Additional Fee Pricing for COBRA Membership

In the Fully-Insured Pricing, the base premium for COBRA memberships is calculated either using the Age Based Pricing Rule Type or Tier Based Pricing Rule Type. In addition to the premium, COBRA membership is also charged with additional fee which can be either defined as flat charges or premium percentage. You can configure the COBRA additional fee by creating an additional fee pricing rule using an additional fee pricing rule type. You must include an additional fee pricing rule type as a related pricing rule type (in the age based or tier based pricing rule type) of the premium pricing rule type defined for the plan with a conditional rule that additional charges are only applicable for those memberships where the membership type is defined as COBRA.

The COBRA additional fee rates are generally not customer specific but remain common across different states or regions. The system provides you with an ability to define the additional fees at a higher level and if required override them at a lower level. You can define the COBRA additional fee at plan, policy, parent customer, and state level. The system checks whether the COBRA additional fee pricing rule definition is defined at the policy plan level. If an effective dated pricing rule does not exist at the policy plan level, the system further checks the additional fee pricing rule definition at policy, parent customer, and state level.

You can define an additional fee pricing rule using an additional fee pricing rule type. It is the additional fee pricing rule type which helps the system to determine:

• C1-PrcRuleTypeCapitationFee Business object using which the additional charges pricing rule should be created in the system.

• Algorithm which should be triggered for deriving the bill group, parent customer, and policy for a membership.

  Note: You must create an algorithm using the C1_​MEMBGDRV algorithm type and attach it to the Bill Group Derivation system event.

• Algorithm which should be triggered for deriving the account and price item for a membership.

  Note: You must create an algorithm using the C1_​ACCPRIMEM algorithm type and attach it to the Account and Price Item Derivation system event.

• Algorithm which should be triggered for deriving the subscription tier.

  Note: You must create an algorithm using the C1-DERSUBTR algorithm type and attach it to the Derive Subscription Tier for Membership system event.

• Algorithm which should be triggered for calculating the COBRA additional fees for each eligible member person.

  Note: You must create an algorithm using the C1_​TIERPREM algorithm type and attach it to the Pricing rule Type Premium Calculation system event.

• Algorithm which should be triggered for deriving the bill period for the account.

  Note: You must create an algorithm using the C1-FIBCBP algorithm type and attach it to the Pricing Rule BC Creation Pre Processing system event.

• Algorithm which should be triggered for creating the SQI based billable charges for each membership and price item combination.

  Note: You must create an algorithm using the C1-BILLRPCR algorithm type and attach it to the Bill Period Time Line Creation system event.

• Algorithm which should be triggered for prorating the calculated COBRA additional fees as per the proration factor.

  Note: You must create an algorithm using the C1-TIERPRFC algorithm type and attach it to the Calculate Proration Factor for Tier Based Pricing Rule system event.

• Algorithm which should be triggered for creating the SQI based billable charges for each membership and price item combination.

  Note: You must create an algorithm using the C1-FICRETBC algorithm type and attach it to the Pricing Rule Billable Charge Creation system event.

• Price items for which you can define pricing rules for COBRA additional fee using the additional charges pricing rule type.

• Rate options that you can use while defining the pricing for the respective price item.

• Type of account to which the respective price item should be billed based on the specified priority.

• Rule type which indicates the rules that should be executed to determine whether the price item is eligible for billing.

• Audit event types of the C1-Membership and C1-PERSON business objects using which the audit event should be created whenever a membership or member person is added, updated, or removed from the policy plan.

• Elements of the C1-Membership and C1-PERSON business objects for which audit event should be created.

  Note: You must ensure that either the Update All option is selected or the elements listed in the age based pricing rule type are already present in the respective audit event type. Otherwise, erroneous results might occur.

• Members, such as main subscriber, spouse, or children in a membership which are eligible for premium calculation. The system will only consider the member with the specified relationship type during premium calculation.

Once an additional fee pricing rule type is defined, you can then define the additional fee pricing rule using the additional fee pricing rule type.

While creating COBRA Admin Fees Pricing rule through a healthcare inbound message, you need to specify the following information:

• Entity type and Entity ID (i.e. Policy Plan and Policy Plan ID, or Policy and Policy ID, or Parent Customer and Parent Customer ID, or State and State Level) for which you want to define the COBRA additional fee pricing rule.

• Pricing Type - Flat or Percentage

• Start and end dates of the COBRA additional fee pricing rule.

• Additional fee pricing rule type using which you want to create the age based pricing rule

• Price Item for which you want to define the COBRA additional fee pricing rule.

• Rate option using which the price assignment should be created for the COBRA additional fees.

  Note: In case you want flat based COBRA additional fees, use the HC_​FRTSC rate schedule. In case of percentage based pricing, use the HC_​CAPRS rate schedule.