Fully-Insured Group Policy

You can create a fully-insured group policy using a policy type where the policy category is set to Fully-Insured Group or Fully-Insured Individual. The policy type indicates the business object using which the fully-insured group policy should be created in the system.

Note: At present, the Fully-Insured Individual policy category is not yet supported in the system.

As per the fully-insured group health insurance business, the system enables you to create a fully-insured group policy for the following:

  • A parent customer (where a bill group is not associated)

  • A bill group (where the parent customer is the policy holder)

You can create or edit a fully-insured group policy from the Policy screen. In addition, you can create or edit a fully-insured group policy through a customer registration object or a health care inbound message. If the fully-insured group policy information is given for a bill group in a health care inbound message, the system does the following:

  • Associates the bill group with the policy using the policy person role which is specified in the Bill Group Policy Person Role option type of the C1-ASOBLLNG feature configuration

  • Associates the parent customer with the policy using the policy person role which is specified in the Parent Customer Policy Person Role option type of the C1-ASOBLLNG feature configuration

However, if the fully-insured group policy information is given for a parent customer in a health care inbound message, the system does the following:

  • Associates the parent customer with the policy using the policy person role which is specified in the Parent Customer Policy Person Role option type of the C1-ASOBLLNG feature configuration

A fully-insured group policy encapsulates the following information:

  • Policy Persons - While creating a fully-insured group policy, you need to associate the person who is the main customer of the policy. While associating a person with a fully-insured group policy, you need to specify the policy person role which indicates the role of the person in the policy. For example, whether the person associated with the policy is the policy holder, broker, or underwriter. You can associate multiple persons with a fully-insured group policy using the same or different policy person role. However, at a time, only one person can be the main customer of the policy.

  • Policy Plans - You can define different types of plans in a fully-insured group policy. For more information, refer to Types of Policy Plan.

  • Memberships - You can define different types of memberships for a fully-insured group policy plan. For more information, refer to Types of Membership.

  • Member Persons - While adding a person to a membership, you need to specify whether the person is the main subscriber of the membership, whether the person is financially responsible for the membership, and how the person is related to the main subscriber. At a time, only one person can be the main subscriber of the membership. You cannot remove a member person, who is the main subscriber, from the membership. You can inactivate a member person whenever required. If you inactivate a member person who is the main subscriber, the system automatically inactivates the membership and all other member persons which are included in the membership.

  • Membership Contracts - You can associate one or more contracts with a membership. At present, the system uses the contract created for a policy plan on the accounts of the parent customer or bill group for billing the respective membership premium. The system does not use the membership contracts for billing the membership premium.

  • Policy Plan Contracts - The system creates or updates contracts of a policy plan when you do either of the following:

    • Create or Edit a Policy Plan from the User Interface or through an Inbound Message

    • Create or Edit an Account from the User Interface or through an Inbound Message

    The system uses the contract created for a policy plan on the accounts of the parent customer or bill group for billing the respective membership premium. For more information, refer to Single Contract Creation Across Fully-Insured Group Policies and Plans and Policy Plan Specific Contract Creation.

On defining a fully-insured group policy, the status of the policy is set to Pending. You can then edit, delete or activate a policy. Once a fully-insured group policy is activated, you can terminate, reinstate, or renew the policy whenever required.

Parent Topic: Fully-Insured Group Health Insurance