Best Practices for Setting Up Eligibility in a Benefits Hierarchy

Setup effort and operating performance vary depending on where you define eligibility requirements within the benefits object hierarchy. This example illustrates best practices.

You can use the eligibility pages in the Setup and Maintenance and Plan Configuration work areas to define eligibility requirements at:

• Three levels when configuring programs: program, plan type in program, and plan in program

• Two levels when configuring plans: plan not in program and option in plan

The following figure shows the eligibility determination hierarchy with components organized from top to bottom, general to detail.

When evaluating eligibility requirements, detail-level requirements augment general-level requirements, rather than overriding them. Therefore, you associate successively restrictive requirements as you move down the hierarchy.

Wellness Program Example Scenario

Your organization is creating a wellness program that's for current and retired employees only. The program hierarchy includes the following configuration:

• Two plan types: medical and recreational.

• Two plans within the recreational plan type:

  • A headquarters plan that provides access to an on campus recreation facility.

  • A field plan that includes options for three national franchises. One franchise restricts membership to the female workers.

You want to set up eligibility to achieve the following results:

• Only retired and current workers can participate in the Wellness program.

• All retired and current workers who live near headquarters can use the on-campus fitness facilities.

• All retired workers and any current workers who don't live near headquarters can join off-campus fitness facilities.

• Only retired and current female workers who don't live near headquarters can join Fitness Franchise C.

Eligibility Requirement Setup

You create the Wellness benefit offering and attach eligibility for the program, plans, and options based on the following criteria:

• Employment status

• Location

• Gender

The following figure shows the resulting eligibility determination hierarchy for your Wellness benefit offering.

The following table identifies the specific eligibility requirements at each level in the hierarchy.

Level	Eligibility Profile Criteria
Program	Employment status that includes only current and retired workers for the Wellness program
Plan type in program	None for either plan type, Medical or Recreational
Plan in program	None for the HMO and PPO medical plans Location that includes persons living near headquarters for the Headquarters recreational plan Location that excludes current workers living near headquarters for the Field recreational plan Applying the location filter any higher in the hierarchy causes the criteria to affect medical plan participants, which you don't want.
Option in plan	None for the Fitness Franchise A and Fitness Franchise B options Gender that includes only females for the Fitness Franchise C option Positioning the gender filter at this level ensures that it affects only the Fitness Franchise C.

This strategy reduces processing time because the eligible population for consideration diminishes as eligibility evaluation proceeds down the hierarchy. While you can attach an eligibility profile to each individual plan or option, that approach is much less efficient in terms of setup and performance.

Resulting Eligibility

John is a retired worker who still lives near headquarters who meets the criteria described in the following table.

Level	Criteria	Resulting Eligibility
Program	Employment status	John can participate in the Wellness program.
Plan in program	Location on the Headquarters plan	John can use the on-campus fitness facility.
Plan in program	Location on the Field plan	John can join a national fitness franchise

John doesn't meet the option in plan level gender criteria, so he can't join Fitness Franchise C.