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Implementing the ratings process

Pega Sales Automation for Healthcare provides ACA-based sample configurations in the form of data and rules to support rating for small group, individual, and Medicare coverage. Large group coverage has a separate rating engine.

Data tables for ratings

Instances of PegaHC-Data-CoverageCode provide eligibility information by state, market segment and rating area. The class includes the following data elements.

  • County
  • Effective Date
  • Market Segment
  • Rating Area
  • State

Instances of PegaHC-Data-SICFactor holds SIC factors by SICLow, SICHigh and Effective Date, with the following data elements.

  • Description
  • Division ID
  • Effective Date
  • Termination Date
  • Factor
  • Group ID
  • SIC High
  • SIC Low

Instances of PegaHC-Data-PlanRatingArea provide plan information by Plan ID, Market Segment, State, and Rating Area. PegaHC-Data-PlanRatingArea includes the following data elements.

  • County
  • Effective Date
  • End Date
  • Market Segment
  • Plan ID
  • Rating Area
  • State
  • Claim Cost PMPM (per member per month)

Instances of PegaHC-Data-RatingAreaConfig provide coverage categories by ID, with the following date elements.

  • RatingArea
  • StatesCovered

The three categories included with the application are definitions for LOCAL, REGIONAL and NATIONAL.

Rating process

Pega Sales Automation for Healthcare uses easy to maintain data transformation rules to calculate rates.

The key data page for creating quotes is D_SPMGetQuoteEngine. It calls the data transform spmRatingEngineMain. This rule uses the following parameters and factors.

  • BaseRate
  • Employer Contribution Employee
  • Employer Contribution for Others
  • Plan Type
  • Market Segment
  • Sic Factor
  • Group Size Factor (not used)
  • Region Factor (not used)
  • AgeFactor (age bands implement as decision rule)

A group of data transform rules, all called GetSampleRates, implement the data page D_SPMGetQuoteEngine for the following use cases.

  • Small group quotes
  • Individual quotes
  • Reference implementation for rates delivered by an external rating engine, which is used for rating during renewal processing.

Finally the data transform spmCalculateRatingEngineTotals provides the actual rates at the quote and the individual member level.

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