Rate Guarantee for Individual Membership

At times, the insurance carriers provide rate guarantee health plans to a fully-insured individual wherein the insurance rate does not change for the rate guarantee period (i.e. lock-in period). Oracle Revenue Management and Billing enables you to configure guaranteed rate for one or more health insurance services offered to an individual person. Unless, there are some qualifying life events (QLE), the system will calculate the premium on the same rate for the next coverage period until the rate guarantee period is over.

The system enables you to maintain the rate guarantee details for each individual membership through a health care inbound message or through membership repricing inbound web service. It enables you to capture the following details:

  • Rate Guarantee Start Date - Used to specify the date from when the rate guarantee is available for the individual membership.

  • Rate Guarantee End Date - Used to specify the date till when the rate guarantee is available for the individual membership.

  • Rate Guarantee Status - Used to indicate the status of the rate guarantee period. The valid values are - Active and Inactive.

You can send the rate guarantee details for an individual membership during enrollment (i.e. on membership creation), during coverage period, or during membership renewal. While sending the rate guarantee details of an individual membership, ensure that the active rate guarantee records do not have overlapping date range.

The system enables you to define the rate guarantee business rules. If the rate guarantee details are not specified for an individual membership during enrollment, the system derives the rate guarantee details for the individual membership through a rate guarantee business rule. The rate guarantee business rule indicates the following:

  • Rate Guarantee Applicability - Used to indicate whether the rate guarantee is available for the individual membership.

  • Rate Guarantee Period - Used to derive the rate guarantee start and end dates. The system sets the rate guarantee start date to the membership start date and the rate guarantee end date to the rate guarantee start date + rate guarantee period.

There might be situations wherein the rate guarantee details are received for an individual membership later during the coverage period or during membership renewal through a health care inbound message. In such scenarios, the system will then give precedence to the rate guarantee details which are received through a health care inbound message and will not derive the rate guarantee details from the rate guarantee business rule which is stamped against the individual membership.

A new column named Rate Guarantee is available in the Price Items section while defining or editing an age based or tier based pricing rule type. While creating a charge for an individual membership, the system checks whether the Rate Guarantee option is selected for the price item in the respective pricing rule type and whether the billable charge timeline falls within the rate guarantee period. If so, the system derives the rate guarantee pricing rule for the price items where the Rate Guarantee option is selected.

The system stores the pricing rule which is effective for such price items on the rate guarantee start date as the rate guarantee pricing rule. Until the rate guarantee period is over, the system considers the rate guarantee pricing rule for the individual membership during premium calculation. This ensures that the same rate is charged for a health insurance service even when the rate has increased for the health insurance service in the system.

The Entity Audit framework is configured for the Rate Guarantee feature. The system will create audit events when the rate guarantee records are added or updated for an individual membership.