Overview

The scenarios to follow explain the premium calculation process. Each scenario focuses on different and multiple aspects of the premium calculation process. The scenario describes the evaluation of the premium configuration and then applies the evaluated configuration to create calculation result lines and calculation results for the calculation period(s). The look back date for each scenario is 1 Jan 2014.

Scenarios

Scenario A

This scenario explains premium calculation for a policy without a group account or contract period. The policy has only one policy enrollment fore the member W. Wright. W. Wright is enrolled on the BASIC PLAN product. The premium calculation in this scenario uses system calculation periods.

This scenario focuses on:

  • The evaluation of the configuration

  • The calculation period based method for premium calculation

  • The creation of the calculation results for the premiums, adjustments and surcharges.

Scenario B

This scenario explains premium calculation for a policy with a contract period. The policy has two policy enrollments, one for M. Henderson and one for J. Henderson. M. Henderson is enrolled on the BASIC PLAN product. J. Henderson is enrolled on the SILVER PLAN product with the Preventive Care add-on. The premium calculation in this scenario uses system calculation periods.

This scenario focuses on:

  • The definition of a contract period on the policy and using the contract period based method for premium calculation.
    The system considers the reference date of the contract period as the reference date for all time dependent data for all calculation periods within that contract period.

  • The calculation of two different enrollment products within one policy.
    Although the same adjustments and surcharges apply to both enrollment products, the applicable amounts vary.

  • The calculation of add-on premiums.

Scenario C

This scenario explains premium calculation for a policy within a group account, without a contract period. The addition of a group account introduces changes in the way the system evaluates time periods. Therefore, the applicable adjustment rules, surcharges and add-on values change in comparison to a policy without a group account for the same enrollment product. The premium calculation in this scenario uses system calculation periods.

This scenario focuses on:

  • Time period resolution for a policy within a group account.

  • The effect of reference date changing with the calculation periods on the calculation period based method.

Scenario D

This scenario explains premium calculation for a policy within a group account and having a contract period. The premium calculation in this scenario uses system calculation periods.

This scenario focuses on:

  • The contract period based calculation method

  • The evenly distribution of amounts

Scenario E

This scenario explains premium calculation for a policy within a group account, a contract period, enrollment product adjustments, and group account product adjustments. The premium calculation in this scenario uses system calculation periods.

This scenario focuses on:

  • The combination of enrollment product adjustments and group account product adjustments.

Scenario F

This scenario explains the premium calculations when the group account and the contract period change within a calculation period. The premium calculation in this scenario uses system calculation periods.

This scenario focuses on:

  • Multiple changes within one calculation period. The calculation period splits into multiple calculation period segments.

Scenario G

This scenario explains premium calculations for a weekly collection setting. The policy has no group account or contract period. It has one policy enrollment product. The premium calculation in this scenario uses policy calculation periods.

This scenario focuses on:

  • Weekly collection cycles

  • Policy period split to charge different premiums as soon as members age changes

Premium Configuration

The scenarios use the following premium configuration.

Default Time Periods

Code Start Date End Date

Calendar Year 2013

1-Jan-2013

31-Dec-2013

Calendar Year 2014

1-Jan-2014

31-Dec-2014

Calendar Year 2015

1-Jan-2015

31-Dec-2015

System Calculation Periods

Alias Start Date End Date Reference Date

Jan'15

1-Jan-2015

31-Jan-2015

1-Jan-2015

Feb'15

1-Feb-2015

28-Feb-2015

1-Feb-2015

Mar'15

1-Mar-2015

31-Mar-2015

1-Mar-2015

Apr'15

1-Apr-2015

30-Apr-2015

1-Apr-2015

May'15

1-May-2015

31-May-2015

1-May-2015

June'15

1-Jun-2015

30-Jun-2015

1-Jun-2015

July'15

1-Jul-2015

31-Jul-2015

1-Jul-2015

Aug'15

1-Aug-2015

31-Aug-2015

1-Aug-2015

Sep'15

1-Sep-2015

30-Sep-2015

1-Sep-2015

Oct'15

1-Oct-2015

31-Oct-2015

1-Oct-2015

Nov'15

1-Nov-2015

30-Nov-2015

1-Nov-2015

Dec'15

1-Dec-2015

31-Dec-2015

1-Dec-2015

Premium Schedules

BASIC PLAN - Amount Interpretation: Calculation Period

Default Time Period Age From Age To Gender Premium

Calendar Year 2013

-

49

-

90.00

Calendar Year 2013

50

-

-

110.00

Calendar Year 2014

-

49

-

100.00

Calendar Year 2014

50

-

-

120.00

Calendar Year 2015

-

49

-

105.00

Calendar Year 2015

50

-

-

125.00

SILVER PLAN - Amount Interpretation: Calculation Period

Default Time Period Age From Age To Gender Premium

Calendar Year 2013

-

49

-

100.00

Calendar Year 2013

50

-

-

120.00

Calendar Year 2014

-

49

-

105.00

Calendar Year 2014

50

-

-

122.00

Calendar Year 2015

-

49

-

110.00

Calendar Year 2015

50

-

-

135.00

GOLD PLAN - Amount Interpretation: Yearly

Default Time Period Age From Age To Gender Premium

Calendar Year 2013

-

49

-

1300.00

Calendar Year 2013

50

-

-

1400.00

Calendar Year 2014

-

49

-

1400.00

Calendar Year 2014

50

-

-

1500.00

Calendar Year 2015

-

49

-

1500.00

Calendar Year 2015

50

-

-

1700.00

KINETIC VISION PLAN - Amount Interpretation: Yearly

Default Time Period Age From Age To Gender Premium

Calendar Year 2014

-

49

-

1400.00

Calendar Year 2014

50

-

-

1500.00

KINETIC BASIC PLAN - Amount Interpretation: Yearly

Default Time Period Age From Age To Gender Premium

Calendar Year 2015

50

65

-

22.00

Calendar Year 2015

66

-

-

25.00

FIT 50 PLAN - Amount Interpretation: Specific - 7 Days

Default Time Period Age From Age To Gender Premium

Calendar Year 2015

-

49

-

1600.00

Calendar Year 2015

50

-

-

1800.00

Adjustment Rules

Payment Frequency Discount

  • Per Calculation Period

  • Premium Scope = Total

  • Line/Rule Evaluation Condition for Payment Frequency Discount
    EVALUATE_COLLECT_FREQ is

    returnpolicyEnrollmentProduct.policyEnrollment.policy.policyCollectionSettings.
asOf(referenceDate)[0].advanceLength = adjustmentRule.paymentFrequency.longValue()
Time Period Frequency (CPs)
Dimension type 'Generic'		 Value Type

Calendar Year 2013

6

-1

Percentage

12

-1.5

Percentage

Calendar Year 2014

6

-1

Percentage

12

-1.5

Percentage

Calendar Year 2015

6

-1.75

Percentage

12

-2.5

Percentage

Office Visit Co-payment

  • Per Year

  • Premium Scope = Total

Time Period Frequency (CPs)
Dimension type 'Generic'		 Value Type

Calendar Year 2013

10

0.00

Amount

20

-50.00

Amount

Calendar Year 2014

10

-0

Percentage

20

-5

Percentage

30

-7

Percentage

Calendar Year 2015

10

0

Percentage

20

-5

Percentage

Surcharge Rules

Regional Tax

  • Per CP

  • Surcharge Rule Evaluation = On Premium

  • Distribute = Yes

Time Period Region Code
Dimension type 'Dynamic Field'		 Value Type

Calendar Year 2013

MH

2

Percentage

AH

3

Amount

Calendar Year 2014

MH

2.5

Percentage

AH

3.25

Percentage

Calendar Year 2015

MH

2.5

Percentage

AH

3.5

Percentage

Post Discount Administrative Surcharge * Per CP * Surcharge Rule Evaluation = After Adjustment * Distribute = No

Time Period Value Type

Calendar Year 2013

1.75

Percentage

Calendar Year 2014

1.5

Percentage

Calendar Year 2015

1

Percentage

=== Enrollment Products

==== BASIC PLAN

Enrollment Product Time Period Adjustment Add-on Premium Schedule

BASIC PLAN 13-14

1-Jan-2013

31-Dec-2014

Payment Frequency Discount

-

BASIC PLAN 15-16

1-Jan-2015

31-Dec-2016

Payment Frequency Discount

-

==== SILVER PLAN

Enrollment Product Time Period Adjustment Add-on Premium Schedule

SILVER PLAN 13

1-Jan-2013

31-Dec-2013

-

Preventive Care, one add-on premium schedule line specifying 5%

SILVER PLAN 14

1-Jan-2014

31-Dec-2014

Office Visit Co-payment
Payment Frequency Discount

Preventive Care, one add-on premium schedule line specifying 5%

SILVER PLAN 15

1-Jan-2015

31-Dec-2015

Office Visit Co-payment
Payment Frequency Discount

Preventive Care, one add-on premium schedule line specifying 4.00 (amount interpretation is calculation period)

==== GOLD PLAN * Amount Distribution Evenly

Enrollment Product Time Period Adjustment Add-on Premium Schedule

BASIC PLAN 13-14

1-Jan-2013

31-Dec-2014

Payment Frequency Discount
Office Visit Co-payment

Preventive Care, one add-on premium schedule line specifying 4.5%

BASIC PLAN 15-16

1-Jan-2015

31-Dec-2016

Payment Frequency Discount
Office Visit Co-payment

Preventive Care, one add-on premium schedule line specifying 4.5%

==== KINETIC VISION PLAN * Amount Distribution Evenly

Enrollment Product Time Period Adjustment Add-on Premium Schedule

KINETIC VISION PLAN 14-15

1-Jan-2014

31-Dec-2014

Office Visit Co-payment
Payment Frequency Discount

-

==== KINETIC BASIC PLAN * Amount Distribution Evenly

Enrollment Product Time Period Adjustment Add-on Premium Schedule

KINETIC BASIC PLAN 15-16

1-Jan-2015

31-Dec-2015

Office Visit Co-payment
Payment Frequency Discount

-

=== Group Accounts

==== ORCL ===== Group Account Time Period - ORCL 2015 - 1-Jun-2014 To 31-May-2015

Group Account Product: SILVER PLAN

Add-on:

  • Premium Schedule: Preventive Care

  • Add-on Override: -4%

Adjustment: Office Visit Co-payment

* Co-payment of 10 gives 0% discount
* Co-payment of 20 gives 5% discount
* Co-payment of 30 gives 7% discount

Group Account Product: GOLD PLAN

Add-on: -

Adjustment: Office Visit Co-payment
* Co-payment of 10 gives 0% discount
* Co-payment of 20 gives 5% discount
* Co-payment of 30 gives 7% discount

===== Group Account Time Period - ORCL 2016 - 1-Jun-2015 To 31-May-2016

Group Account Product: SILVER PLAN

Add-on: -

Adjustment: Office Visit Co-payment

* Co-payment of 10 gives 0% discount
* Co-payment of 20 gives 6% discount

Group Account Product: GOLD PLAN

Add-on: -

Adjustment: Office Visit Co-payment
* Co-payment of 10 gives 0% discount
* Co-payment of 20 gives 6% discount

=== ORCL CORP 2015 ==== Group Account Time Period - ORCL CORP - 1-Jun-2014 To 31-May-2015

Group Account Product: SILVER PLAN

Add-on:

  • Premium Schedule: Preventive Care

  • Add-on Override: -4%

Adjustment sequence 1: Office Visit Co-payment

* Co-payment of 10 gives 0% discount
* Co-payment of 20 gives 5% discount
* Co-payment of 30 gives 6% discount

Adjustment sequense 2: Payment Frequency Discount
* Payment Frequency of 6 gives 1% discount
* Payment Frequency of 12 gives 1.5% discount

=== ORCL PART TIME 2014 ==== Group Account Time Period - ORCL PART TIME 2014 - 15-Jan-2014 To 14-Jan-2015

Group Account Product: SILVER PLAN

Add-on: -

Adjustment: Payment Frequency Discount
* Payment Frequency of 6 gives 1% discount
* Payment Frequency of 12 gives 1.5% discount

=== ORCL FULL TIME 2015 ==== Group Account Time Period - ORCL FULL TIME 2015 - 15-Jan-2015 To 14-Jan-2016

Group Account Product: SILVER PLAN

Add-on: -

Adjustment: Payment Frequency Discount
* Payment Frequency of 6 gives 1% discount
* Payment Frequency of 12 gives 1.5% discount