Use Case Texas Teachers Retirement System - Rule 0155

 

Purpose of the Rule

The rule is described in appendix A as

This business rule reflects TRS’ authority to establish optional group health benefit plans for retirees, dependents, surviving spouses, or surviving dependent children.

However examining the detailed tables in the appendix seems to suggest that the pupose is to determine the premiums payable for the various plans – we’ll go on that assumption for now since the notes in the appendix state:

The two charts below list the plan codes (Premium Costs Rate Sheet 2012 & MA Internal Rate Sheet 2012 - 2013 with codes) used to determine premium rate. One is for the Standard TRS-Care Plans and the other is for the Medicare Advantage Plans.

 

The fact that there are two plans to consider suggests two subcomponents (one for each)

In order to determine the premium for either plan a number of factors are considered:

  1. The plan
  2. The years of service
  3. Various combinations of situations of retiree, spouse and dependents (codes shown in red are used to identify these various combinations)

 

 

Step 1 Determine the Object Model that is required for this Rule.

There are references to Member, Retiree, Spouse, Dependent.

Essentially all these references are to instances of a Person. Each person will have various attributes (such as years of service etc). Some of the attributes will only be populated for the retiree (such as the years of service)

In order to model the retiree and possible dependents we can use a vocabulary such as this:

Note that we have allowed a retiree to have multiple spouses.

 

Step 2 Model the Rules

At this point we can begin to sketch out a possible structure for a rule sheet based on this fragment of the table in the appendix:

 

Because the three plans are mutually exclusive we could model this with a separate rule sheet for each plan.

The rule sheet for plan 1 would be very simple (it either means there is no premium or that this plan is not available – its not clear which howver)

 

The nine cells  in the plan 2 column can be expressed as follows:

 

Notice that the condition that tests which plan has been moved into the FILTER part of the rule:

Essentially this means that this rule sheet only activates for retirees that have the Premium TRS Care 2 plan

  

The rule sheet that deals with plan 3 (or plan1) would have a similar filter condition)

 

Incidentally if we run the completeness checker on this rule sheet we will discover there are some missing rules:

Corticon wants to know what to do when the retiree has medicare part A but not part B.

 

Here’s the same rule sheet with the natural language replaced by the actual underlying implementation:

Let’s assume for now that the situation described in rule 10 represents an invalid combination. We might add a message that indicates the violation. If in fact it’s a valid situation then we need to determine the premiums for the various years of service. Either way the rule sheet ends up being complete and specific for all situations.

The ambiguity checker confirms that there are no conflicts in this rule sheet.

 

Step 3 Test the Rules

Now we might go ahead and create some test data to verify this rule sheet:

Let’s say Tom has A and B and Premium TRS Care 2 and 17 years of service. His premium (according to the tables in appendix A should be $80.

We can set up this test case with the expected result as follows:

Running the rules produces this output:

Which is the correct answer.

Similarly we need to set up test cases and expected results for every column in the rule sheet.

How do we know that? Because we used the completeness checker to make sure we have every combination of conditions and the ambiguity checker to make sure there are no overlaps we MUST have a test case for every column.

What happens if we pass in a test case for Premium TRS Care 3?

Nothing will happen:

This is because we only have one rule sheet and its filter only activates for plan 2.

So to handle plan 3 (and plan 1) we must add more rule sheets with structures similar to the plan 2 sheet.

In fact the simplest way to do this is to copy/paste the tested plan2 rule sheet and then change the details.

Eventually we will have three rule sheets one each for Plan 1, Plan 2 and Plan 3.

 

If we assume that for plan 1 the premium is always zero then this rule sheet might look like this:

Notice there are no conditions and we put the action in column zero

Plan 3 would look more like plan 2:

  

 

Step 4 Continue Modeling

The next section is tackled in asimilar fashion:

But now in our scope section we need to accommodate the retiree AND their spouse:

And the rule sheet would look like this. There are more rule columns because there are more combinations to consider.

  

 

 

Step 5 Define the Decision Structure with a Rule Flow

Now we are accumulating a variety of rule sheets each of which deals with a part of the overall decision.

In order to define the entire decision we use the rule flow to indicate which rule sheets shoud be used.

Here’s a partial rule flow:

For any give retiree only one of these rule sheets will activate (based on the filter conditions) and since these sheets are all mutually exclusive it doesn’t really matter order we arrange them in.

We do need to add a bit more to the filter in order to specify which sheet applies to the Retiree Only versus the Retiree AND spouse:

Here’s how we limit the Retiree Only sheet:

The other table for Aetna MA Premium Rates 2012 - 2013 for TRS-Care would be handled in a similar fashion – and since the structure is very similar copy/paste of the existing rule sheets would get you 90% of the way there

 

 

 

 

Appendix A

Business Rule: 0155                                                 

 

TRS Chapter Title:  Texas Public School Employees Group Benefits Program

(Maps to chapters in code)

SME: Edward Esquivel & Teresa Luna

Writer:  Null, Brian

 

Date Created:  3/13/2013

Date Approved: [DateApproved]

Date Modified:       

 

Version: 

     

Primary Process Owner:  TRS-Care

Rule Name:  (Unique name which describes what the rule does)

TRS-Care plans

TGC Reference:

Texas Insurance Code 1575.158

TAC Reference:

[TACReference]

TRS Decision Repository

Reference:

[TRSDecisionRepos]

Other Reference:

(if applicable)

 

Summary: (Enter a paragraph describing the rule)

This business rule reflects TRS’ authority to establish optional group health benefit plans for retirees, dependents, surviving spouses, or surviving dependent children.

Processes:  (Processes which use this rule)

Insurance – TRS-Care

Effective Begin Date:       

Effective End Date:       

 (Begin and end dates should be left blank unless the law or rule specifies a beginning or end date; the begin date is left blank, lock and explain)  

BR Cross References: BR_0154

Explanation:

TRS may, in addition to providing a basic plan, contract for and make available optional group health benefit plan(s) for retirees, dependents, surviving spouses, or surviving dependent children. Basic Coverage is TRS-Care 1 Retiree only coverage. Optional coverage is any dependent coverage in TRS-Care 1, and any coverage for a retiree and dependent in TRS-Care 2 and TRS-Care 3

 

This optional group health benefit plan(s)* may provide for:

  1. a deductible in an amount that is less than the amount for the basic plan;
  2. coinsurance in an amount that is less than the amount for the basic plan; or
  3. additional benefits permitted under Section 1575.151, Texas Insurance Code, which include:
    • life insurance;
    • accidental death and dismemberment coverage;
    • protection against loss of salary; and
    • coverage for
      • hospital care and benefits;
      • surgical care and treatment;
      • medical care and treatment;
      • dental care;
      • eye care;
      • obstetrical benefits;
      • long-term care;
      • prescribed drugs, medicines, and prosthetic devices; and
      • supplemental benefits, supplies, and services in accordance with Chapter 1575

 

*See notes for list of current optional group health benefit plans

Exceptions:

Of the benefits listed above, the following are not currently offered:

  • life insurance;
  • accidental death and dismemberment coverage;
  • protection against loss of salary;
  • Dental care
  • Eye care (There is no individual vision care plan offered through TRS-Care; medical conditions of the eye are covered, one eye exam is covered/year in the Medicare Advantage plan)
  • Long Term (offered outside of TRS-Care)

 

Examples/Notes:

  1. The two charts below list the plan codes (Premium Costs Rate Sheet 2012 & MA Internal Rate Sheet 2012 - 2013 with codes) used to determine premium rate. One is for the Standard TRS-Care Plans and the other is for the Medicare Advantage Plans.
  1. On the Premium Costs Rate Sheet 2012 (for Standard Plans), a letter is inserted between the letters with the number-dash-number in red replacing the “dash” to designate the plan level.
  • TRS-Care 1 is “A”;
  • TRS-Care 2 is “B” ;
  • TRS-Care 3 is “C”,
  • The first character denotes the retiree’s Medicare Status/eligibility - there is various statuses. The second character denotes what plan level has been selected (a=level 1, b=level 2, c=level 3). The third character denotes the tier of coverage that has been selected (retiree only = 1, retiree and spouse =2, etc...) *.
  • For example, a retiree with 20 years of service with spouse enrolled in TRS-Care 2 and not eligible for Medicare. The plan code for this member would be 2B2.

  • TRS-Care has a number of lists with codes not included and available upon request if needed.

  • Additional Option Group Health Plansincludes all plans other than the “Basic Plan” which is TRS-Care 1 for Retirees. All TRS-Care plans with the exception of TRS-Care 1 include a prescription benefits option (e.g. Medicare Part D plan). The plans within TRS-Care include:
    1. TRS-Care 1 standard,
    2. TRS-Care 2 standard,
    3. TRS-Care 3 standard,
    4. Medicare Advantage Care 2, and
    5. Medicare Advantage Care 3
    6. TRS-Care United Healthcare Medicare Advantage HMO. This plan is no longer open to new enrollees.

  • Optional Group Health Plans Requirements: Retirees must meet retirement eligibility requirements to enroll in any of the TRS-Care plans. Dependents must meet eligibility requirement for enrollment as well. Specific condition requirements (Disability requirements) are only applicable when considering enrollment for a disabled retiree or an incapacitated child over age 26.

 

 

TRS DIRECT RATING SHEET Plan Year 9/1/12 - 9/1/13

 

1st - 3rd

Retiree Premium TRS Care

Retiree Premium TRS-Care 2   

Retiree Premium TRS-Care 3

Plan

1

Years of Service

Years of Service

Codes

N/A

< 20

20-29

30+

< 20

20-29

30+

Retiree or Surviving Spouse Only

With Part A & B of Medicare

1-1, 1-5

 $         -  

$80

$70

$60

$110

$100

$90

With Part B of Medicare Only

5-1, 5-5

 $         -  

$165

$155

$145

$245

$230

$215

Not eligible for Medicare

2-1, 2-5

 $         -  

$210

$200

$190

$310

$295

$280

Retiree and Spouse

Both with Part A & B of Medicare

1-2

$20

$190

$175

$160

$275

$255

$235

Both with Part B of Medicare Only

5-2

$75

$360

$340

$320

$535

$505

$475

Not eligible for Medicare

2-2

$140

$450

$430

$410

$665

$635

$605

Retiree with A & B /Spouse with B Only

7-2

$60

$275

$255

$235

$400

$375

$350

Retiree with A&B /Spouse not  MDCR Eligible

4-2

$90

$320

$300

$280

$465

$440

$415

Retiree B Only/Spouse not MDCR Eligible

9-2

$120

$405

$385

$365

$600

$570

$540

Retiree with B Only/Spouse with A & B

6-2

$25

$275

$260

$245

$410

$385

$360

Retiree not Eligible for MDCR/Spouse with A&B

3-2

$30

$320

$305

$290

$475

$450

$425

Retiree not Eligible for MDCR/Spouse with B Only

8-2

$80

$405

$385

$365

$600

$570

$540

Retiree or Surviving Spouse and Child(ren)

With Part A & B of Medicare

1-3, 1-6

$41

$142

$132

$122

$192

$182

$172

With Part B of Medicare Only

5-3, 5-6

$34

$227

$217

$207

$327

$312

$297

Not eligible for Medicare

2-3, 2-6

$28

$272

$262

$252

$392

$377

$362

Retiree, Spouse and Child(ren)

Both with Part A & B of Medicare

1-4

$61

$252

$237

$222

$357

$337

$317

Both with Part B of Medicare Only

5-4

$109

$422

$402

$382

$617

$587

$557

Not eligible for Medicare

2-4

$168

$512

$492

$472

$747

$717

$687

Retiree with A & B /Spouse with B Only

7-4

$101

$337

$317

$297

$482

$457

$432

Retiree with A&B /Spouse not  MDCR Eligible

4-4

$131

$382

$362

$342

$547

$522

$497

Retiree B Only/Spouse not MDCR Eligible

9-4

$154

$467

$447

$427

$682

$652

$622

Retiree with B Only/Spouse with A & B

6-4

$59

$337

$322

$307

$492

$467

$442

Retiree not Eligible for MDCR/Spouse with A&B

3-4

$58

$382

$367

$352

$557

$532

$507

Retiree not Eligible for MDCR/Spouse with B Only

8-4

$108

$467

$447

$427

$682

$652

$622

Surviving Child(ren) Only

2-7

$28

$62

$62

$62

$82

$82

$82

Part B Only means the individual is not covered by Medicare Part A and is eligible to purchase Medicare Part B.

 

 

Aetna MA Premium Rates 2012 - 2013 for TRS-Care

 

 

 

MA  Care 2

MA Care 3

Plan Codes

Years of Service

Years of Service

Plan 2

Plan 3

< 20

20-29

30+

< 20

20-29

30+

Retiree or Surviving Spouse Only

With MA

QXX

RXX

$65

$55

$45

$95

$85

$75

Retiree and Spouse

Both w/MA

QQX

RRX

$160

$145

$130

$245

$225

$205

Retiree with MA/Spouse w/A&B

QBX

RCX

$175

$160

$145

$260

$240

$220

Retiree with MA/Spouse with B Only*

QHX

RIX

$260

$240

$220

$385

$360

$335

Retiree with MA / Spouse not eligible for Medicare

QEX

RFX

$305

$285

$265

$450

$425

$400

Retiree with A&B/Spouse with MA

BQX

CRX

$175

$160

$145

$260

$240

$220

Retiree with B Only*/Spouse with MA 

HQX

IRX

$260

$245

$230

$395

$370

$345

Retiree not eligible for Medicare / Spouse with MA

EQX

FRX

$305

$290

$275

$460

$435

$410

Retiree or Surviving Spouse and Child(ren)**

Retiree or Surviving Spouse with MA/child not eligible for Medicare

QXE

RXF

$127

$117

$107

$177

$167

$157

Retiree or Surviving Spouse with MA/child with MA

QXQ

RXR

$112

$102

$92

$162

$152

$142

Retiree or Surviving Spouse with A&B/child with MA

BXQ

CXR

$127

$117

$107

$177

$167

$157

Retiree or Surviving Spouse with  B  Only*/child with MA

HXQ

IXR

$212

$202

$192

$312

$297

$282

Retiree or Surviving Spouse not eligible for Medicare / Child with MA

EXQ

FXR

$257

$247

$237

$377

$362

$347

Retiree , Spouse & Child(ren), where children are not enrolled in MA

Retiree and Spouse with MA

QQE

RRF

$222

$207

$192

$327

$307

$287

Retiree with MA/Spouse with A&B

QBE

RCF

$237

$222

$207

$342

$322

$302

Retiree with MA /Spouse with Medicare B Only*

QHE

RIF

$322

$302

$282

$467

$442

$417

Retiree with MA / Spouse not eligible for Medicare

QEE

RFF

$367

$347

$327

$532

$507

$482

Retiree with A&B/Spouse with MA

BQE

CRF

$237

$222

$207

$342

$322

$302

Retiree with B Only */Spouse with MA

HQE

IRF

$322

$307

$292

$477

$452

$427

Retiree not eligible for Medicare / Spouse with MA

EQE

FRF

$367

$352

$337

$542

$517

$492

Retiree , Spouse & Child(ren), where children are enrolled in MA**

Retiree, Spouse & Child(ren) with MA

QQQ

RRR

$207

$192

$177

$312

$292

$272

Retiree and Child with MA/Spouse with A&B

QBQ

RCR

$222

$207

$192

$327

$307

$287

Retiree and Child with MA/Spouse B Only*

QHQ

RIR

$307

$287

$267

$452

$427

$402

Retiree & Child with MA/Spouse not eligible for Medicare

QEQ

RFR

$352

$332

$312

$517

$492

$467

Retiree with A&B/Spouse and Child with MA

BQQ

CRR

$222

$207

$192

$327

$307

$287

Retiree with A&B/Spouse with A&B/Child with MA

BBQ

CCR

$237

$222

$207

$342

$322

$302

Retiree with A&B/Spouse with B Only*/Child with MA

BHQ

CIR

$322

$302

$282

$467

$442

$417

Retiree with A&B/Spouse not eligible for Medicare/Child with MA

BEQ

CFR

$367

$347

$327

$532

$507

$482

Retiree with B Only*/Spouse and Child with MA

HQQ

IRR

$307

$292

$277

$462

$437

$412

Retiree with B Only*/Spouse with A&B/Child with MA

HBQ

ICR

$322

$307

$292

$477

$452

$427

Retiree with B Only*/Spouse with B Only*/Child with MA

HHQ

IIR

$407

$387

$367

$602

$572

$542

Retiree with B Only*/Spouse not eligible for Medicare/Child with MA

HEQ

IFR

$452

$432

$412

$667

$637

$607

Retiree not eligible for Medicare/Spouse & Child with MA

EQQ

FRR

$352

$337

$322

$527

$502

$477

Retiree not eligible for Medicare/Spouse with A&B/Child with MA

FBQ

FCR

$367

$352

$337

$542

$517

$492

Retiree not eligible for Medicare/Spouse with B Only*/Child with MA

EHQ

FIR

$452

$432

$412

$667

$637

$607

Retiree & Spouse not eligible for Medicare/Child with MA

EEQ

FFR

$497

$477

$457

$732

$702

$672

Surviving Children Only with MA

Surviving Children Only with Medicare Advantage

XXQ

XXR

$47

$47

$47

$67

$67

$67

*"Part B Of Medicare Only" means the individual is not covered by Medicare Part A and is eligible to purchase Medicare Part B.

 

**Rates are shown for one dependent child enrolled in a MA plan. For families with two or more dependent children enrolled in a MA Plan, there will be an additional $15 per month reduction in premium for the second or subsequent children enrolled in a MA plan; however, in no case shall premium be less than $0.

 

*3-digit coverage code:

 

1st     1 - both member & spouse have Medicare  Part A

2 - neither member or spouse  have Medicare  Part A

3 - spouse has Medicare  Part A member  does not

4 - member  has Medicare  Part A spouse does not

 

2nd    A- TRS-Care 1 $4000 deductible/prescription drug discount 

B- TRS-Care 2 $1000 deductible/prescription drug co-pay

C- TRS-Care 3 $300 deductible/prescription drug co-pay

 

3rd     1 - retiree only

2 - retiree & spouse

3 - retiree & child(ren)

4 - retiree, spouse & Child(ren)

5 - surviving  spouse

6 - surviving  spouse & child(ren)

7 - surviving  child(ren)

 

Example: 2C2 = neither member  or spouse have Medicare  Part- A

TRS-Care 

3 Retiree  & spouse covered

 

Legend: First Position Codes related to Medicare Part A

1 = Retiree/Surviving Spouse or Spouse enrolled
2 = Retiree/Surviving Spouse or Spouse not eligible (<65)
3 = Retiree/Surviving Spouse not eligible (<65), or Spouse enrolled
4 = Retiree/Surviving Spouse enrolled, or Spouse not eligible (<65)
5 = Retiree/Surviving Spouse or Spouse not enrolled (65+)
6 = Retiree/Surviving Spouse not enrolled (65+), or Spouse enrolled
7 = Retiree/Surviving Spouse enrolled, or Spouse not enrolled (65+)
8 = Retiree/Surviving Spouse not eligible (<65)or Spouse not enrolled (65+)
9 = Retiree/Surviving Spouse not enrolled (65+), Spouse not eligible (<65)

 

Medicare Advantage Plan Code Fields

[Left to Right]: Retiree - Spouse - Dependent

Codes [One to be used in each of the three fields]

A   TRS-Care 1 (A) With Part A & B of Medicare
B   TRS-Care 2 (B) With Part A &B of Medicare
C   TRS-Care 3 (C) With Part A & B. of Medicare
D   TRS-Care 1 (A) Not eligible for Medicare
E   TRS-Care 2 (B) Not eligible for Medicare
F   TRS-Care 3 (C) Not eligible for Medicare
G   TRS-Care 1 (A) With Part B of Medicare Only
H   TRS-Care 2 (B) With Part B of Medicare Only
I    TRS-Care 3 (C) With Part B of Medicare Only
Q   Medicare Advantage 2
R   Medicare Advantage 3
V   2 (or more) Dependent Children with 1 (or more) enrolled in Medicare Advantage
X   N/A-Not Enrolled

 

 

 

 

Note:  The information in this business rule was approved by TRS-Care; a determination was made by the BR Project Team to label this rule as ‘NRN’.

Rule Engine Version:

(This section is being added to the Rule template for future use, when we know more about Rule Engine use)