Retiree Membership

An employer may offer a retirement health plan coverage to its retired employees through a fully-insured group policy or an individual can independently opt for a government sponsored retirement health plan coverage. Oracle Revenue Management and Billing enables you to maintain a retiree membership for both the fully-insured group and individual business. The system enables you to maintain a flat or percentage based contribution of employer or sponsor for a retiree membership.

The system enables you to create and edit a retiree membership through a health care inbound message or through membership repricing inbound web service. While creating a retiree membership, the membership type must be set to Retiree. The system requires the following information to create charges for a retiree membership:

  • Whom to bill the premium for the retiree membership (i.e. retiree billing arrangement details)

  • Whom to bill the employer or sponsor contribution (i.e. sponsor billing arrangement details)

  • Age based or tier based pricing rule using which the premium should be calculated for the retiree membership

  • Discount charge pricing rule using which the employer or sponsor contribution should be calculated for the retiree membership

In case of the fully-insured individual business, the premium for a retiree membership is billed to the member who is financially responsible for the retiree membership. However, in case of the fully-insured group business, the system supports the following billing arrangements for the retiree membership:

  • Group Billing - Here, the premium is billed to a bill group which is derived for the retiree membership.

  • TPA Billing - Here, the premium is billed to the third party administrator (i.e. TPA person).

  • Direct Billing - Here, the premium is billed to the member who is financially responsible for the retiree membership.

You can indicate the billing arrangement for a retiree membership in the fully-insured group business by defining a characteristic on the policy plan, policy, or parent customer. The system searches for the characteristic which is specified in the Retiree Billing Arrangement option type of the C1-ASOBLLNG feature configuration on the following entities in the specified sequence:

  1. Policy Plan

  2. Policy

  3. Parent Customer

The system enables you to maintain a flat or percentage based contribution of employer or sponsor through a discount charge pricing rule. A field named Sponsored is available in the Price Items section while defining or editing a discount charge pricing rule type. If the Sponsored option is selected for a price item, the system creates and bills the charge for the price item as per the sponsor billing arrangement. The system searches for the characteristic which is specified in the Sponsors Billing Arrangement option type of the C1-ASOBLLNG feature configuration on the following entities in the specified sequence:

  1. Policy Plan

  2. Policy

  3. Parent Customer

In the fully-insured group and individual business, the system supports the following sponsor billing arrangements for the retiree membership:

  • Group Billing - Here, the system creates a negative charge for the employer or sponsor contribution against the beneficiary account and a positive charge for the employer or sponsor contribution against the sponsor account.

  • TPA Billing - Here, the system creates a negative charge for the employer or sponsor contribution against the beneficiary account and a positive charge for the employer or sponsor contribution against the sponsor account.

  • Direct Billing - Here, the system creates a memo only charge for the employer or sponsor contribution against the beneficiary account. A bill message code is derived from the Retiree Bill Message Code option type of the C1-ASOBLLNG feature configuration and stamped against the beneficiary account.

In case of the group and TPA billing, the system derives the characteristic types which are specified in the Sponsor Account Identifier Type Char Type and Sponsor Account Identifier Value Char Type option types of the C1-ASOBLLNG feature configuration. The system then checks whether these characteristics are defined on any of the following entity in the specified sequence:

  1. Policy Plan

  2. Policy

  3. Parent Customer

If these characteristics are defined on any of the above entity, the system derives the sponsor account for the bill group. The system then bills the employer or sponsor contribution charges to the sponsor account.

However, if the Sponsored option is not selected for a price item in a discount charge pricing rule type, the system creates and bills the charge for the price item as per the retiree billing arrangement.