Individual Health Insurance Pricing

Oracle Revenue Management and Billing enables you to define pricing for different services offered in a health plan. Each service offered in a health plan should be defined as a price item in the system. For example, services may include medical insurance, home care, hospital visits, etc.

You can define the age based, tier based, or additional fee pricing for a price item using the respective pricing rule. You can create an age based, tier based, and additional fee pricing rule using the respective pricing rule type. The following pricing rule type and pricing rule business objects are enhanced to support the fully-insured individual business:

  • C1-PrcRuleTypeAgeBased

  • C1-PricingRuleAgeBased

  • C1-PrcRuleTypeTierBased

  • C1-PricingRuleTierBased

  • C1-PrcRuleTypeCapitationFee

  • C1-PricingRuleCapitationFee

  • C1-PrcRuleTypeBenefit

You can create a pricing rule for a health plan using a pricing rule type only when the pricing rule type is associated with the health plan. The system enables you to define pricing rules for various services offered in the health plan. You must add the required price items in a pricing rule type. The system then enables you to create a pricing rule for a price item using the respective pricing rule type. While defining an age based pricing rule for a price item, you can offer different rates to different member persons based on the age, member relationship, geographic rating area, member person attributes, etc. You can also charge additional fee or given discount to a member person based on modifier attributes. For example, you may charge more premium to an alcoholic person compared to a non-alcoholic person for the same service (i.e. price item). While defining a tier based pricing rule for a price item, you can offer different rates to different memberships based on the subscription tier, geographic rating area, member person attributes, etc.

You can associate one or more pricing rule types with a health plan through a health product and plan inbound message. You can define one or more pricing rules for a health plan through a health product and plan inbound message. The system creates the pricing rule for a price item using the business object which is specified in the pricing rule type. While creating a pricing rule for a health plan, you can define pricing eligibility rules for a pricing rule. The system considers the pricing rule for an individual membership when the pricing eligibility rule (i.e. eligibility criteria) is satisfied.

The system enables you to define a pricing rule for a price item without the pricing rule eligibility. Such pricing rule is considered as a default pricing rule for the price item. If an individual membership is not eligible for any pricing rule, the system uses the default pricing rule of the price item for the individual membership.

Note: On inactivating a health plan, the system will not automatically inactivate the pricing rules defined for the health plan.

Parent topic: Oracle Revenue Management and Billing Insurance Business Processes