02 — Capability · BC-1870.20
Benefit & Plan Configuration
Define each plan's covered services, cost sharing, limits and coverage rules once, and configure them so every claim, accumulator and member document applies the same terms. Choosing which plans to offer and at what price is product strategy and pricing.
- Benefit Configuration
- Plan Build
- Benefit Setup
In scope
- Covered services and cost-sharing definitions by plan
- Benefit configuration and testing in the claims system
- Deductible and out-of-pocket accumulators
- Medical coverage policies, and pharmacy benefit and formulary tiers
Out of scope
- Plan portfolio and product decisions (see BC-510.20)
- Premium rate setting (see BC-470.20)
- Provider fee schedules and reimbursement terms (see BC-1870.30)
Realized by · 1
- HealthEdge · HealthRules Language Configurationcore via BC-1870.20.10
Used in · 1
Build it · 1
Decomposes into · 5
- BC-1870.20.10Covered Service RulesDefine each plan's covered services, cost sharing, limits, exclusions and network tiers in a structured form ready to configure.
- BC-1870.20.20Claims Benefit ConfigurationConfigure each plan's benefits in the claims system and test them with sample claims before the plan year starts.
- BC-1870.20.30Cost-Sharing AccumulatorsTrack deductibles and out-of-pocket maximums for every member and family across medical and pharmacy claims, and share them with partners.
- BC-1870.20.40Medical Coverage PoliciesWrite and maintain the policies that say when a service is covered, publish them, and keep claim edits and review criteria aligned with them.
- BC-1870.20.50Pharmacy Benefit AdministrationDefine each plan's drug formulary tiers, pharmacy network and drug-specific rules, adjudicate pharmacy claims at the point of sale directly or through a pharmacy benefit manager, and oversee that manager's performance and pricing.