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 2018. The advance length/advance UoM is a premium calculation done in advance, expressed in numbers and is a measure of time.

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.

  • 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 and surcharges 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

Table 1. Default Time Periods
Code Start Date End Date

Calendar Year 2017

January 1, 2017

December 31, 2017

Calendar Year 2018

January 1, 2018

December 31, 2018

Calendar Year 2019

January 1, 2019

December 31, 2019

System Calculation Periods

Table 2. System Calculation Periods
Alias Start Date End Date Reference Date

Jan 2019

January 1, 2019

January 31, 2019

January 1, 2019

Feb 2019

February 1, 2019

February 28, 2019

February 1, 2019

Mar 2019

March 1, 2019

March 31, 2019

March 1, 2019

Apr 2019

April 1, 2019

April 30, 2019

April 1, 2019

May 2019

May 1, 2019

May 31, 2019

May 1, 2019

Jun 2019

June 1, 2019

June 30, 2019

June 1, 2019

Jul 2019

July 1, 2019

July 31, 2019

July 1, 2019 9

Aug 2019

August 1, 2019

August 31, 2019

August 1, 2019

Sep 2019

September 1, 2019

September 30, 2019

September 1, 20199

Oct 2019

October 1, 2019

October 31, 2019

October 1, 20199

Nov 2019

November 1, 2019

November 30, 2019

November 1, 2019

Dec 2019

December 1, 2019

December 31, 2019

December 1, 2019

Premium Schedules

BASIC PLAN - Amount Interpretation: Calculation Period

Table 3. BASIC PLAN - Amount Interpretation: Calculation Period
Default Time Period Age From Age To Gender Premium

Calendar Year 2017

-

49

-

90.00

Calendar Year 2017

50

-

-

110.00

Calendar Year 2018

-

49

-

100.00

Calendar Year 2018

50

-

-

120.00

Calendar Year 2019

-

49

-

105.00

Calendar Year 2019

50

-

-

125.00

SILVER PLAN - Amount Interpretation: Calculation Period

Table 4. SILVER PLAN - Amount Interpretation: Calculation Period
Default Time Period Age From Age To Gender Premium

Calendar Year 2017

-

49

-

100.00

Calendar Year 2017

50

-

-

120.00

Calendar Year 2018

-

49

-

105.00

Calendar Year 2018

50

-

-

122.00

Calendar Year 2019

-

49

-

110.00

Calendar Year 2019

50

-

-

135.00

GOLD PLAN - Amount Interpretation: Yearly

Table 5. GOLD PLAN - Amount Interpretation: Yearly
Default Time Period Age From Age To Gender Premium

Calendar Year 2017

-

49

-

1300.00

Calendar Year 2017

50

-

-

1400.00

Calendar Year 2018

-

49

-

1400.00

Calendar Year 2018

50

-

-

1500.00

Calendar Year 2019

-

49

-

1500.00

Calendar Year 2019

50

-

-

1700.00

KINETIC VISION PLAN - Amount Interpretation: Yearly

Table 6. KINETIC VISION PLAN - Amount Interpretation: Yearly
Default Time Period Age From Age To Gender Premium

Calendar Year 2018

-

49

-

1400.00

Calendar Year 2018

50

-

-

1500.00

KINETIC BASIC PLAN - Amount Interpretation: Yearly

Table 7. KINETIC BASIC PLAN - Amount Interpretation: Yearly
Default Time Period Age From Age To Gender Premium

Calendar Year 2019

50

65

-

22.00

Calendar Year 2019

66

-

-

25.00

FIT 50 PLAN - Amount Interpretation: Specific - 7 Days

Table 8. FIT 50 PLAN - Amount Interpretation: Specific - 7 Days
Default Time Period Age From Age To Gender Premium

Calendar Year 2019

-

49

-

1600.00

Calendar Year 2019

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()
Table 9. Payment Frequency Discount
Time Period Frequency (CPs)
Dimension type 'Generic'		 Value Type

Calendar Year 2017

6

-1

Percentage

12

-1.5

Percentage

Calendar Year 2018

6

-1

Percentage

12

-1.5

Percentage

Calendar Year 2019

6

-1.75

Percentage

12

-2.5

Percentage

Office Visit Co-payment

  • Per Year

  • Premium Scope = Total

Table 10. Office Visit Co-payment
Time Period Frequency (CPs)
Dimension type 'Generic'		 Value Type

Calendar Year 2017

10

0.00

Amount

20

-50.00

Amount

Calendar Year 2018

10

-0

Percentage

20

-5

Percentage

30

-7

Percentage

Calendar Year 2019

10

0

Percentage

20

-5

Percentage

Surcharge Rules

Regional Tax

  • Per CP

  • Surcharge Rule Evaluation = On Premium

  • Distribute = Yes

Table 11. Regional Tax
Time Period Region Code
Dimension type 'Dynamic Field'		 Value Type

Calendar Year 2017

MH

2

Percentage

AH

3

Amount

Calendar Year 2018

MH

2.5

Percentage

AH

3.25

Percentage

Calendar Year 2019

MH

2.5

Percentage

AH

3.5

Percentage

Post Discount Administrative Surcharge

  • Per CP

  • Surcharge Rule Evaluation = After Adjustment

  • Distribute = No

Table 12. Post Discount Administrative Surcharge
Time Period Value Type

Calendar Year 2017

1.75

Percentage

Calendar Year 2018

1.5

Percentage

Calendar Year 2019

1

Percentage

Enrollment Products

BASIC PLAN

Table 13. BASIC PLAN
Enrollment Product Time Period Adjustment Add-on Premium Schedule

BASIC PLAN 17-18

January 1, 2017

December 31, 2018

Payment Frequency Discount

-

BASIC PLAN 19-20

January 1, 2019

December 31, 2020

Payment Frequency Discount

-

SILVER PLAN

Table 14. SILVER PLAN
Enrollment Product Time Period Adjustment Add-on Premium Schedule

SILVER PLAN 17

January 1, 2017

December 31, 2017

-

Preventive Care, premium schedule line specifying a flat charge of 20

SILVER PLAN 18

January 1, 2018

December 31, 2018

Office Visit Co-payment
Payment Frequency Discount

Preventive Care, premium schedule line specifying a flat charge of 20

SILVER PLAN 19

January 1, 2019

December 31, 2019

Office Visit Co-payment
Payment Frequency Discount

Preventive Care, premium schedule line specifying a flat charge of 20 (amount interpretation is calculation period)

GOLD PLAN

  • Amount Distribution Evenly

Table 15. GOLD PLAN
Enrollment Product Time Period Adjustment Add-on Premium Schedule

BASIC PLAN 17-18

January 1, 2017

December 31, 2018

Payment Frequency Discount
Office Visit Co-payment

Preventive Care, premium schedule line specifying a flat charge of $15

BASIC PLAN 19-20

January 1, 2019

December 31, 2020

Payment Frequency Discount
Office Visit Co-payment

Preventive Care, premium schedule line specifying a flat charge of $10

KINETIC VISION PLAN

  • Amount Distribution Evenly

Table 16. KINETIC VISION PLAN
Enrollment Product Time Period Adjustment Add-on Premium Schedule

KINETIC VISION PLAN 18-19

January 1, 2018

December 31, 2018

Office Visit Co-payment
Payment Frequency Discount

-

KINETIC BASIC PLAN

  • Amount Distribution Evenly

Table 17. KINETIC BASIC PLAN
Enrollment Product Time Period Adjustment Add-on Premium Schedule

KINETIC BASIC PLAN 19-20

January 1, 2019

December 31, 2019

Office Visit Co-payment
Payment Frequency Discount

-

Group Accounts

ORCL 2019

Group Account Time Period - ORCL 2019: 1-Jun-2018 To 31-May-2019
Table 18. Group Account Time Period - ORCL 2019: 1-Jun-2018 To 31-May-2019

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 2020: 1-Jun-2019 To 31-May-2020
Table 19. Group Account Time Period - ORCL 2020: 1-Jun-2019 To 31-May-2020

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 2019

Group Account Time Period - ORCL CORP: 1-Jun-2018 To 31-May-2019

Table 20. Group Account Time Period - ORCL CORP: 1-Jun-2018 To 31-May-2019
Group Account Product: SILVER PLAN 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 sequence 2: Payment Frequency Discount * Payment Frequency of 6 gives 1% discount * Payment Frequency of 12 gives 1.5% discount

ORCL PART TIME 2018

Group Account Time Period - ORCL PART TIME 2018: 15-Jan-2018 To 14-Jan-2019

Table 21. Group Account Time Period - ORCL PART TIME 2018: 15-Jan-2018 To 14-Jan-2019

Group Account Product: SILVER PLAN

Adjustment: Payment Frequency Discount

  • Payment Frequency of 6 gives 1% discount

  • Payment Frequency of 12 gives 1.5% discount

ORCL FULL TIME 2019

Group Account Time Period - ORCL FULL TIME 2019: 15-Jan-2019 To 14-Jan-2020

Table 22. Group Account Time Period - ORCL FULL TIME 2019: 15-Jan-2019 To 14-Jan-2020

Group Account Product: SILVER PLAN

Adjustment: Payment Frequency Discount

  • Payment Frequency of 6 gives 1% discount

  • Payment Frequency of 12 gives 1.5% discount