Enrolment Certifications


Enrolment Certifications

These are more or less same as the Action Types, however with an extra set of handles. We can do a lot of things with the Enrolment Certifications. First of all let's discuss the business need of the Certifications. We will take an example. This guy Joe is enrolled in a "2 X Base Pay" tier in the Employee Term Life Insurance Plan type. However with the Open Life Event he opts for "6 X Base Pay". In scenarios like this, our firm might want a certificate that Joe is doing well in terms of Health, to make sure there are no intentional reasons behind the Jump from 2 X to 6 X; so Joe has to submit a Certificate from a Doctor. And until he gets the Certificate, he will not be eligible to get in to the 6 X tier. Now till the time he submits the Certificate he will be put in 2 X as an interim coverage, and 6 X will be suspended; and the moment he submits the certificate, he will be switched back to the 6 X tier.

So Certifications are one of the major items with which the firm can ensure there is no misuse being done on the Plan elections. Until the Participant submits the Certificate, the elected comp object remains suspended, let's call it the suspended plan. And till that time he might just enjoy the comp object he was in, or may be another comp object with allowable coverage limits, let's call that the Interim plan.

The Certifications are also known as EOI - Evidence of Insurability. There can be a lot of types of Certifications, to name a few examples:

  • Proof Of Good Health
  • Proof of External Coverage
  • Proof of Other Coverage
  • Domestic Partner Affidavit

Let's see the levels at which we can attach EOI and the priority amongst themselves.

  • Generic Plan Level
  • Life Event Plan Level
  • Generic OIPL Level
  • Life Event OIPL Level
  • Generic Coverage Level
  • Life Event Coverage Level

Generic Plan Level

This level, as the name suggests stays at the plan level with no dependency on the Life Event. So if an EOI is attached here, it will always get applied to the Participant making an election in the plan. See Figure 6.30 – EOI Generic Plan.

Responsibility: HRMS Manager

Navigation: Total Compensation -> Program and Plans -> Plan Enrolment Requirements

Figure 30 EOI Generic Plan

(Figure 6.30 – EOI Generic Plan)

Steps: Click on Certifications Button

Enrolment Certification Type

This is where we choose the type of Certification we would need on the Plan

Certification Required by Rule

If we want to add the certification based on some data / business conditions, we can use a rule here.

Required

This flag makes sure the Certification is taken as a Mandatory one. If there are more than one Certification rows, it works the way Eligibility does.

 

Life Event Plan Level

This is specific to Life Events. If the Participant experiences the Life Event and opts for the plan in context, he will have to go for a Certification, provided the rule (if any) satisfies. See Figure 6.31 – EOI Life Event Plan.

Responsibility: HRMS Manager

Navigation: Total Compensation -> Program and Plans -> Plan Enrolment Requirements


(Figure 6.31 – EOI Life Event Plan)

Steps: Click on Life Event Certifications Button

Life Event

Choose the Life Event

Suspend Enrolment

If checked, the plan goes for suspension until the Certificate is submitted.

Determination Code

We can add another level of checks on the Certifications. The Certification will be required, if the Condition in the Determination code matches.

Certification Required By Rule

If we are using a Determination Code for EOI, we can also use a Rule to add in the Business Logic in there.

Enrolment Certification Type

This is where we choose the type of Certification we would need on the Plan.

Certification Required By Rule

If we want to add the certification based on some data / business conditions, we can use a rule here. 

 

Generic OIPL Level

This level is exactly the same as Generic Plan Level, with just one difference. The level is at OIPL; so it is specific to OIPLs.

Responsibility: HRMS Manager

Navigation: Total Compensation -> Program and Plans -> Plan Enrolment Requirements

Steps: Click on General Tab -> Click on Option Tab and now on the "Certifications" tab.

 

Life Event OIPL Level

This Level is similar to the Life Event Plan Level; however unlike the later, it is specific to OIPLs.

Responsibility: HRMS Manager

Navigation: Total Compensation -> Program and Plans -> Plan Enrolment Requirements

Steps: Click on General Tab -> Click on Option Tab and now on the "Life Event Certifications" tab.

Generic Coverage Level

This is the level at which we can have restrictions based on the Coverage amount of the Comp Object. In the Plan level, the Coverage amount is unknown, hence all the Conditions mapped there by the rule, must be based on the enrolments not on the Current Coverage. However in this level, we can add up rules to check the Coverage amount and then decide whether a Certification is required or not, based on the same.

This level is the Generic level, so the restrictions applied here will be working the same way for Life Events. See Figure 6.32 – EOI Generic Coverage.

Responsibility: HRMS Manager

Navigation: Total Compensation -> Program and Plans -> Plan Enrolment Requirements


(Figure 6.32 – EOI Generic Coverage)

Steps: Click on Coverage Drop down; click on Coverage Restrictions.

Restrict Change Based On

There are two choices here:

Benefit Restriction Applies: It is used when we want to have a check at the Plan Level.
Option Restriction Applies: This is for the OIPL Level.

So, if we have OIPLs in place for the Plan, it’s better to use the "Option Restriction Applies".

Change Restriction

We can choose a value from the LOV. This is where we can define the changes allowed with respect to the Coverage amount.

Values

We can enter the min and Max Values that are allowed without certification. Or May be a rule to decide the amounts on the run.

Max Multiple with Certification

We can select the Maximum Multiple of Coverage that is allowed even with a Certification. Multiple Of Coverage is usually based on Option Tiers, for an Example, if this field is marked with 3, one cannot choose 4 X. (Provided 1 X to 4 X are listed in a sequence in the OIPLs)

Max with Certification

This field tells the system about the Maximum Coverage that can be chosen, even if the Participant submits a Certification. In case the Coverage amount goes beyond that number it gets rounded to the Max number.

Increases

If a Participant is already enrolled in a Plan, then the Maximum flat amount up to which the Participant can increase his Coverage amount can be added here. The system simply subtracts the new Coverage and the old Coverage and then compares the Outcome with the Max and Max with Certification. If the number is greater than Max, the Part needs a Certification. If it’s more than the Max with Certification, the Part cannot just opt for it. The Coverage finally gets rounded to the Old Coverage + Max with Certification Number.

Multiple Increases

This acts the same way as the Increases work. However the numbers are not flat amounts, but Multiple Numbers. For an example, if we have 2 as Max, and 4 as Max with Certification, this means, If a Participant is at 1X, he will have to give a certification to go to 4X and he cannot select 6 X.

Interim Assign Code

This is where we can tell the system about the Interim Coverage. If a Participant is required to submit a certification, until he does the same, he gets enrolled in a Com Object for the interim period. The Comp Object is called the Interim Coverage. We will learn more about the interim codes later.

Interim Assign Rule

In a case where the Code does not satisfy the business requirement, we can select a Rule to do that job.

Unsuspend Code

This is where we tell the system the date as per which the Suspended Plan will become the actual plan. Let's say we choose this code to be "First of Month On or After Event"; now, if the participant submits the Certification as of 15th of October, he will be in the interim plan till 30th of November and his suspended plan will be his actual plan as of 1st November.

Certification 

With all this restrictions in place, now it’s time to provide the details on the kind of Certifications that will be needed. This is the screen where we can add a Certification type and/ or a Rule.

 

Life Event Coverage Level

This level is almost the same as the Generic Level; however it is specific to the Life Events. So if a Life event is mentioned here, it will have its own set of restrictions defined, and the system will consider those rules only, ignoring the restrictions at the generic level. There are mainly two differences from the Generic level and the Life Event level here, other than the fact that Generic level is not specific to Life Events:

  • Restrict Change Based on: It is added only at the generic level, as the Comp Object as a whole has to be configured in one way only; either by Plans or by OIPLs. It cannot be based on the Life Events, so it’s missing at the Life Event level.
  • Suspend Enrolment: In a case where the Restriction rules call for a Certification, we have another handle at the Certification block, to either suspend the election or let it be continued, based on a set of determination codes. A few examples of the codes can be: "If never Produced in the Past", "If Enrolled for the first time" etc.

Interim Codes

The Interim code is the one that helps system decide the Plan in which the Participant should stay until the Certification is submitted and the suspended election becomes the actual election. In the Coverage levels, we can define a Code / Rule to set up the Interim. It can either be at the Generic Level or can also be at the Life Event level.


(Figure 6.33 – EOI Interim Codes)

There are a set of 60 values that can be chosen as an Interim Code, or we can simply use a rule instead. If we look at the codes carefully there are three sets. See Figure 6.33 – EOI Interim Codes.

  • Current Same OIPL: If currently enrolled in the same OIPL as being evaluated.
  • Current Same Plan Type: If currently enrolled in the Plan Type.
  • Current Same Plan: If currently enrolled in the Plan being evaluated.

Now, as we know the bigger classification, let's go to the depth. Each of these sets has 20 values each. These are a combination of codes. The codes are:

Default: The one with assign on Default flag checked should be the interim.

Min: The one with the minimum sequence should be the interim. If the tiers are sequenced as 1 X to 5 X, then the Interim will be 1 X

Next Lower: The next available tier where no EOI is required will be the interim. If the tiers are 1X to 5X and anyone with 4X and above requires EOI then, the interim will be 3X, as that's the next lower available with No EOI required on it.

Nothing: No Interim.

Now, we know the codes; then let's take an example: "Current Same Plan Type, Next Lower; New, Min".

What does the code mean?

If the Participant was enrolled in the same plan type earlier, then the Interim will be the Next Lower tier available. Else, if it’s a new enrolment in to the plan then the tier with the minimum sequence should be the Interim coverage.