Age Monitoring

Age is one of the most critical factor in determining health insurance premium. Therefore, Oracle Revenue Management and Billing enables you to monitor age for premium calculation.

In the age based pricing, the premium is calculated for each eligible member person based on age, employee attributes and modifiers, and then aggregated to derive the total premium for the membership. Until now, the age of a member person was calculated using the member enrollment date, plan start date, or policy renewal or start date. Now, in addition, a new predefined value named MEMNRAGE (Member Enrollment Nearest Age) is added to the Age Calculation Date Basis (C1-AGCAL) characteristic type. If you set the C1-AGCAL characteristic type to MEMNRAGE, the system considers the number of days specified in the C1-PPRAMAGE algorithm to calculate the nearest age of a member person. The system then derives the rate using the nearest age of the member person and accordingly calculates the premium for the member person. For example, a member person with the date of birth as 02-15-1980 has enrolled to the HMO Med Bronze plan from 01-01-2020 to 12-31-2020. And, the C1-AGCAL characteristic type is set to MEMNRAGE on the HMO Med Bronze plan where the following age based pricing is defined:

Age Group Rate Value
0-15 $100.00
16-18 $120.00
19-20 $140.00
21-40 $160.00
41-60 $180.00
61-65 $200.00
66-99 $250.00

Let us assume that the No. of Days parameter in the C1-PPRAMAGE algorithm is set to 90. The system will calculate the nearest age of the member person through a cutoff date which is calculated using the following formula: Member Enrollment Date + No. of Days. In this case, the cutoff date is 03-30-2020 (01-01-2020 + 90). If the birthday of the member person falls within the cutoff date, the system charges the premium based on the nearest age. However, if the birthday of the member person does not fall within the cutoff date, the system charges the premium based on the actual age. In this case, the birthday falls within the cutoff date, and therefore the premium will be charged using the rate defined for the 41-60 age group (i.e. $180) and not using the rate defined for the 21-40 age group (i.e. $160).

Oracle Revenue Management and Billing enables you to recalculate the age of a member person in a membership in the following scenarios:

  • When the policy is renewed

  • When the age changes

  • From the next month when the age changes

A new characteristic type named Age Recalculation Date Basis (C1-AGREC) is introduced in this release. We support the following predefined list of values:

  • AGECHNG (Age Changes)

  • CHGAGNTMNT (Next Month)

  • RENEWAL (Policy Renewal)

If you want to recalculate the membership premium for a plan based on the recalculated age of a member person, you need to do the following:

  • Define the Age Recalculation Date Basis (C1-AGREC) characteristic for the policy plan or for the policy to which the plan belongs

  • Set the Age Re-Calculation Date Basis attribute to Age Recalculation Date Basis (C1-AGREC) in the age based pricing rule type which is associated with the policy plan

The system does the following when you add a membership to a policy plan or a member person to a membership:

If the Age Recalculation Date Basis characteristic type is set to… Then,
AGECHNG The system creates an audit event for a member person when the birthday falls within the enrollment date range. Here, the effective date of the audit event is set to the birth date of the member person.
CHGAGNTMNT The system creates an audit event for a member person when the birthday falls within the enrollment date range. Here, the effective date of the audit event is set to the billing date of the next month. For example, if the bill date in a bill period starts 1st of every month and the date of birth of a member person is 05-10-2020, the effective date of the audit event is set to 01-11-2020.
RENEWAL The system creates an audit event for a member person when the birthday falls within the new enrollment date range (i.e. from original policy end date+1 to new policy end date). Here, the effective date of the audit event is set to the birth date of the member person.

Apart from the membership premium recalculation, the Age Recalculation Date Basis (C1-AGREC) characteristic is used to evaluate the member relationship characteristic of each member person and subscription tier characteristic of the membership when the Young Adult Applicability characteristic is set to Y and the child or dependent enrolling to the membership becomes young adult in the enrollment period.

The C1-FIAUDEV algorithm is enhanced to support the age recalculation feature. It creates audit events in the C1_​AUDIT_​EVENT table and repricing entity detail records in the CI_​REPRC_​ENTITY_​DTL table when the age of a member person changes within the enrollment period.