Membership Benefits (Such as Medicare, APTC, and Others)

The system enables you to define and edit the membership benefits from the user interface (i.e. through the Benefit screen), through a health care inbound message, or through the membership repricing inbound web service. While defining a membership benefit, you need to specify the following details:

  • The date range for which the benefit is availed for the membership.

  • The source (i.e. health insurance exchange) from where the benefit is received for the membership. The valid values are:

    • Centers for Medicare and Medicaid Services

    • State

  • The type of benefit availed for the membership. The valid values are:

    • Commercial

    • Medicare Affiliated

  • The benefit sub type that indicates whether the membership benefit is a Medicare Part A, Part B, or Part D benefit, Medicare Part D LIS, Medicare Part D LEP, APTC benefit, or any other membership benefit.

  • The Medicare plan benefit package (i.e. 800 series plan) which is applicable for Medicare Part A, Part B, or Part D membership benefit.

    Note: You can define an Employer Group Waiver Plan (EGWP) (i.e. 800 series plan) as a Medicare plan benefit package in the system. While defining a Medicare Part A, Part B, or Part D membership benefit, you need to indicate the Medicare plan benefit package which is applicable for the membership benefit. You can then use the Medicare plan benefit package as a pricing parameter in the age-based or tier-based pricing rules using which the Medicare Part A, Part B, or Part D membership premium is calculated. In this way, the system enables you to offer different pricing for different EGWPs (i.e. 800 series plans).

    The system enables you to define, edit, delete, and copy a Medicare plan benefit package through the Field Mapping screen. For more information, refer to Medicare Plan Benefit Package.

  • The pass-through amount for Medicare Part D LIS, Medicare Part D LEP or other benefits such as APTC.

Once the membership benefit is created, the status of the benefit is set to Active. You can also edit a membership benefit from the user interface (i.e. through the Benefit screen), through a health care inbound message, or through the membership repricing inbound web service. 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 also enables you to discard an active or inactive membership benefit from the user interface by clicking the Discard button or by changing its status through a health care inbound message or through the membership repricing inbound web service.

For more information on how to maintain the membership benefits through the Benefit screen, refer to Benefit (Used for Searching). For more information on how to maintain the membership benefits through a health care inbound message, refer to Health Care Inbound Message. For more information on how to maintain the membership benefits through the membership repricing inbound web service, refer to C1-MembershipRepricing Business Service.