Examples

Example 1 - Better Previous Plan

The predefined method checks if a previous connecting product time window exists.
'Previous connecting' means:

1. The start date of the current product time window is the end date + 1 of the previous product.

2. The product in the previous product time window has a product covered service with the same service option service code but an equal or better score as the person covered service the method is currently creating.

   In order to find the earliest start date of the service in a previous product, the system keeps moving back in the product history, as long as the previous covered service has an equal or better score.

Consider the following product covered services:

NOTE

The Limit value is not part of the product covered service. It is only included in the table for explanation.

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5
Plan B	Vision	Limit	700	7
Plan C	Vision	Limit	600	6

Member John Doe enrolled on Plan A from the start of January 2019 up to the end of March 2019. Then he moved to Plan B where he enrolled at the start of April 2019 until the end of May 2019. In May he moved to plan C where he enrolled as of 1 Jun 2019.

Moving from plan A to plan B was an upgrade because plan B has a higher cover limit, which reflects in the higher score. Moving from plan B to plan C is a downgrade because plan C has a lower cover limit, which reflects in a lower score.

The method generates three person covered services:

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	31 Mar 2019	5	Limit	1 Jan 2019
Plan B	Vision	1 April 2019	31 May 2019	7	Limit	1 April 2019
Plan C	Vision	1 Jun 2019	-	6	Limit	1 April 2019

The wait start date for plan A is the product start date. There is no previous plan. The wait start date for plan B is 1 April 2019; there is a previous product but that has a lower score therefore the method does not consider the start date of that previous plan. Plan C has a previous plan with a better score. Therefore the wait start date of the previous plan applies to plan C.

Example 2 - Chain of Better Previous Plans

The product covered services are the same as in example 1

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5
Plan B	Vision	Limit	700	7
Plan C	Vision	Limit	600	6

Member John Doe enrolled on Plan B from the start of January 2019 up to the end of March 2019. Then he moved to Plan C where he enrolled at the start of April 2019 until the end of May 2019. In May he moved to plan A where he enrolled as of 1 Jun 2019.

Moving from plan B to plan C was a downgrade because product B has a higher cover limit, which reflects in the lower score. Moving from product C to product A is also a downgrade because product C has a lower cover limit, which reflects in a lower score.

The method generates three person covered services:

Product	Service	Start	End	Score	Type	Wait Start Date
Plan B	Vision	1 Jan 2019	31 Mar 2019	7	Limit	1 Jan 2019
Plan C	Vision	1 April 2019	31 May 2019	6	Limit	1 Jan 2019
Plan A	Vision	1 Jun 2019	-	5	Limit	1 Jan 2019

The wait start date for plan B is the product start date for plan B. There is no previous plan. Plan C has a previous plan with a better score. Therefore the wait start date of the previous plan (B) applies to plan C. Plan A has a previous plan with a better score. Therefore the wait start date of the previous plan (B) applies to plan C.

Example 3 - Previous Lesser Plan

The product covered services are the same as in example 1

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5
Plan B	Vision	Limit	700	7
Plan C	Vision	Limit	600	6

Member John Doe enrolled on Plan A from the start of January 2019 up to the end of March 2019. Then he moved to Plan C where he enrolled at the start of April 2019 until the end of May 2019. In May he moved to plan B where he enrolled as of 1 Jun 2019.

Moving from plan A to plan B was an upgrade because plan C has a higher cover limit, which reflects in the higher score. Moving from plan C to plan B is an upgrade because plan B has a higher cover limit, which reflects in a higher score.

The method generates three person covered services:

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	31 Mar 2019	6	Limit	1 Jan 2019
Plan C	Vision	1 April 2019	31 May 2019	7	Limit	1 April 2019
Plan B	Vision	1 Jun 2019	-	5	Limit	1 June 2019

The wait start date for plan A is the product start date for plan A. There is no previous plan. The wait start date for plan C is 1 April 2019; there is a previous plan but that has a lower score therefore the method does not consider the start date of that previous plan. The wait start date for plan B is 1 June 2019; there is a previous plan but that has a lower score therefore the method does not consider the start date of that previous plan.

Example 4 - Enrollment Gap

The product covered services are the same as in example 1

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5
Plan B	Vision	Limit	700	7
Plan C	Vision	Limit	600	6

Member John Doe enrolled on Plan B from the start of January 2019 up to the end of February 2019. Then he moved to Plan C where he enrolled at the start of March 2019 until the end of April 2019. In May he was not enrolled. In June he enrolled on plan A as of 1 June 2019.

Moving from plan B to plan C was a downgrade because plan C has a lower cover limit, which reflects in the lower score. Moving from plan C to plan A is also a downgrade because plan A has a lower cover limit, which reflects in a lower score.

The method generates three person covered services:

Product	Service	Start	End	Score	Type	Wait Start Date
Plan B	Vision	1 Jan 2019	28 Feb 2019	7	Limit	1 Jan 2019
Plan C	Vision	1 Mar 2019	30 April 2019	6	Limit	1 Jan 2019
Plan A	Vision	1 Jun 2019	-	5	Limit	1 Jun 2019

The wait start date for plan B is the product start date for plan B. There is no previous plan. The wait start date for plan C is 1 Jan 2019; there is a previous plan with a higher score, therefore the method picks the start date of that previous plan. Plan A has a previous plan C with a better score. However the gap between the enrollment on plan C and the enrollment on plan A restricts the use of the earlier start date.

Example 5 - Previous Plan does not cover Service

The product covered services are different from example 1. Only plan C has the service Vision.

Product	Service	Type	Value	Score
Plan C	Vision	Limit	600	6

Member John Doe enrolled on Plan B from the start of January 2019 up to the end of April 2019. Then he moved to Plan C where he enrolled at the start of May 2019.

As plan B does not cover Vision, the system does not create a person covered service for plan B and Vision.

NOTE

The system wiil create person covered services for the other services under plan B but these are out of the context of this example.

As plan C does cover Vision the system creates a person covered service for plan C Vision.

Product	Service	Start	End	Score	Type	Wait Start Date
Plan C	Vision	1 May 2019	-	6	Limit	1 May 2019

Example 6 - Previous Plan Does Not Cover Service In Between

The product covered services are different from example 1. Only plan A and plan C have the service Vision.

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5
Plan C	Vision	Limit	600	6

Member John Doe enrolled on Plan C from the start of January 2019 up to the end of March 2019. Then he moved to Plan B where he enrolled at the start of April 2019. Plan B does not cover the service Vision. Then he moved to plan A as of 1 June 2019.

As plan B does not cover Vision, the system does not create a person covered service for plan B and Vision.

NOTE

The system wiil create person covered services for the other services under plan B but these are out of the context of this example.

As plan C does cover Vision the system creates a person covered service for plan C Vision.

Product	Service	Start	End	Score	Type	Wait Start Date
Plan C	Vision	1 Jan 2019	31 Mar 2019	5	Limit	1 Jan 2019
Plan A	Vision	1 Jun 2019	-	6	Limit	1 Jun 2019

Although the member was enrolled on plan C with a higher score for Vision, plan A does not inherit plan C’s wait start date because of the 'Vision-less' plan B in between.

Example 7 - Two Covered Service Types

In this example each product / service combination has a score for the limit(s) and a score for the parameter(s).

NOTE

The limit score represents all limits for this product / service combination. If, for example, a product / service combination would have a cover limit and a out of pocket limit, the two limits together have one score. The same applies for the parameters. If a product / service combination would have a copay and a coinsurance parameter, the two parameters would have one score.

Consider the following product covered services

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5
Plan A	Vision	Parameter	100	-1
Plan B	Vision	Limit	700	7
Plan B	Vision	Parameter	150	-2

In this example we gave the parameter scores a negative value to reflect that the higher copay is a lesser score. This however is not necessary. We could have chosen a score 1 for copay 150 and a score 2 for a copay 100 with the same result.

Member John Doe enrolled on Plan A from the start of January 2019 up to the end of May 2019. Then he moved to Plan B where he enrolled at the start of June 2019.

From a limit point of view, moving from plan A to plan B is an upgrade because plan B has a higher cover limit, which reflects in the higher limit score. However, from a parameter point of view, moving from plan A to plan B is a downgrade because plan B has a higher copay. which reflects in a lower score.

The method generates four person covered services:

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	31 May 2019	5	Limit	1 Jan 2019
Plan A	Vision	1 Jan 2019	31 May 2019	-1	Parameter	1 Jan 2019
Plan B	Vision	1 Jun 2019	-	7	Limit	1 Jun 2019
Plan B	Vision	1 Jun 2019	-	-2	Parameter	1 Jan 2019

The wait start date for the limit of plan A is the product start date. There is no previous plan.

The wait start date for the parameter of plan A is the product start date. There is no previous plan.

The wait start date for the limit for plan B is 1 Jun 2019; there is a previous product but that has a lower score, therefore the method does not consider the start date of that previous plan.

The wait start date for the parameter for plan B is 1 Jan 2019; there is a previous product with a higher score, therefore the method applies the start date of that previous plan.

Example 8A - Transfer Certificates

In this example we only look at the product covered service Vision for Plan A. Of course there could exist more services for this product.

Product	Service	Type	Value	Score
Plan A	Vision	Limit	500	5

Member John Doe enrolls on Plan A on 1 June 2019. He had been enrolled on Plan Q up to the end of April at a previous payer. The current payer received a transfer certificate for Vision covering the period from the beginning of January up to the end of April. This transfer certificate is stored under the member as a person covered service for product code 'TC'.

NOTE

Person covered services that represent a transfer certificate should have the 'Locked' indicator set to Yes, to prevent that the predefined method discards them as part of regeneration.

In this example we specify the 'Number of Portability Days' and the 'Product Code for Transfer Certificates' parameters of the predefined method as '60' and 'TC'.

NOTE

The member does not need to have a policy product for this Transfer Certificate product.

If the start date of the current product time window is between start date + 1 and (end date + 1 + Number of Portability Days), of the transaction certificate person covered service, the method uses the start date of that person covered service as wait start date for the new person covered service.

In this example the start date of the enrollment on plan A is 1 June 2019. This date is between the start date + 1 of the transfer certificate (1 January 2019) and the end date + 1 + Number of portability days of the transfer certificate (1 May + 60 days = 29 June 2019). The wait start date is set to the start date of the transfer certificate.

NOTE

The score of the person covered service that represents the transfer certificate is optional. If the score is empty, the transfer certificate is considered 'equal or better' than the current product covered service. If the score is not empty, the system only considers transfer certificates with an equal or better score as the current product covered service.

Portability Not Met

Now consider that the 'Number of Portability Days' would have been set to 25 days instead of 60. Then the enrollment start date would NOT have been between the start date + 1 of the transfer certificate (1 January 2019) and the end date + 1 + Number of portability days of the transfer certificate (1 May + 25 days = 26 May 2019). The wait start date is set to the start date of the enrollment on Plan A, not to the start date of the transfer certificate.

Example 8B - Transfer Certificates - No TC Received

Like in example 8A member John Doe enrolls on Plan A on 1 June 2019. He had been enrolled on Plan Q up to the end of April at a previous payer. In this example the current payer did not receive a transfer certificate from the previous payer yet. As a service to the customer the current payer waives the waiting period.

Step 1

The predefined method generates person covered services with a wait start date equal to the date of the current enrollment . The dynamic logic function sets the 'Waived?' indicator to Yes, based on a customer defined dynamic field that specifies that a transfer certificate is expected. Note that it should only set the 'Waived' indicator if it does not find a transfer certificate. The dynamic logic function also sets the waiver reason (optional).

Step 2

When the transfer certificate is loaded, the user submits the policy for approval, which includes the (re-)generation of the person covered services. The predefined method discards all person covered services except for the locked ones ^[1], and regenerates them. Like in example 8A it will check the portability of the transfer certificate and set the wait start date of the new person covered services accordingly. Because the dynamic logic found a transfer certificate, it does not set the 'Waived' indicator to Yes.

Example 9 - Locked Person Covered Services

This example explains how the method regenerates person covered services if Locked person covered services are in place. In this example we only look at the product covered service Vision for plan B.

Product	Service	Type	Value	Score
Plan B	Vision	Limit	400	4

Member John Doe enrolled on Plan B from the start of January 2019 up to the end of April 2019.

Person covered services were generated for this enrollment and they were, for some reason, locked.

Product	Service	Start	End	Score	Type	Wait Start Date	Locked?
Plan B	Vision	1 Jan 2019	30 April 2019	4	Limit	1 Jan 2019	Yes

Then the enrollment on Plan B was updated. It now starts on the first of February and ends on 31 July 2019.

The predefined method will not remove the existing person covered services as it is locked. It will add a person covered service for the additional enrollment time period. This person covered service will not be locked by the predefined method. The wait start date is equal to the wait start date of the existing, locked, person covered service.

Product	Service	Start	End	Score	Type	Wait Start Date	Locked?
Plan B	Vision	1 Jan 2019	30 April 2019	4	Limit	1 Jan 2019	Yes
Plan B	Vision	1 May 2019	31 July 2019	4	Limit	1 Jan 2019	No

NOTE

The score of the new person covered service is selected from the product covered service, not from the locked person covered service. This means that the new person covered service can have a different score than the existing, locked, person covered service.

Example 10 - Locked and Waived Person Covered Services

This example explains how the method regenerates person covered services if a Locked and Waived person covered service is in place. In this example we only look at the product covered service Vision for plan B.

Product	Service	Type	Value	Score
Plan B	Vision	Limit	400	4

Member John Doe enrolled on Plan B from the start of January 2019 up to the end of April 2019.

Person covered services were generated for this enrollment and they were Waived and locked.

Product	Service	Start	End	Score	Type	Wait Start Date	Locked?	Waived?
Plan B	Vision	1 Jan 2019	30 April 2019	4	Limit	1 Jan 2019	Yes	Yes

Then the enrollment on Plan B was updated. It now starts on the first of February and ends on 31 July 2019.

The predefined method will not remove the existing person covered services as it is locked. It will add a person covered service for the additional enrollment time period. This person covered service will be locked and waived by the predefined method. The wait start date is equal to the wait start date of the existing person covered service.

Product	Service	Start	End	Score	Type	Wait Start Date	Locked?	Waived?
Plan B	Vision	1 Jan 2019	30 April 2019	4	Limit	1 Jan 2019	Yes	Yes
Plan B	Vision	1 May 2019	31 July 2019	4	Limit	1 Jan 2019	Yes	Yes

NOTE

The score of the new person covered service is selected from the product covered service, not from the locked person covered service. This means that the new person covered service can have a different score than the existing, locked, person covered service.

Example 11 - Suspended Enrollment

There are multiple ways to define a suspension period in OHI Enterprise Policy Administration, therefor the user must set the wait start date on a person covered service through custome code in the dynammic logic function. In addition, the user must include the suspension period as a policy product in the enrollment response towards OHI Claims Adjudication and Pricing. This policy product must have the Indicator Suspended set to Yes. Suspending an enrollment does not impact the behavior of the predefined method.

In this example we discuss two ways of defining a suspension period and how they define the waiting period.

Continuous Policy Enrollment Period

In this example the member has one, continuous, policy enrollment product with a dynamic record defining the suspension period.

The predefined method generates the default person covered service.

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	-	5	Limit	1 Jan 2019

The custom dynamic logic checks if a 'suspension' dynamic logic record exists that overlaps with the person covered service. If so that logic will

1. set the end date of the person covered service to the start date of the suspension dynamic record - 1.

2. create a new person covered service for the same product, service, type and score. Set the start date to the start date of the suspension dynamic record + 1, set the end date (if applicable) to the end date of the first peco, and set the wait start date to end date of the suspension dynamic record minus the number of days of the first person covered service.

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	28 Feb 2019	5	Limit	1 Jan 2019
Plan A	Vision	1 Jun 2019	-	5	Limit	3 Apr 2019

The Enrollment response that OHI Enterprise Policy Administration sends to OHI Claims Adjudication and Pricing needs to hold the following policy products.

Product	Start	End	Suspended?
Plan A	1 Jan 2019	28 Feb 2019	No
Plan A	1 Mar 2019	31 May 2019	Yes
Plan A	1 Jun 2019	-	No

Two Policy Enrollment Products with a Gap

In this example the member has two policy enrollment products with a gap in betwee that defines the suspension period. The first policy enrollment product holds a dynamic field, defining that the enrollment is suspended until the next enrollment.

The predefined method generates the default person covered services.

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	28 Feb 2019	5	Limit	1 Jan 2019
Plan A	Vision	1 Jun 2019	-	5	Limit	1 Jun 2019

The custom dynamic logic checks if a suspended policy enrollment product exists. If so that logic will update the wait start date of the upcoming person covered service (if applicable). It will set the start date to the generated start date minus the number of days of the first person covered service.

Product	Service	Start	End	Score	Type	Wait Start Date
Plan A	Vision	1 Jan 2019	28 Feb 2019	5	Limit	1 Jan 2019
Plan A	Vision	1 Jun 2019	-	5	Limit	3 Apr 2019

The Enrollment response that OHI Enterprise Policy Administration sends to OHI Claims Adjudication and Pricing needs to hold the following policy products.

Product	Start	End	Suspended?
Plan A	1 Jan 2019	28 Feb 2019	No
Plan A	1 Mar 2019	31 May 2019	Yes
Plan A	1 Jun 2019	-	No

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1. which would include those that represent transfer certificates