligible to be selected.

Changing Eligibility Flags

At the processing level, the Eligibility Rules table is made up of a set of tables: a primary table and numerous secondary tables. The primary table is linked to the Eligibility Rules table. It consists of the eligibility rule effective date, status, and descriptions. The secondary tables are linked to the eligibility field scroll bars list on the Eligibility Rules Table page. A separate subordinate table exists for each listed eligibility field.

The primary table has a hidden internal flag for each of the secondary tables. The flag indicates to the system whether data is in the secondary table. The processing system uses this flag to determine whether to read the secondary table, thereby improving performance.

If all you need to do is define an eligibility rule, select the Benefit Status, Full and Part Time, and Regular and Temporary parameters. The system selects the Benefits Status, Full and Part Time, and Regular and Temporary options and deselects the rest. The system reads these flags and knows that it has to read only three tables to get all the eligibility information for the BAS rule instead of checking 29 tables only to find data in three of them. The system properly maintains these flags when you use the supplied pages. Some customers, however, use modified programs and scripts to populate their eligibility rules. In cases like these, the flags may be set incorrectly, resulting in slower performance or, even worse, inaccurate eligibility.

PeopleSoft Benefits Administration supplies a script, BAELIGLD.DMS, that sets all the flags correctly. Run this script in Data Mover anytime that you update the eligibility rules outside of the delivered pages. You can run this script as often as you want.

Warning! If you plan to use modified programs and scripts to populate the tables linked from the Eligibility Rules table, you will need to run BAELIGLD.DMS to reset the eligibility processing flags on the primary eligibility table.

Setting Up Geographic Location Eligibility Rules

To set up geographic location eligibility rules, use the Geographic Location Elig Table (GEOG_LOCN_TABLE) component.

This section provides an overview of geographic location eligibility rules and discusses how to enter geographic location rules.

Understanding Geographic Location Eligibility Rules

You can define eligibility for a benefit program or plan according to the postal code of the employee's home and work location. This table describes how the system uses postal ranges to determine employee eligibility:

Note. Users can specify the outcome of the evaluation for each of the preceding scenarios, that is, whether passing the criteria means the employee is eligible or ineligible.

Pages Used to Set Up Geographic Location Eligibility Rules

Entering Geographic Location Rules

Access the Geographic Location Elig Table page (Set Up HRMS, Product Related, Automated Benefits, Eligibility and Event Rules, Geographic Location Elig Table, Geographic Location Elig Table).

Based On	Select the location that you want evaluated by this set of postal code ranges. Select from the following values: Home: The employee must reside in the displayed postal codes or postal code ranges to pass. Location: The employee must work in the displayed postal codes or postal code ranges to pass. Both: The employee must both work and live in the displayed postal codes or postal code ranges to pass. Either: The employee must either work or live in the displayed postal codes or postal code ranges to pass.
Eligible or Ineligible	Tells the system how to interpret a match with the criteria. If the employee's data matches (passes) the criteria, the system determines whether to make the employee eligible or ineligible for benefits.
Group Method	Appears if you have activated the Multiple Jobs feature. This enables you to choose which jobs to include when the system evaluates the employee's benefit eligibility. Select from the following values: All Flagged Jobs: Group all jobs for all benefit record numbers. Flagged Jobs in Benefit Record: Group all jobs within the current benefit record number. Primary Job in Benefit Record: Look at only the primary job within the current benefit record number.
Evaluation Method	Appears if you have activated the Multiple Jobs feature. This field enables you to define how the jobs selected from the grouping method are evaluated against the eligibility field. Select from the following values: One or More in Group: At least one job must satisfy the rule. All in Group: All jobs must satisfy the rule.
Consider Active Jobs Only	This field appears if you have activated the Multiple Jobs feature. If this field is selected, the system does not look at a job that has a terminated employee status when evaluating the employee's benefit eligibility. If the group method is Primary Job in Benefit Record, this check box is automatically selected and cannot be changed.
Beginning of Range andEnd of Range	Use the Location Range group box to define specific postal codes to be evaluated. Enter the beginning and end of the range. To specify a particular postal code, enter the same postal code in both fields. To specify a range, change the last postal code number. In the United States, you can mix 5-digit codes with 9-digit codes.