COBRA Membership

Oracle Revenue Management and Billing enables you to maintain a COBRA membership and charge age based or tier based premium and administration fee for the COBRA membership. In COBRA membership, an employer provides temporary continuation of group health coverage in certain situations where it would otherwise be terminated. This may be include situations, such as:

  • Death of the covered employee

  • Reduction in the hours or termination of the covered employee's employment

  • Covered employee becoming entitled for Medicare

  • Divorce or legal separation from the covered employee

  • A dependent child ceasing to be a dependent in an active employee coverage membership

The system enables you to create and edit a COBRA membership from the user interface, through a health care inbound message, or through the membership repricing inbound web service. While creating a COBRA membership, you must set the membership type to COBRA. Ideally, you must define a COBRA membership on a Commercial policy plan. However, at present, the system does not validate whether a COBRA membership is defined only on a Commercial policy plan and not on a Medicare Affiliated policy plan.

Through a health care inbound message, the system must receive the end date of the active employee coverage membership along with the details of the COBRA membership. You can create a COBRA membership when you specify the main subscriber of the membership. Here, the main subscriber can be an employee or member of the organization or a family member who is covered through the COBRA membership. In a COBRA membership, you need to specify the member person who is financially responsible for the COBRA membership. Note that, at a time, only one member person can be financially responsible for the COBRA membership.

On creating a COBRA 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 a COBRA 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 a COBRA membership, the system automatically inactivates the membership and all other member persons which are included in the membership. The status of the COBRA 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 a COBRA membership, from the user interface, through a health care inbound message, or through the membership repricing inbound web service. On inactivating a member person, the status of the member person is set to Inactive.

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

The system requires the following information to create charges for a COBRA membership:

  • Whom to bill the COBRA membership (i.e. billing arrangement details)

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

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

  • Additional fee pricing rule using which the administration fee should be calculated for the COBRA membership

  • Respective additional fee pricing rule type associated with the respective policy plan

The system supports the following billing arrangements for a COBRA membership:

  • Group Billing - Here, a COBRA membership is billed to a bill group which is derived for the COBRA membership.

  • TPA Billing - Here, a COBRA membership is billed to the third party administrator (i.e. TPA person).

  • Direct Billing - Here, a COBRA membership is billed to the member who is financially responsible for the COBRA membership.

You can indicate the billing arrangement for the COBRA memberships by defining a characteristic on the policy plan, policy, or parent customer. The system searches for the characteristic which is specified in the Cobra Billing Arrangement option type of the C1-ASOBLLNG feature configuration on the following entities in the specified sequence:

  1. Policy Plan

  2. Policy

  3. Parent Customer

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

The system requires the bill group and its account to bill the COBRA memberships when the COBRA 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 third party administrator (i.e. TPA person) and its account to bill the COBRA memberships when the COBRA billing arrangement is set to TPA Billing. You can create a third party administrator (i.e. TPA person) and its accounts through a health care inbound message. While sending the details of a TPA person through an inbound message, you must specify the parent of the TPA person and its account details. The system associates the parent customer with the TPA person using the relationship type which is specified in the TPA Person Relationship Type option type of the C1-ASOBLLNG feature configuration. If the person type specified in the health care inbound message matches the person type specified in the TPA Person Type option type of the C1-PERSTYPE feature configuration, the system creates or updates the TPA person and its account through a customer registration object. However, if the person type specified in the health care inbound message does not match the person type specified in the TPA Person Type option type of the C1-PERSTYPE feature configuration, the system creates or updates the TPA person and its accounts directly and not through a customer registration object.

The system associates the TPA person with the TPA account using the relationship type which is specified in the TPA Account Relationship Type option type of the C1-ASOBLLNG feature configuration. On creating an account for a TPA person, 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 COBRA membership when the COBRA billing arrangement is set to Direct Billing. You can create an account for a member person who is financially responsible for the COBRA 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.