9Individual Health Policies
Individual Health Policies
This chapter describes individual health policies. It includes the following topics:
About Individual Health Policies
Individual health policies are insurance policies issued to individuals for themselves and their family members or dependents. Each individual health policy includes one primary member and might include additional members.
Each individual health policy offers one or more products, called policy coverages. Examples of individual health insurance products are HMO, PPO, dental, and vision coverage.
The Individual Health Policies screen allows end users to manage individual health insurance policies. Using the procedures given in this chapter, end users can generate quotes, accept applications, handling service requests, and process claims.
For more information on views common to all policy screens, see Common Policy Views.
Scenario for Health Insurance Quote and Application
This scenario features sample tasks performed by a licensed sales representative. Your company might follow a different workflow according to its business requirements.
In this scenario, a licensed sales representative for an insurance company is on the phone with a prospective customer who has called to request a quote for individual health insurance.
The sales representative adds information about the prospect and the prospect’s dependents (including coordination of benefits). The prospect requests a quote for PPO coverage, dental insurance, and vision insurance. The sales representative adds the products and reviews the product attributes. Next, he asks the prospect for enough information to provide an initial premium quote to the prospect. He gives the prospect a verbal quote and ends the conversation.
One week later, he receives an email message that the prospect has called back and would like to purchase a policy. In Siebel Healthcare, he adds information about coverages for each applicant according to the needs of the prospect. In this case, one of the dependents will receive both dental and vision coverage. Another will receive vision coverage only. Therefore, he associates the first dependent with both vision and dental, and the second dependent with vision only. Next, he schedules an activity as a reminder to call the prospect back with the revised premium information.
During the second call, he gathers information from the prospect in order to process the application. First, he performs a health risk assessment for each applicant. Then he adds billing and payment arrangements. Finally, he follows the procedures implemented by his company to submit the policy for issuance and billing.
In this scenario, end users are a sales representatives who manages customer requests. They enter information to:
Generate customer quotes
Add an applicant
Perform a health risk assessment
Convert a quote to an active policy
Associate a policy coverage with an applicant
Add a service request
Set up a payment plan
Add detailed payment information for a payment plan
Administering Individual Health Policies
The following administrator procedures are described in this section:
Adding Insurance Products and Product Lines
As an administrator, you can add products to the Siebel database. This section describes the procedure for setting up products and product lines in general terms. You can also specify that a product line is one that your company contracts agencies to sell, or that the state licenses agencies to sell, or both.
For more information about adding product and product lines, see Siebel Product Administration Guide and Siebel Applications Administration Guide.
To add an insurance product
Set up the product class structure, including product class attributes.
Add the products to the Siebel database and associate them with the appropriate class.
In the Category field in the Products list, select Individual Health Insurance.
Include the product in a product line.
Specifying Product Line Type
Use the following procedure to specify product line type.
To specify product line type
Navigate to Site Map, Administration - Product, and then Product Lines.
In the Product Line list, select the desired product line record and then check one or both of the following fields:
Contracting. To specify that the product line is one that your company contracts agencies to sell.
This product line will appear to end users as a choice in the Lines of Business dialog box in the Partners screen and then the Contracts view tab.
Licensing. To specify that the product line is one that agencies can be granted a state license to sell.
This product line will appear to end-users as a choice in the Lines of Business dialog box in the Partners screen and then the Licenses & Appointments view tab.
Adding Insurance Rate Bands
After you add a product in the Administration - Product screen, you can use the Administration - Insurance screen to associate a rate band with the product.
A rate band is pricing information about the deductible, the premium, and the payroll deduction for each insurance product.
To add a rate band
Navigate to Site Map, Administration - Insurance, and then the Health and Group Products.
In the Products list, select a product.
In the Rate Bands list, add a record and complete the necessary fields.
End-User Procedures for Individual Health Policies
The following end-user procedures are described in this section:
Providing Individual Health Policy Quotes
In Siebel Healthcare, a quote is a policy that has not been issued. End users can provide a quote for a new policy or make changes to an existing quote. The following procedure shows how to provide a quote for a new policy. The Individual Health Policies screen captures the information necessary to generate a quote. If a plan has predefined rates for individuals,Siebel Healthcare can access this information in two ways:
Using Siebel Pricer. For information, see Siebel Pricing Administration Guide.
Using an external table that your company has integrated with Siebel Healthcare.
To provide a quote
Navigate to the Individual Health Policies screen.
In the Individual Health Policies list, add a record and complete the necessary fields.
To add a new applicant:
Click the Applicants view tab.
Scroll down to the Applicants form and add a record.
In the Add Applicants dialog box, select an existing applicant or click New to add a new applicant.
If you select an existing contact who is not a member, the Coordination of Benefits field will not be hyperlinked to the Members and then the Applicants view.
- Repeat Step 3 for each new applicant that you want to add to this quote.
To select an existing contact:
Click the Applicants view tab.
Scroll down to the Applicants form and click the Show More button.
In the Applicants form, add a record.
In the Add Applicants dialog box, select a record and click OK.
Note: If you select an existing contact who is not a member, the Coordination of Benefits field will not be hyperlinked to the Members and then the Applicants view.To specify a contact as a member, select the Members check box.
After you save the record, the Coordination of Benefits value is hyperlinked to the Members then Applicants view.
If you plan to add records to the Coordination of Benefits field, select the Coordination of Benefits check box.
After you save the record, the Coordination of Benefits field changes to Yes.
Repeat Step 4 for each existing contact that you want to add to this quote.
Note: For information about Coordination of Benefits, see Adding Additional Benefits Coverage for Members.
In the Applicants list, select the record for the primary applicant for this quote and click the Primary field.
A check mark appears, indicating that this applicant is the primary applicant.
Note: If you do not select the primary field for one of the applicants, you will not be able to successfully add a product in the Policy Coverages view.Click the Policy Coverages view tab.
In the Policy Coverages product list, add a record and complete the necessary fields.
Repeat 6 and 7 for each product you would like to add for this applicant.
After end users generate the quote, the Primary field is automatically added. The quote for this applicant appears in the Premium Totals field in the Policy Coverages list.
Accepting Individual Health Policy Applications
Accepting applications requires adding applicants, performing health risk assessments for each applicant, and associating policy coverages with each applicant. If end users have already provided a quote for an application, they can begin by performing a health risk assessment for each applicant listed in the quote.
To add an applicant
Navigate to the Individual Health Policies screen.
Click the Applicants view tab.
In the Applicants list, add a record.
In the Add Applicants dialog box, perform the appropriate task:
To choose an existing record, select a record and click OK.
To add a new record, click New and complete the fields.
Note: The Primary field is filled automatically after you generate a quote.
Repeat Step 3 and Step 4 for each applicant you would like to add.
In the Applicants list, select the record for the primary applicant for this quote and click the Primary field.
A check box appears in the Primary field.
If the check box is empty, select it.
A check mark appears, indicating that the selected applicant is the primary applicant.
Performing a Health Risk Assessment
After end users add an applicant, they need to perform a health risk assessment for each one.
To perform a health risk assessment
Navigate to the Individual Health Policies screen.
In the Individual Health Policies list, select a record.
Click the Health Risk Assessments view tab.
The Health Risk Assessments form appears, showing the selected record.
Scroll down to the Risk Assessment form, add a record, and complete the necessary fields
Repeat Step 4 for each applicant.
Converting a Quote to an Active Policy
After end users complete the risk assessment, they can convert the quote to an active policy.
To convert a quote to an active policy
Navigate to the Individual Health Policies screen.
In the Individual Health Policies list, select a record.
Click the Applicants view tab and scroll up to the Individual Health Policies form.
In the Individual Health Policies, More Info form, change the following fields:
In the Status field, select Inforce.
In the Effective Date field, add the date that the policy will go into effect.
Associating Policy Coverages with an Applicant
After end users convert the quote to an active policy, they can associate policy coverages with an applicant.
To associate policy coverages with an applicant
Navigate to the Individual Health Policies screen.
Select the record in the Individual Health Policies list for which you would like to set up policy coverages.
Click the Member Coverages view tab.
In the Member Coverages product list, add a record, and complete the necessary fields.
Repeat Step 4 for each additional applicant.
Note: You can also use the Member Coverage Matrix view to select applicant and dependent coverages. However, the Member Coverage view must be used to associate a primary care provider. For additional information, see Changing the Primary Network or IPA for Members.
Adding Service Requests to Individual Health Policies
End users can add service requests for individual health policies. Examples of service requests are a change of primary care provider, a request for literature, or a question about an insurance claim.
To add a service request
Navigate to the Individual Health Policies screen.
In the Individual Health Policies list, select a policy.
Click the Service Requests view tab.
In the Service Requests list, add a record and complete the necessary fields.
Setting Up Pay Plans for Individual Health Policies
End users can use the Pay Plans view tab to set up pay plans for individual health insurance policies and to add details about payment methods and due dates.
To set up a pay plan for an individual health policy
Navigate to the Individual Health Policies screen.
In the Individual Health Policies list, select a policy, and click the Pay Plans view tab.
In the Pay Plan list, add a record and complete the necessary fields.
Scroll down to the Payment Details form and update the statement information.
In the Last Name field, click the select button.
In the Pick Contact dialog box, select a name and click OK.