Age Based Pricing

In the Fully-Insured Pricing, the base rate for premium and fees depend upon the age, member attributes (such as employee type, employee status, etc.) and modifiers (such as tobacco usage, gender, alcohol usage, etc.). Oracle Revenue Management and Billing enables you to offer an age based pricing to a fully-insured group and individual customers. In the Age Based pricing, the premium is calculated for each eligible member based on age, member attributes and modifiers, and then aggregated to derive the total premium for the membership. An age based pricing can be defined using the age based pricing rule. You can define an age based pricing rule for a price item on the policy plan. If the age based pricing rule is defined for a price item on a policy plan, all memberships which belong to the policy plan will inherit the age based pricing from the policy plan. If the system does not find any effective pricing rule for a price item on the policy plan, it inherits the effective pricing rule for the price item from the parent customer level.

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

• C1-PricingRuleAgeBased Business object using which the age based pricing rule should be created in the system.

• 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 bill period for a membership.

  Note: You must create an algorithm using the C1-BILLPDRV algorithm type and attach it to the Account and Price Item Derivation Post-Processing system event.

• Algorithm which should be triggered for creating the bill period timeline (based on the derived bill period) for a membership.

  Note: You must create an algorithm using the C1-BILLRPCR algorithm type and attach it to the Account and Price Item Derivation Post-Processing system event.

• 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 calculating the age based premium for a membership.

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

• Algorithm which should be triggered for identifying eligible member persons for premium calculation.

  Note: You must create an algorithm using the C1_​AGEBDELG algorithm type and attach it to the Pricing Rule Pre-Processing system event.

• Algorithm which should be triggered for calculating the premium for each eligible member person.

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

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

  Note: You must create an algorithm using the C1-AGEPRFC algorithm type and attach it to the Pricing Rule Proration Amount Calculation system event.

• Algorithm which should be triggered to configure skip months for an account.

  Note: You must create an algorithm using the C1-SKPMNTHPC algorithm type and attach it to the Skip Month Premium Calculation (in case you want to use the 9/10 Billing feature) system event.

• Price items for which you can define age based pricing rules using the age based 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 are eligible for premium calculation.

• Following are the additional dependents attributes which can affect the premium calculation if they are considered as part of pricing rules. These additional attributes are defined as characteristics for the policy plan. You must specify the following characteristic types in the age based pricing rule type:

  • Maximum Number of Dependents - This characteristic type stores the maximum number of children which are eligible for premium calculation. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Maximum Age Limit for Maximum Dependent Count - This characteristic type stores the maximum age limit for children which are eligible for premium calculation. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Maximum Number of Dependents Order Priority - This characteristic type indicates whether the youngest or eldest children should be considered during premium calculation. Each plan may set a limit to consider the number of dependents, either the eldest or youngest one for premium calculation. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Age Calculation Date Basis - This characteristic type indicates whether the member person's age should be calculated using the member person's enrollment date or policy's start or renewal date. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Newborn Gift Days - This characteristic type stores the number of days you want to offer as gift days from the new born child's enrollment date. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Newborn Gift Days Applicability - This characteristic type indicates whether the gift days should be offered in case of a new born. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Young Adult Max Age Limit - This characteristic type stores the maximum age limit for young adults which are eligible for premium calculation. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

  • Young Adult Inclusion Applicability - This characteristic type indicates whether the young adults should be considered during the premium calculation. You must specify a characteristic type where the characteristic entity is set to Member Person, Membership, Policy Plan, Policy, and State.

Once an age based pricing rule type is defined, you can define age based pricing rules using the age based pricing rule type. Note that, at present, you can define age based pricing rules only through a health care inbound message and not from the user interface. However, you can view the age based pricing rules defined for a policy plan from the Customer 360° Information screen. While creating an age based pricing rule through a health care inbound message, you need to specify the following information:

• Entity type (i.e. Policy Plan) and entity ID (i.e. policy plan ID) for which you want to define the age based pricing rule

• Start and end dates of the age based pricing rule

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

• Price Item for which you want to define age based pricing

• Rate option using which the price assignment should be created for the age based pricing rule

  Note: If the rate option is not given in the pricing rule data, by default, it is set to a value specified in the Default Rate Option - Flat or Default Rate Option - Percentage option type of the C1-ASOBLLNG feature configuration depending on whether the modifier method is set to FLAT, EXPT or INPT.

• Whether you want to increase or decrease the premium of an eligible member by a flat amount or in percentage based on some modifier attributes (such as tobacco usage, alcohol usage, and so on).

• Age limit and employee attributes for which the base fee is applicable

  Note:

  The system defines the lower age limit and upper age limit pricing eligibility criteria using the parameter which is specified in the Age Based Parameter option type of the C1-ASOBLLNG feature configuration.

  The employee attributes can be defined as the parameters in the system. These parameters can then be used to define eligibility criteria in the age based pricing. Here, you can use only those parameters where the parameter usage is set to Pricing Eligibility.

• Modifiers based on which you want to charge additional or offer discount to an eligible member

  Note: The modifiers can be defined as the parameters in the system. These parameters can then be used to define eligibility criteria in the age based pricing. Here, you can use only those parameters where the parameter usage is set to Pricing Eligibility.

Once the age based pricing rule is defined for a policy plan, the system creates a price item pricing and price list and then assigns the price item pricing to the price list.

Related Topics

Parent Topic: Fully-Insured Pricing