Individual Health Insurance

Individual health insurance is a coverage that an individual purchase on its own, on an individual or family basis, as opposed to obtaining through an employer. An individual can buy a generic, Medicare, Medicaid, or CHIP health insurance plan from a health insurance payer or from an insurance exchange.

A health insurance payer and insurance exchange sells different plans from the health products to an individual. A health product is a discrete package of health insurance coverage benefits that are offered using a particular product network type (such as health maintenance organization, preferred provider organization, exclusive provider organization, point of service, or indemnity) within a service area.

A health product can include multiple health benefit plans which may cover medical expenses, hospitalization, doctor and hospital visits, prescription drugs, wellness care, etc. A health benefit plan can be a primary or add-on plan. A primary health benefit plan is a standalone plan, which is sold directly. For example, Medical Insurance is a primary health insurance plan.

An add-on plan is also known as supplemental plan. An add-on plan can be an ancillary or rider plan. An add-on plan is not a standalone plan and hence it is not sold directly. For example, the Dental, Vision, Accidental Death, Disability, Critical Illness, Long-Term Care, and Life Insurance plans can be sold as add-on health insurance plans.

Oracle Revenue Management and Billing enables you to create and edit the following entities for a fully-insured individual business:

  • Health Products

  • Health Plans

  • Individual Memberships

  • Member Persons

  • Medicare or Other Benefits

  • Accounts

  • Contracts

  • Price Items (offered as services)

  • Pricing Rule Types

  • Pricing Rules

  • Price Assignments

  • Billable Charges

Two new business objects named C1-HealthcareProduct and C1-HealthPlan are introduced in this release. The C1-HealthcareProduct business object enables you to create a health product. You can define and edit a health product through a health product and plan inbound message. While defining a health product, you need to specify the following details - product type, product sub type, product category, product LOB, product LOB category, start date, end date, status, etc. A health product can be a bundled or non-bundled product. A bundled product means it includes one or more health products. You can define characteristics for a health product. A health product should be associated with a division (i.e. service area). You can associate a health product to one or more divisions and one division can have one or more health products.

The C1-HealthPlan business object enables you to create a health plan for a health product. You can define and edit a health plan through a health product and plan inbound message. While defining a health plan, you need to specify the following details - health product, start date, end date, status, etc. In addition, you need to indicate whether the health plan is a charitable plan, standard plan, grandfather plan, qualified from exchange, ancillary plan, rider plan, add-on plan, etc. You can define characteristics for a health plan.

A health product can have one or more health plans. On inactivating a health product, the system will not automatically inactivate the respective health plans. An individual can subscribe for one or more health plans. The system creates an individual membership for each subscribed health plan. An individual membership can have one or more member persons. One member person in an individual membership must be the main subscriber. You can add one or more dependent persons in the individual membership. One member person in an individual membership should be financially responsible for the individual membership. For more information, see the Individual Membership section.

If an individual subscribe for an add-on health plan along with a primary health plan, the system enables you to indirectly link a primary health plan with an add-on health plan by associating the primary individual membership with the add-on individual membership. At present, you can associate only one add-on individual membership with the primary individual membership. The system creates the billable charges for both primary and add-on individual memberships independently.

On terminating the primary individual membership, the system provides a facility to automatically terminate the individual membership on the add-on health plan. For more information, see the Individual Membership Termination section. However, on canceling, reinstating, or renewing a primary individual membership, the system does not automatically cancel, reinstate, or renew the individual membership on the add-on health plan. To cancel, reinstate, or renew an individual membership on the add-on health plan, the system must receive the required information for the individual membership from the enrollment system.

Parent topic: Oracle Revenue Management and Billing Insurance Business Processes