Medicare Membership
Oracle Revenue Management and Billing enables you to maintain an employer sponsored group medicare membership (800 series plans) for a fully-insured large group customer and create age based or tier based premium charges for the Medicare Part A, Part B, and Part D. A Medicare beneficiary may qualify for a low income subsidy (LIS) for Medicare Part D or may incur late enrollment penalty (LEP) for Medicare Part D. In such case, the system enables you to consider the low income subsidy (LIS) and late enrollment penalty (LEP) while calculating the Medicare Part D premium.
The system enables you to create and edit a Medicare membership from the user interface, through a health care inbound message, or through the membership repricing inbound web service. While creating a Medicare membership, you must set the membership type to Medicare. Ideally, you must define a Medicare membership on a Medicare Affiliated policy plan. However, at present, the system does not validate whether a Medicare membership is defined only on a Medicare Affiliated policy plan and not on a Commercial policy plan.
You can create a Medicare membership when you specify the main subscriber of the membership. A Medicare membership should have only one member person who is covered for Medicare and who is financially responsible for the membership. Ideally, the main subscriber should exists as a person in the system before creating the Medicare membership from the user interface, through a health care inbound message, or through the membership repricing inbound web service. The system enables you to create the main subscriber and Medicare membership through the same health care inbound message or through the same membership repricing request. In such case, the system will first create the person record for the main subscriber and then create the Medicare membership.
On creating a Medicare membership, the status of the membership and main subscriber is set to Active. You can inactivate a Medicare 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:
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On clicking the Inactivate button
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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 a Medicare membership, the system does the following:
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Set the status of the membership and main subscriber to Inactive
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Cancels the billable charges which are created for the membership
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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.
On terminating a fully-insured group policy, the status of all Medicare memberships on the respective policy plans is set to Terminated. Similarly, on reinstating a fully-insured group policy, the status of all Medicare memberships on the respective policy plans is set to Active.
The system enables you to maintain the Membership benefits (such as, Part A, Part B, Part D, Part D LIS, and Part D LEP) of a member person through the Benefit screen. The system enables you to define and edit the Membership benefits from the user interface, through a health care inbound message, or through the membership repricing inbound web service. While defining a Membership benefit of a member person for Part A, Part B, and Part D, you need to specify a Medicare plan benefit package (i.e. 800 series plan) which is applicable for the Membership benefit. The system enables you to define and edit a Medicare plan benefit package through the Field Mapping screen. You can use the Medicare plan benefit package as a pricing parameter in the age based or tier based pricing rules using which the Medicare premium is calculated. While defining a Membership benefit of a member person for Part D LIS and Part D LEP, you need to specify the benefit amount (i.e. subsidy or penalty amount).
While editing a Membership benefit of a member person from the user interface, you can only edit the characteristics of the Membership benefit. However, while editing a Membership benefit of a member person through a health care inbound message or through the membership repricing inbound web service, you can edit the end date, benefit amount, and characteristics of the Membership benefit. On editing a Membership benefit, the system inactivates the old record and creates a new record in the system. The status of the old benefit record is set to Inactive and the status of the new benefit record is set to Active.
The system enables you to discard an active or inactive Membership benefit from the user interface by clicking the Discard button. You can also discard an active or inactive Membership benefit through a health care inbound message or through the membership repricing inbound web service by changing its status to Discarded.
The system requires the following information to create charges for a Medicare membership:
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Whom to bill the Medicare membership (i.e. billing arrangement details)
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Age based or tier based pricing rules using which the premium should be calculated for the Medicare Part A, Part B, and Part D.
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Respective age based, tier based, and benefit pricing rule types associated with the respective policy plan
The system supports the following billing arrangements for a Medicare membership:
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Group Billing - Here, a Membership benefit is billed to a bill group which is derived for the Medicare membership.
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Direct Billing - Here, a Membership benefit is billed to a member person who is financially responsible for the Medicare membership.
You can indicate the billing arrangement for the Medicare memberships by defining a characteristic on the policy plan, policy, or parent customer. The system searches for the characteristic which is specified in the Benefit Billing Arrangement option type of the C1-ASOBLLNG feature configuration on the following entities in the specified sequence:
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Policy Plan
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Policy
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Parent Customer
The system requires the bill group and its account to bill the Medicare memberships when the benefit 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 member person's account to bill the Medicare membership when the benefit billing arrangement is set to Direct Billing. You can create an account for a member person who is financially responsible for the Medicare 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.