Group Customer Overview
Group Customer
Group Insurance provides a single insurance policy that covers groups of employees and their dependents on behalf of the company or organization to which they belong. The company or organization is called a Group Customer in the Oracle Insurance Group Policy Administration system. See Customer.
Agreements
Based on the organization's needs, the terms of the Group insurance product are negotiated and the organization is designated as a Group Customer, enters into an Agreement with the Insurance Carrier. The Agreement will provide information on the contract between the Carrier and the Group Customer detailing the Plan/Sub-Plan offerings available to members(Master Agreement). However, the Agreements may be funding, financial, or service related and may not have Plan/Sub-Plan offerings or coverage attached. New Plans can be created within the Plans tab under a specific Agreement. See Agreements.
Relationships
The Group Customer will have Relationships with clients and non-group customer entities. The ability to connect or link the Group Customer to employees, contacts, Human Resources Administrators and Account Managers, and other affiliations is key in establishing relationships within OIPA. Relationships have types that include Primary and Secondary. A Primary Relationship type describes the general point of contact. The Secondary Relationship further defines the specific title, properties / characteristics of the Relationship. For example, the Primary Relationship may be an employee. The Secondary Relationship further defines the employee as Full Time, Part Time, or Contractor. Users can add and maintain Relationships. The type of Relationship will drive what activities (Client-Relationship Activities) are eligible for processing for the Group Customer Relationship. See Relationships
Class Groups and Classes
The Group Customer selects the product and plan offerings that will be offered to various subsets [Classes] of its overall employee population. Classes provide a way for the employee population to be divided into groups based on similar characteristics the employees share. Rules provide a systematic way for determining which employees belong to a particular Class as a Member. Membership Rules are configured similarly to Math Variables with the Class > Class Rule Variables and Class Rules. Class Rule Variables can exist at the Global, Group Customer, Class Group, and Class level. See Membership Rules
Note: The Group Customer can divide the population for an infinite number of reasons, such as billing, reporting, or eligibility purposes. See Classes
Examples of Classes include:
- Full Time
- Part Time
- Union
- Non-Union
- Management
- Non-Management
- Location (Payroll location)
- Active Employees
- Retried Employees
Classes are arranged into a collection called a Class Group based on the Group Customer's needs. See Class Groups.
The example above illustrates that any EE in "Local 1 EEs" had to funnel down through (and were considered a 'virtual' member of) "Union EEs", "Full Time EEs", "Hourly EEs", and "ALL Employees (Root)" starting from the bottom up.
The execution of Membership Rules will begin at the Root Class and work down with the intent that the Rules are defined that every Class will be defined such that an individual can only resolve to one leaf / terminal node Class within the Class Group.
Plan Eligibility and Enrollment
Eligibility provides the stipulated requirements (to participate, compete, or work) in which a class member is qualified to enroll in a Plan / Sub-Plan. Based on parameters and rules set by the Group Customer, the Group Customer will filter what Plans/Sub-Plans are available to the members at a particular point in time, via Classes. As a member's characteristics change over time (salary change, job title, or status, qualifying life event ) they may become eligible for different Plans/Sub-Plans. The Plans available or associated to a Class and the participants enrolled in the Plan can be viewed on the Plan Class Segment Screen. See Plan Class Segments
Note: For definitions of Product, Plan, Sub-Plan refer to Product Plan Overview.
Enrollment or to enroll is the act of selecting/registering coverage(s) for the members/dependents. The enrollment period can be any of the following types:
- Open: specified number of months to enroll and guaranteed issue/no underwriting.
- Relaxed: set number of questions, relaxed underwriting
- Evergreen: no closed period, can enroll at any time, no relaxed underwriting rules
- Qualified Life Event: Open 30 day window for the member
- Auto Enrollment: Noncontributory benefits that do not require enrollment by the member
Enrollment
Enrollment is the process performed by an eligible member or an employee of the Group Customer where benefits are chosen and dependents / beneficiaries are designated. The Enrollment Screen allows for the manual entry of enrollments for a Group Customer.
Logic and rules defined by the Group Customer are enforced during the enrollment process. An enrollment period designates the timeframe in which the member has to register for coverage(s).
A policy certificate will be issued to the participant upon completion of the enrollment and approval of the coverage(s). The participant that has enrolled in a group plan has the right to elect dependents and beneficiaries.
Data Intake
Insurance Companies/Carriers must be able to receive, process, and apply Group Customer Data Intake files which provide Employee/Sponsor and/or Policy Coverage data. The files include additions, changes, and deletions pertaining to both Employee and Coverage data. The Sponsor information as well as the Coverage information will need to be updated. This is achieved through the use of a transaction, at the Group Customer level where the receipt of the intake file will trigger and produce individual transactions at the policy/certificate level. The process is housed on Data Intake Screen. The transactions may be viewed, filtered, reversed, and you may also drill down to member record level details.