Membership Benefit Sub Type

You can create a membership benefit using the respective benefit sub type. Therefore, you need to create an appropriate benefit sub type for the following:

  • Medicare Part A, Part B, or Part D - While creating a benefit sub type for Medicare Part A, Part B, or Part D membership benefits, you need to set the value type to Not applicable.

  • Medicare Part D LIS - While creating a benefit sub type for Medicare Part D LIS, you need to set the value type to Flat and ensure that the Charge Negatively option is selected.

  • Medicare Part D LEP - While creating a benefit sub type for Medicare Part D LEP, you need to set the value type to Flat and ensure that the Charge Negatively option is not selected.

  • APTC or Any Other Benefits - While creating a benefit sub type for APTC or any other benefits, you need to set the value type to Flat and ensure that the Charge Negatively option is selected.

The Charge Negatively option indicates that you want to create a negative charge for the benefit amount. The system will then accordingly deduct the negative charge from the membership premium while billing.

The system also enables you to create the reverse membership benefit charges on the benefit sponsor account (i.e. for the health benefit exchange; for example, CMS or State account who has offered the membership benefit). If you want to create the reverse membership benefit charges on the benefit sponsor account, you need to select the Charge Benefit Sponsor option and specify the benefit sponsor account while defining the benefit sub type. The system will then create a reverse charge on the membership benefit sponsor account. The reverse charge can then be used by the health insurance payer for reconciliation.

In the individual health insurance business, the benefit sponsor account for the membership benefits varies depending on the health benefit exchange through which the benefit is availed. Therefore, there arises a need to derive the benefit sponsor account for each individual membership. The system also provides the ability to derive the benefit sponsor account for the respective health benefit exchange. You can attach an algorithm to the Sponsor Account Derivation Algorithm field which will derive the benefit sponsor account for the respective health benefit exchange. The system will then create a reverse charge on the derived membership benefit sponsor account.

A new algorithm type named C1-SPONSAC is shipped with the product. You can create an algorithm using the C1-SPONSAC algorithm type and attach it to the Sponsor Account Derivation Algorithm field while defining a benefit sub type. This algorithm contains the following parameter:

  • Account Identifier Type - Used to indicate that account identifier type that you want to use while deriving the benefit sponsor account.

The C1-SPONSAC algorithm validates the account identifier type and derives the membership exchange ID from the respective individual membership. It considers the membership exchange ID as the account identifier and derives the account using the account identifier type and membership exchange ID.

Note: If the Charge Benefit Sponsor option is selected while defining or editing a benefit sub type, you must either specify the benefit sponsor account or sponsor account derivation algorithm in the benefit sub type.