Enrollment Screen Business Rule
Employee / members of a particular class will have the opportunity to enroll in benefits offered by the Group Customer. The determination of eligibility for the employee/member is often based on employment status (full-time, part-time, salaried, or hourly), other rules that may be defined for eligibility and is specific to a class based on or created for the purpose of Eligibility.
Employees are individuals employed by the Group Customer (who may be subject to further qualification such as employment status, as stated above).
Members are those individuals who are not employees, but are individuals belonging to a group, association, or organization such as an alumni, church, or trade association.
The Group Customer divides the population into Classes and an employee can become a Member of a Class.
Membership is defined and executed using Rules (Class Rules and Class Rule Variables) within OIPA. Membership Rules are defined by the Group Customer. The rules define the logic and criteria for which an individual becomes a member of a Class.
A Member may belong to a Class outside of the realm for Enrollment. The Class may be specific to billing, reporting, etc... and not specific to Eligibility and/or Enrollment.
Enrollment is the act performed by an eligible member / employee of the Group Customer where benefits are selected 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.
The policy owner for group insurance is the Group Customer.
How it Works
A member or employee will meet the stipulated requirements set forth by the Group Customer in order to participate and/or qualify for coverage/benefits. Based on the parameters defined by the Group Customer, particular plans are offered to the member/employee at a particular point in time (enrollment period).
Enrollment periods:
- Open: specific number of months for enrollment
- Qualified Life Event: open window based on marriage, divorce, birth of a child
- Auto: Noncontributory benefits that do not require enrollment by the member
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