Portable Waiting Periods

When a member changes cover within the same health fund the application of waiting periods differs:

• If they have taken the clinical category or modality for the first time the full waiting period is served from the date of upgrade.

• If they have moved to a product with a higher level of cover then the full waiting period is served from the date of upgrade. They will have the lower level of cover until the waiting period for the higher level of cover is served (assuming they have served the waiting period for the lower level of cover).

• If they have moved to a product with a lower level of cover then provided they have served the waiting period for that clinical category or modality the lower level of cover applies immediately.

• If they no longer have cover for a clinical category or modality then cover is lost as at the date of the downgrade. The portability only applies to waiting periods, not to coverage.

• If they downgrade to a lower level and then upgrade they must reserve the waiting period for the higher level of cover.

• A lower coverage level number represents a better coverage.

Cover from prior funds is considered the highest level of cover for upgrade purposes.

Products or enrollment products in OHI do not have a fixed property for storing a coverage level. Typically it will be set by Policies within the enrollment response based on the Enrollment Product within the policy.

Assumptions

The examples in this document are based on the following assumptions:

• The products that cover the same clinical category or modality have the same service option service code.

• The coverage levels for all service options covered by an enrollment product are equal. That is, if a product covers Therapy and Physician Services, the coverage levels for both service options is the same.

If the service options within the product have different coverage levels, a dynamic record holding the service option service code and the coverage level is required.

• The waiting period regime raises a Fatal message when the waiting period is not served. Because of the Fatal type of message the claim line will be denied. If the waiting period regime would raise an Informational message, then the claim line would not be denied.

• In general the waiting period for products that cover the same clinical category or modality have the same waiting period.

Examples 4c and 5c cover situations where the waiting periods of previous periods differ from the waiting period of the current product.

No (previous) Products

Example 1 - Product ended.

Member terminated Product(s) before the claim line service date.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product B	01/Jan/2019	30/Jun/2019	2	4 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	No current product found
Waiting Period Served?	No, claim line is denied

Example 2 - No previous product.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product B	01/Jul/2019	n/a	2	4 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product B
Waiting Period Served	No, claim line is denied

Waiting Period Product B

Waiting Period Start Date	01/Jul/2019
Waiting Period	4 months
Waiting Period Served	False
Previous Product?	n/a	No previous product found

Example 3 - Gap with previous product

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product C	01/Jul/2019	n/a	1	4 months
Product B	01/Jul/2018	31/Dec/2018	2	4 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product C
Waiting Period Served?	No, claim line is denied

Waiting Period Product C

Waiting Period Start Date	01/Jul/2019
Waiting Period	4 months
Waiting Period Served	False
Previous Product?	n/a	Since there is a gap between the enrollment on product B and product C, product B is not considered a consecutive previous product

Previous Products (from the current payer)

Upgrades

If a member has moved to a product with a higher cover then the full waiting period is served from the date of upgrade. They will have the lower level of cover until the waiting period for the higher level of cover is served (assuming they have served the waiting period for the lower level of cover).

Example 4a - Upgrade

Member switched on 1st of July 2019 from product A to product B where product B has a better coverage. The Claim Line start date is 17 July 2019.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product B	01/Jul/2019	n/a	2	4 months
Product A	01/Jan/2019	30/Jun/2019	3	4 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product B
Waiting Period Served?	Yes, continue flow with product A

Waiting Period Product B

Waiting Period Start Date	01/Jul/2019	Since previous product (A) has lower coverage use start date of current product (B)
Waiting Period	4 months
Waiting Period End Date	31/Oct/2019
Waiting Period Served	False
Previous Product?	Product A	Move to Evaluation Product A

Waiting Period Product A

Waiting Period Start Date	01/Jan/2019
Waiting Period	4 months
Waiting Period End Date	30/Apr/2019
Waiting Period Served	True
Previous Product?	n/a

Example 4b - Upgrade

Member switched on 1st of July 2019 from product A to product B where product B has a better coverage. The Claim Line start date is 17 July 2019.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product B	01/Jul/2019	n/a	2	8 months
Product A	01/Jan/2019	30/Jun/2019	3	8 months

Evaluation:

Claim Line Start Date	17/July/2019
Chosen Product	Product B
Waiting Period Served?	No, claim line is denied. For both products the waiting period is not served.

Waiting Period Product B

Waiting Period Start Date	01/Jul/2019	Since previous product (A) has lower coverage use start date of current product (B)
Waiting Period	8 months
Waiting Period End Date	29/Feb/2020
Waiting Period Served	False
Previous Product?	Product A	Move to Evaluation Product A

Waiting Period Product A

Waiting Period Start Date	01/Jan/2019
Waiting Period	8 months
Waiting Period End Date	31/Aug/2019
Waiting Period Served	False
Previous Product?	n/a

Example 4c - Upgrade with different waiting periods

Member switched on 1st of July 2019 from product A to product B where product B has a better coverage. Product B has a longer waiting period than product A. The Claim Line start date is 17 July 2019.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product B	01/Jul/2019	n/a	2	8 months
Product A	01/Jan/2019	30/Jun/2019	3	4 months

Evaluation:

Claim Line Start Date	17/July/2019
Chosen Product	Product B
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product B

Waiting Period Start Date	01/Jul/2019	Since previous product (A) has lower coverage use start date of current product (B)
Waiting Period	8 months
Waiting Period End Date	29/Feb/2020
Waiting Period Served	False
Previous Product?	Product A	Move to Evaluation Product A

Waiting Period Product A

Waiting Period Start Date	01/Jan/2019
Waiting Period	4 months	Note that when evaluating a previous product, the waiting period of the previous period is used, not the waiting period of the current product.
Waiting Period End Date	30/Apr/2019
Waiting Period Served	True
Previous Product?	n/a

Downgrades

Example 5a - Downgrade

Member switched on 1st of July 2019 from product B to product A where product B had a better coverage. The Claim Line service date is 17 July 2019.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product A	01/Jul/2019	n/a	3	4 months
Product B	01/Jan/2019	30/Jun/2019	2	4 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product A
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product A

Waiting Period Start Date	01/Jan/2019	Since previous product (B) has higher coverage use start date of that product (B)
Waiting Period	4 months
Waiting Period End Date	30/Apr/2019
Waiting Period Served	True
Previous Product?	n/a

Example 5b - Downgrade

Member switched on 1st of July 2019 from product B to product A where product B had a better coverage. The Claim Line start date is 17 July 2019.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product A	01/Jul/2019	n/a	3	8 months
Product B	01/Jan/2019	30/Jun/2019	2	8 months

Evaluation:

Claim Line Start Date	17/July/2019
Chosen Product	Product A
Waiting Period Served?	No, claim line is denied

Waiting Period Product A

Waiting Period Start Date	01/Jan/2019	Since previous product (B) has higher coverage use start date of that product (B)
Waiting Period	8 months
Waiting Period End Date	31/Aug/2019
Waiting Period Served	False
Previous Product?	n/a

Example 5c - Downgrade with different waiting periods

Member switched on 1st of July 2019 from product B to product A where product B had a better coverage. Product B has a shorter waiting period than product A.The Claim Line start date is 17 July 2019.

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product A	01/Jul/2019	n/a	3	8 months
Product B	01/Jan/2019	30/Jun/2019	2	4 months

Evaluation:

Claim Line Start Date	17/July/2019
Chosen Product	Product A
waiting Period Served?	No, claim line is denied

Waiting Period Product A

Waiting Period Start Date	01/Jan/2019	Since previous product (B) has higher coverage use start date of that product (B)
Waiting Period	8 months	Although the start date of product B is used, still the waiting period of product A applies
Waiting Period End Date	31/Aug/2019
Waiting Period Served	False
Previous Product?	n/a

Mixed Changes

Example 6a - Multiple changes, all downgrades

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product A	01/Jul/2019	n/a	3	8 months
Product B	01/Jan/2019	30/Jun/2019	2	8 months
Product C	01/Jul/2018	31/Dec/2018	1	8 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product A
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product C

Waiting Period Start Date	01/Jul/2018	Since previous products (B and C) have higher coverage use earliest start date of product with higher coverage i.e. product C
Waiting Period	8 months
Waiting Period End Date	28/Feb/2019
Waiting Period Served	True
Previous Product?	n/a

Example 6b - Multiple changes, all upgrades

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product C	01/Jul/2019	n/a	1	6 months
Product B	01/Jan/2019	30/Jun/2019	2	6 months
Product A	01/Jul/2018	31/Dec/2018	3	6 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product C
Waiting Period Served?	Yes, continue flow on product B

Waiting Period Product C

Waiting Period Start Date	01/Jul/2019	Since previous product (B) has a lower coverage use start date of current product ( C )
Waiting Period	6 months
Waiting Period End Date	31/Dec/2019
Waiting Period Served	False
Previous Product?	Product B	Move to Evaluation Product B

Waiting Period Product B

Waiting Period Start Date	01/Jan/2019	Since previous product (A) has lower coverage use start date of current product (B)
Waiting Period	6 months
Waiting Period End Date	30/Jun/2019
Waiting Period Served	True
Previous Product?	n/a	No need to evaluate product A as the waiting period is already served

Example 6c - Multiple changes, all upgrades

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product C	01/Jul/2019	n/a	1	12 months
Product B	01/Jan/2019	30/Jun/2019	2	12 months
Product A	01/Jul/2018	31/Dec/2018	3	12 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product C
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product C

Waiting Period Start Date	01/Jul/2019	Since previous product (B) has a lower coverage use start date of current product ©
Waiting Period	12 months
Waiting Period End Date	30/Jun/2020
Waiting Period Served	False
Previous Product?	Product B	Move to Evaluation Product B

Waitong Period Product B

Waiting Period Start Date	01/Jan/2019	Since previous product (A) has lower coverage use start date of current product (B)
Waiting Period	12 months
Waiting Period End Date	31/Dec/2019
Waiting Period Served	False
Previous Product?	Product A	Move to Evaluation Product A

Waiting Period Product A

Waiting Period Start Date	01/Jul/2018
Waiting Period	12 months
Waiting Period End Date	30/Jun/2019
Waiting Period Served	True
Previous Product?	n/a

Example 6d(i) - Multiple changes, first upgrade and then downgrade (1)

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product B	01/Jul/2019	n/a	2	12 months
Product C	01/Jan/2019	30/Jun/2019	1	12 months
Product A	01/Jul/2018	31/Dec/2018	3	12 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product B
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product B

Waiting Period Start Date	01/Jan/2019	Since previous product ( C ) has higher coverage use the start date of that product ( C ). Product A has lower coverage and is therefore not considered for the startdate.
Waiting Period	12 months
Waiting Period End Date	31/Dec/2019
Waiting Period Served	False
Previous Product?	A	Move to evaluation product A

Waiting Period Product A

Waiting Period Start Date	01/Jul/2018
Waiting Period	12 months
Waiting Period End Date	30/Jun/2019
Waiting Period Served	True
Previous Product?	n/a

Example 6d(ii) - Multiple changes, first upgrade and then downgrade (2)

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product A	01/Jul/2019	n/a	3	12 months
Product C	01/Jan/2019	30/Jun/2019	1	12 months
Product B	01/Jul/2018	31/Dec/2018	2	12 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product A
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product C

Waiting Period Start Date	01/Jul/2018	Since previous products (B and C) have higher coverage use earliest start date of the products with a higher coverage i.e. product B
Waiting Period	12 months
Waiting Period End Date	30/Jun/2019
Waiting Period Served	True
Previous Product?	n/a

Example 6e - Multiple changes, first downgrade and then upgrade

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period
Product C	01/Jul/2019	n/a	1	12 months
Product A	01/Jan/2019	30/Jun/2019	3	12 months
Product B	01/Jul/2018	31/Dec/2018	2	12 months

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product C
Waiting Period Served?	Yes, continue flow on product A

Waiting Period Product C

Waiting Period Start Date	01/Jul/2019	Since previous product (A) has lower coverage use the start date of current product ©
Waiting Period	12 months
Waiting Period End Date	30/Jun/2020
Waiting Period Served	False
Previous Product?	Product A

Waiting Period Product A

Waiting Period Start Date	01/Jul/2018	Since previous product (B) has higher coverage use the start date of that product (B).
Waiting Period	12 months
Waiting Period End Date	30/Jun/2019
Waiting Period Served	True
Previous Product?	n/a

Waiting Periods Based on Previous Payer

In these examples the policy enrollment is extended with a dynamic field holding the start date of an enrollment for this product at the previous payer. This is based on the following assumptions:

• There is no need to specify the coverage level for the product enrollment at the previous payer because such an enrollment is always considered to be the highest coverage.

• There is no need to specify the service option service code because all service option service codes within the product enrollment at the previous payer have the same start date.

If these assumptions are not correct it will require a dynamic record on the enrollment product to store the necessary detail of information.

Example 7a - Previous Payer Portability on Current Product

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period	Previous Payer Start Date
Product C	01/Jul/2019	n/a	1	6 months	01/Jan/2019

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product C
Waiting Period Served?	Yes, continue flow on product C

Waiting Period Product C

Waiting Period Start Date	01/Jan/2019	Since the 'previous payer start date' coverage for a previous payer product is always considered of highest coverage, this date is used
Waiting Period	6 months
Waiting Period End Date	30/Jun/2019
Waiting Period Served	True
Previous Product?	n/a

Example 7b - Previous Payer Portability on Previous Product

Scenario:

Product	Start Date	End Date	Coverage Level	Waiting Period	Previous Payer Start Date
Product C	01/Jul/2019	n/a	1	12 months
Product B	01/Jan/2019	30/Jun/2019	2	12 months	01/Jan/2018

Evaluation:

Claim Line Start Date	17/Jul/2019
Chosen Product	Product C
Waiting Period Served?	Yes, continue flow on product B

Waiting Period Product C

Waiting Period Start Date	01/Jul/2019	Since previous product (B) has lower coverage use start date of current product ( C )
Waiting Period	12 months
Waiting Period End Date	30/Jun/2020
Waiting Period Served	False
Previous Product?	Product B

Waiting Period Product B

Waiting Period Start Date	01/Jan/2018	Since the 'previous payer start date' coverage for a previous payer product is always considered of highest coverage, this date is used
Waiting Period	12 months
Waiting Period End Date	31/Dec/2018
Waiting Period Served	True
Previous Product?	n/a

Enrollment Response

Previous payer portability is not a fixed property in Policies or Claims. It must be configured on policy enrollment level or policy enrollment product level and set by the user. The enrollment status response definition must provide logic to extract these data from the policies data model and include them in the response message for Claims.

In Claims corresponding dynamic fields must be configured on the claim line to store these data. Dynamic logic must be set up to extract the correct waiting period start date as part of waiting period evaluation, e.g. by using a waiting period start date function on the waiting period regime.

Previous Payer Portability on Current Product

Based on example 7a, member is enrolled on product PROD_C from 01 July 2019 (also start date of the contract) and only one claim line start date 17July 2019, the enrollment response looks like this:

<families>
  <family
     code="FAM01"
     startDate="2016-01-01"
  />
</families>
<products>
  <product
     code="PROD_C"
     contractDate="2019-07-01"
     startDate="2019-07-17"
     endDate="2019-07-17"
     coverageLevel="1"
     previousPayerStartDate="2019-01-01"
  </product>
</products>

• The startDate and endDate reflect the actual enrollment period within the claim line service dates of the request.

• The subscriptionDate (contractDate) and subscriptionEndDate (contractEndDate) are the first and last day of the person’s contract for this product in Policies.

• The coverage level of the policy product is not a fixed property in Policies. It must be configured as a dynamic field on enrollment product level or policy enrollment product level. It must be set by the user or be deducted from the existing configuration by the policies enrollment response dynamic logic.

Previous Payer Portability on Previous Product

Based on example 7b, member is enrolled on product B form 01 Jan 2019 until 30 Jun 2019 and (within the same contract) on product PROD_C from 01 July 2019 and only one claim line start date 17July 2019, the enrollment response looks like this:

<families>
  <family
     code="FAM01"
     startDate="2016-01-01"
  />
</families>
<products>
  <product
     code="PROD_B"
     contractDate="2019-01-01"
     contractEndDate="2019-06-30"
     startDate="2019-07-17"
     endDate="2019-07-17"
     coverageLevel="2"
  </product>
  <product
     code="PROD_C"
     contractDate="2019-07-01"
     startDate="2019-07-17"
     endDate="2019-07-17"
     coverageLevel="1"
     previousPayerStartDate="2019-01-01"
   />
  </product>
 </products>

Previous Payer Portability - Advanced Options

In the case that the waiting period start date from a previous payer is not directly related to a (policy enrollment) product but to a service type (e.g. Surgical, Radiation Therapy) extensibility on the policy enrollment can be used to store waiting period start date and coverage level for a specific service type. The service types in policies should match those defined in Claims (e.g. through a flex code definition).

The enrollment status response dynamic logic in Policies uses this information to include waitingPeriodStartDate elements in the enrollment response. Waiting period start dates are stored in Claims as Policy Waiting Period Start Dates when receiving the enrollment response. Dynamic logic must be set up in Claims to extract the correct waiting period start date as part of waiting period evaluation, e.g. by using a waiting period start date function on the waiting period regime.

In the example below the member has waiting period start dates in Policies for two service types: Therapy and Physician Services.

<families>
   <family
      code="FAM01"
      startDate="2016-01-01"
   />
</families>
<waitingPeriodStartDates>
   <waitingPeriodStartDate
      serviceOptionServiceCode="Therapy"
      startDate="2018-01-01"
      coverageLevel="2"
  />
  <waitingPeriodStartDate
      serviceOptionServiceCode="Physician Services"
      startDate="2018-08-01"
      coverageLevel="3"
  />
</waitingPeriodStartDates>
<products>
   <product
      code="PROD_B"
      contractDate="2019-07-01"
      startDate="2019-09-17"
      endDate="2019-09-17"
      coverageLevel="1"
   />
</products>

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