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:
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.
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.
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:
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.
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
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]
Primary Process Owner: TRS-Care
Rule Name: (Unique name which describes what the rule does)
Texas Insurance Code 1575.158
TRS Decision Repository
Summary: (Enter a paragraph describing the rule)
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
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:
*See notes for list of current optional group health benefit plans
Of the benefits listed above, the following are not currently offered:
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
Years of Service
Retiree or Surviving Spouse Only
With Part A & B of Medicare
With Part B of Medicare Only
Not eligible for Medicare
Retiree and Spouse
Both with Part A & B of Medicare
Both with Part B of Medicare Only
Retiree with A & B /Spouse with B Only
Retiree with A&B /Spouse not MDCR Eligible
Retiree B Only/Spouse not MDCR Eligible
Retiree with B Only/Spouse with A & B
Retiree not Eligible for MDCR/Spouse with A&B
Retiree not Eligible for MDCR/Spouse with B Only
Retiree or Surviving Spouse and Child(ren)
Retiree, Spouse and Child(ren)
Surviving Child(ren) Only
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
Retiree with MA/Spouse w/A&B
Retiree with MA/Spouse with B Only*
Retiree with MA / Spouse not eligible for Medicare
Retiree with A&B/Spouse with MA
Retiree with B Only*/Spouse with MA
Retiree not eligible for Medicare / Spouse with MA
Retiree or Surviving Spouse and Child(ren)**
Retiree or Surviving Spouse with MA/child not eligible for Medicare
Retiree or Surviving Spouse with MA/child with MA
Retiree or Surviving Spouse with A&B/child with MA
Retiree or Surviving Spouse with B Only*/child with MA
Retiree or Surviving Spouse not eligible for Medicare / Child with MA
Retiree , Spouse & Child(ren), where children are not enrolled in MA
Retiree and Spouse with MA
Retiree with MA/Spouse with A&B
Retiree with MA /Spouse with Medicare B Only*
Retiree with B Only */Spouse with MA
Retiree , Spouse & Child(ren), where children are enrolled in MA**
Retiree, Spouse & Child(ren) with MA
Retiree and Child with MA/Spouse with A&B
Retiree and Child with MA/Spouse B Only*
Retiree & Child with MA/Spouse not eligible for Medicare
Retiree with A&B/Spouse and Child with MA
Retiree with A&B/Spouse with A&B/Child with MA
Retiree with A&B/Spouse with B Only*/Child with MA
Retiree with A&B/Spouse not eligible for Medicare/Child with MA
Retiree with B Only*/Spouse and Child with MA
Retiree with B Only*/Spouse with A&B/Child with MA
Retiree with B Only*/Spouse with B Only*/Child with MA
Retiree with B Only*/Spouse not eligible for Medicare/Child with MA
Retiree not eligible for Medicare/Spouse & Child with MA
Retiree not eligible for Medicare/Spouse with A&B/Child with MA
Retiree not eligible for Medicare/Spouse with B Only*/Child with MA
Retiree & Spouse not eligible for Medicare/Child with MA
Surviving Children Only with MA
Surviving Children Only with Medicare Advantage
*"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
3 Retiree & spouse covered
Legend: First Position Codes related to Medicare Part A
1 = Retiree/Surviving Spouse or Spouse enrolled2 = Retiree/Surviving Spouse or Spouse not eligible (<65)3 = Retiree/Surviving Spouse not eligible (<65), or Spouse enrolled4 = 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 enrolled7 = 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 MedicareB TRS-Care 2 (B) With Part A &B of MedicareC TRS-Care 3 (C) With Part A & B. of MedicareD TRS-Care 1 (A) Not eligible for MedicareE TRS-Care 2 (B) Not eligible for MedicareF TRS-Care 3 (C) Not eligible for MedicareG TRS-Care 1 (A) With Part B of Medicare OnlyH TRS-Care 2 (B) With Part B of Medicare OnlyI TRS-Care 3 (C) With Part B of Medicare OnlyQ Medicare Advantage 2R Medicare Advantage 3V 2 (or more) Dependent Children with 1 (or more) enrolled in Medicare AdvantageX 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)