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ER: Re-calculate Premium Per Member Instead of Per Policy (Doc ID 2513106.1)

Last updated on DECEMBER 04, 2019

Applies to:

Oracle Health Insurance Enterprise Policy Administration - Version 3.18.3.0.0 and later
Information in this document applies to any platform.

Goal

ENHANCEMENT REQUEST:
=====================

Add the option to run premium calculation for a single member on a single policy, for example by adding two parameters to the calculation process that accept the member code and the policy code. Leaving policy code empty would recalculate the member for all policies. Leaving member code open would recalculate all members for this single policy.

Example 1:
Configuration:
Premiums are based on product, age and gender. Lower age results in lower premium. Females have lower premiums than males in the same age range.
The standard change event on member updates only recalculates from the start of the current contract period.
An exceptional change event on member updates (for example in case of fraud) recalculates from the start of the first contract period of the member.
Use case:
1 Policy with 5 contract periods and 2 members  (A & B)
Step 1:  
An employee accidentally insertsmember A as Female instead of Male.
Result: After correction of the gender of member A premium re-calculation is calculated ONLY for the current contract period.
Step 2:
A few days later  it shows that member B has intentionally subscribed with a lower age to get a lower premium.
Result: This is considered fraud and it is decided that all 5 contract periods will be recalculated, but only for member B. Member A’s premium of the first 4 contract periods should NOT be recalculated and should stay the same amount even if the gender for member A has changed for these 4 contract periods.

.
Example 2:
Configuration:
Premiums are based on product, age and gender. Lower age results in lower premium. Females have lower premiums than males in the same age range. Product X has lower rates than product Y. Enrollment for product X is restricted to members living in Abu Dhabi.
The standard change event on member updates only recalculates from the start of the current contract period.
Use case:
1 Policy with 5 contract periods and 2 members  (A & B)
Step 1:  
An employee accidentally inserts member A as Female instead of Male.
Result: After correction of the gender of member A premium re-calculation is calculated ONLY for the current contract period.
Step 2:
Member B is enrolled on product X. For member B it was recently discovered that he moved from Abu Dhabi to Dubai in the previous contract period. Because of that new location he was not eligible for product X anymore. Starting on the effective date (in the previous contract period) member B's enrollment on product X is ended and from that date on he is enrolled on product Y.
The move from product X to Y must be recalculated and billed to the customer. Also the previous contract period should be recalculated. But the change of the gender of member A should NOT be recalculated for the previous contract period.


Solution

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In this Document
Goal
Solution
References


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