Creating benefit plan coverage

Coverage varies depending on the benefit group and the coverage class. Benefits administrators define the dependent rules and the default coverage rules.

Fields vary depending on the coverage type and coverage class selected for the benefit plan.

  1. Select Benefits > Plans > Benefit Plans > Benefit Plan.
  2. Click the Coverage tab, and then click Create.
  3. Specify this information:
    Coverage Class
    Select a coverage class for the enrollee. Records for employee, retiree, and COBRA participants are created separately.
    Benefit Group
    Select the benefit group.
    Coverage Date
    Specify a date to mark the start of the coverage.
  4. Click the Details tab and specify this information:
    Currency
    Select the currency of the coverage amount.
    Calculation Type
    Select the calculation type of the coverage amount.
    Additional fields are displayed depending on the calculation type selected.
  5. Click the Limits tab. On the Amount Limits section, specify this information:
    Minimum
    Specify a minimum amount for the benefit plan.
    Maximum
    Specify a maximum amount for the benefit plan.
  6. On the Multiple of Salary Limits section, specify this information:
    Minimum
    Specify a minimum multiple of the salary limit.
    Maximum
    Specify a maximum multiple of the salary limit.
    If the coverage is a multiple of an employee's salary, then specify the multiple where coverage is purchased. For example, if you specify 0.5, then it means that coverage is purchased in multiples of .5. Valid coverage multiples are 0.5, 1.0, 1.5, etc.
  7. On the Limit Of Another Benefit section, specify this information:
    Percent
    Specify the percentage of coverage of an employee's salary.
    Benefit Plan
    Specify a benefit plan where the percentage of coverage reflects.
    Specify the coverage limits when the benefit plan coverage type is the coverage amount. This is applied when a benefit plan’s coverage is limited by the coverage in another plan.
    Amounts that are over the approved amount on the limiting plan multiplied by the percent, require evidence of insurability (EOI).
    There are no EOI rules set up on the coverage rules. The exceeding amount on the limiting plan is approved only after the coverage on the limiting plan is approved.
  8. On the Salary tab which becomes available when the coverage type is the coverage amount, specify how the employee salary is calculated.
  9. Click the Evidence of Insurability Rules tab. On the New Plan Entrant section, specify this information:
    EOI Days
    Specify the number of days after enrollment that a newly eligible employee makes an election without being subject to providing Evidence of Insurability. When the employee makes an election after this time period expires beyond eligibility, the employee must provide EOI.
    From Date
    Specify a date to compare with the eligibility date. This date determines if an entrant is late.
    Late Entry Always
    Select this check box if the EOI enrollment is pending.
    Salary Changes
    Select a field to determine if a salary increase affects an employee’s coverage. This is used when the enrollee's EOI status is approved, the reason is Late Entrant, and where salary increases affect the coverage. Note that this only applies to salary increases. For salary decreases, the approved amount does not change.

    When the EOI status is pending, salary changes are allowed:

    • Allow Change: Salary changes are processed to update employee benefits. All EOI rules apply after the change.
    • Change Not Allowed: Salary changes do not update coverage.
    Message
    Specify the message on an enrollment event.
    Email Template

    Select the email template to send a notification to the enrollee when the EOI days have passed.

    Use the email template on enrollments with pending EOI with the Reason Late Entrant and the actions of Send EOI Email or Create Notifications For Evidence Of Insurability is used.

    Email Attachment
    Attach a document to include in the email which is sent to late enrollees and are newly eligible.
  10. In the Guaranteed Issue Limit section, specify this information:
    Salary Multiple
    Specify the largest salary multiple amount of coverage an eligible person elects without submitting evidence of insurability. The limit amount is calculated by using the value in the salary multiple field multiplied by the employee's salary.
    Guarantee Limit
    Specify the limit of salary multiple and amount.

    These values are allowed in the guarantee limit:

    • Lower: If you specify the lower limit, then the value becomes zero. The guaranteed limit becomes the lower salary multiple or amount. If the field is unspecified, then the value is 0.
    • Higher: If you specify the higher limit, then the value is one. The guaranteed limit is the higher salary multiple or the higher amount.

      If the employee does not sign up in the allotted time, then the amount goes to EOI. If the employee signs up within the allowed time, the amount goes to the Guarantee Issue Limit.

    Always Enforce Issue Limit
    Select the check box if the coverage exceeds the issue limit amount and if the amount is not yet approved. This requires EOI with the reason of Issue Limit.
    Any amount higher than the salary of the enrollee requires EOI for coverage. The amount is determined by the lower salary multiple or amount, or the approved amount of coverage, depending on which is greater.
    For example, the amount for the Guarantee Issue Limit is 10,000, and the employee enrolled for 200,000. EOI is required for 190,000. The EOI becomes approved.
    The year after the initial enrollment, the employee enrolls for 250,000, which exceeds the guarantee issue limit amounting to 10,000. The enrollment is still evaluated for the same EOI under the Guarantee Issue Limit rule. The employee already has 200,000 in coverage. Therefore, 50,000 requires EOI.
    Salary Changes
    Select the Allow Change or Change Not Allowed option to determine if an employee’s plan coverage is affected due to a salary increase. This rule is applied when the EOI of an enrollment is approved. The enrollment required EOI for issue limit and salary increase change the coverage of the plan. This rule applies only to salary increases.

    For salary decreases, the approved amount is not changed. When the EOI status is pending, salary changes are allowed.

    Change on an employee plan coverage is determined by selecting the allowed changes on the salary:

    • Allow Change: Salary changes are processed to update employee benefits. All EOI rules apply after the change.
    • Change Not Allowed: Salary changes do not affect the coverage.
    Message
    Specify an issue limit message that shows on the employee enrollment if they elect an amount that exceeds the guaranteed issue amount.
    Email Template
    Select the email template to send notifications to the enrollee when the guaranteed issue limit is exceeded.
    Email Attachment
    Attach a document to include in the email which is sent to enrollees with exceeding amounts for the guaranteed issue limit.
  11. In the Coverage Increase Limit section, specify this information:
    Salary Multiples
    Specify the largest salary multiple amount of coverage an employee is allowed to elect without submitting an EOI. You can calculate the limit amount by using the value in this field multiplied by the employee’s salary.
    Amount
    Specify the largest amount of coverage an eligible person elects without submitting Evidence of Insurability. If you specify both Salary Multiple and Amount, the smaller amount is used to determine the coverage limit.
    Coverage Limit
    Specify the coverage limit for salary multiple or amount.

    Change on an employee plan coverage is determined by selecting the allowed changes on the salary:

    • Lower: The coverage limit becomes the lower salary multiple or the lower amount.
    • Higher: The guaranteed limit becomes the higher salary multiple or the higher amount.
    If the value of the coverage limit is not specified, the value becomes lower.
    Any Increase
    Specify this field if EOI is required for any increase in coverage. If this field is not specified, the salary multiple and amount fields determine the increase.
    Salary Changes
    Select the Allow Change or Change Not Allowed option to determine the increase of an employee’s plan coverage. This rule is applied when the EOI of an enrollment is approved. The enrollment required EOI for issue limit and salary increase change the coverage of the plan. Note that this only applies to salary increases.
    Message
    Specify an issue limit message that is shown on the employee enrollment if the elected amount exceeds the guaranteed issue amount.
    Email Template
    Select the email template to send notifications to the enrollee when the guaranteed issue limit is exceeded.
    Email Attachment
    Attach a document to include in the email that is sent to enrollees with exceeding amounts for the guaranteed issue limit.
  12. Click Save.

    To view all records for Evidence of Insurability, see Evidence of insurability records.