Active Employee Coverage Membership

Oracle Revenue Management and Billing enables you to maintain an active employee coverage membership for the group insurance health plans and charge age based or tier based premium for the active employee coverage membership. An active employee coverage membership includes the employee or member of the organization who is covered under the group health insurance plan. Here, the covered employee or member is known as the main subscriber of the membership.

If the health insurance coverage is extended to the immediate family and/or other dependents of group members for an extra cost, the active employee coverage membership may include dependents who are related to the main subscriber. The system enables you to define various relationship types using which you can relate main subscriber and other dependent persons in a membership. You can define and edit relationship types through the Contract Relationship Type screen. The dependents can be members or non-members in an active employee coverage membership. The system calculates age based premium for both eligible members and non-members in an active employee coverage membership. If you select the Skip Non-Members option in the age based pricing rule type, the system will only consider the eligible members and not non-members of the active employee coverage membership during age based premium calculation.

The system enables you to create and edit an active employee coverage membership from the user interface, through a health care inbound message, or through the membership repricing inbound web service. While creating an active employee coverage membership, you must not set the membership type of the membership (i.e. leave the Membership Type field blank). Ideally, you must define an active employee coverage membership on a Commercial policy plan. However, at present, the system does not validate whether an active employee coverage membership is defined only on a Commercial policy plan and not on a Medicare Affiliated policy plan.

You can create an active employee coverage membership when you specify the main subscriber of the membership. Ideally, the main subscriber and dependent persons should exist as persons in the system before creating the active employee coverage membership from the user interface, through a health care inbound message, or through the membership repricing inbound web service. The system enables you to create the main subscriber, dependent persons, and active employee coverage membership through the same health care inbound message or through the same membership repricing request. In such case, the system will first create the person records for the main subscriber and dependent persons and then create the active employee coverage membership.

On creating an active employee coverage membership, the status of the membership and main subscriber is set to Active. On adding a dependent person to a membership, the status of the dependent person is set to Active. You can inactivate an active employee coverage membership from the user interface, through a health care inbound message, or through the membership repricing inbound web service. There are two ways in which you can inactivate the membership from the user interface:

  • On clicking the Inactivate button

  • On inactivating the main subscriber of the membership

However, through a health care inbound message or through the membership repricing inbound web service, you can inactivate the membership only by inactivating the main subscriber of the membership. On inactivating the main subscriber of an active employee coverage membership, the system automatically inactivates the membership and all other member persons which are included in the membership. The status of the active employee coverage membership, main subscriber, and other member persons (if any) is set to Inactive. In addition, the system does the following:

  • Cancels the billable charges which are created for the membership

  • Cancels the corresponding bill segments (if any)

If an audit event exists for the membership which is inactivated, the BO_​STATUS_​CD column corresponding to the record in the C1_​AUDIT_​EVENT, C1_​AUDIT_​EVENT_​LOG, and CI_​PRCE_​CALC tables is set to INVALID. If a repricing entity detail record exists for the membership in the PENDING or ERROR status, then the BO_​STATUS_​CD column corresponding to the record in the CI_​REPRC_​ENTITY_​DTL table is set to COMPLETE. If a repricing request exists for the membership in the PENDING or ERROR status, then the BO_​STATUS_​CD column corresponding to the record in the CI_​REPRC_​REQ_​DTL table is set to COMPLETE.

You can also inactivate a member person, who is not the main subscriber of an active employee coverage membership, from the user interface, through a health care inbound message, or through the membership repricing inbound web service. On inactivating the member person, the status of the member person is set to Inactive.

On terminating a fully-insured group policy, the status of all active employee coverage memberships on the respective policy plans is set to Terminated. Similarly, on reinstating a fully-insured group policy, the status of all active employee coverage memberships on the respective policy plans is set to Active.

The system requires the following information to create charges for an active employee coverage membership:

  • Whom to bill the active employee coverage membership charges

  • Age based or tier based pricing rules using which the premium should be calculated for the active employee coverage membership

  • Respective age based or tier based pricing rule type associated with the respective policy plan

The system supports the following billing arrangements for an active employee coverage membership:

  • Group Billing - Here, an active employee coverage membership is billed to a bill group which is derived for the active employee coverage membership.

  • Direct Billing - Here, an active employee coverage membership is billed to the member who is financially responsible for the active employee coverage membership.

You can indicate the billing arrangement for the active employee coverage memberships by defining a characteristic on the bill group or parent customer. The system searches for the characteristic which is specified in the Billing Arrangement option type of the C1-ASOBLLNG feature configuration on the following entities in the specified sequence:

  1. Bill Group

  2. Parent Customer

Note: If the billing arrangement characteristic is not defined for any of the above listed entities, the system, by default, charges the active employee coverage membership premium to the bill group.

The system requires the bill group and its account to bill the active employee coverage memberships when the billing arrangement is set to Group Billing. You can create a bill group and its account from the user interface or through a health care inbound message. On creating an account for a bill group, the system automatically creates a contract on the account using distinct contract types for all policy plans of the parent customer and bill group policies. While creating a contract, the system considers all price items in all pricing rule types (including the related pricing rule types) which are associated with the policy plans of the parent customer and bill group policies.

The system requires the member person's account to bill the active employee coverage membership when the billing arrangement is set to Direct Billing. You can create an account for a member person who is financially responsible for the active employee coverage membership through a health care inbound message. On creating an account for a member person, the system automatically creates a contract on the account using distinct contract types for the respective policy plan. While creating a contract, the system considers all price items in all pricing rule types (including the related pricing rule types) which are associated with the respective policy plan.