Fully-Insured Group Health Insurance

Group insurance health plans provide coverage to a group of members, usually comprised of company employees or members of an organization. Among all types of group insurance health plans, the fully-insured plan is one of the traditional way to structure an employer-sponsored health plan. It is also commonly known as fully-insured employee health insurance.

In the fully-insured group health plan, the employer contracts an insurance company to cover the employees and their dependents. The employer pays a premium to the insurance carrier. The premium rates are fixed for a year based on the number of employees which are enrolled in the plan. The monthly premium changes during the year when the number of enrolled employees change in the plan. The insurance carrier collects the premium from the employer and pays the health insurance claims to the employees based on the coverage benefits outlined in the policy. The covered persons (i.e. employees and dependents) are responsible to pay any deductible amounts or co-payments required for covered services under the policy.

Oracle Revenue Management and Billing (ORMB) provides specialized methodologies for calculating premium for the employees and their dependents and then bill the total premium to the employer (known as the parent customer in ORMB) or to its logical designed billing entities (known as the bill groups in ORMB). The system enables you to offer different rates for a covered service depending on the following:

  • Age of the employee or dependent

  • How dependent person is related to the main subscriber

  • Membership subscription tier

  • Geographic rating area

  • Membership or member person attributes

Oracle Revenue Management and Billing (ORMB) enables you to use the pricing methodologies and the billing engine for the fully-insured group health insurance business. To design the pricing and billing models for the fully-insured group health insurance business, you need to create the following entities in ORMB:

  • Parent Customer

  • Bill Groups

  • Bill Group's Account

  • Fully-Insured Group Policy

  • Policy Plans

  • Price Items (for each covered service in the policy)

  • Pricing Rule Types

  • Pricing Rules

Parent Topic: Oracle Revenue Management and Billing Insurance Business Processes