## 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:

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

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
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)

[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
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)