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Pega Product Composer for Healthcare accumulators

Suggest edit Updated on September 10, 2021

Accumulators are running totals that track dollar amounts or limits, such as units or member visits. Once the accumulator total reaches the plan maximum, an action occurs.

For example, a physical therapy benefit has a limit of 30 visits per benefit year. After the member has used 30 visits, the benefit maximum is reached and the service is no longer payable. Another example is a plan with an individual $4,000 out-of-pocket maximum in a benefit year. When the member has exhausted this amount, the benefits are then covered at 100%.

Pega Product Composer for Healthcare™ provides for accumulator accrual within products and plans for a specific network or across networks. It also provides for accrual at the benefit and benefit grouper-specific levels within or across networks.

How accumulators work in Pega Product Composer for Healthcare

Accumulators specify which cost shares contribute to a maximum amount. You define maximums at the network level for product templates, products, plans, networks, specific benefits, and specific groupers. In Pega Product Composer for Healthcare, the following default accumulators are available at the product, plan, network, benefit, and benefit-grouper levels:

  • Deductible
  • Out-of-pocket maximum
  • Annual maximum
  • Lifetime maximum (only for individuals)

You can further define accumulators for individual and family maximums. Individual contributions can also accrue to the family accumulator maximum. At the network level, you can define values for individual and family maximums. For benefits and groupers, you can specify values only for individual maximums.

Networks inherit the values that you define at the product or plan level. You can edit these values for each network if required. Benefit and grouper accumulators do not inherit values from the network level. However, for benefit-specific or grouper-specific accumulators, you can edit the values for each network. A benefit or grouper might have different deductibles and annual maximums for in-network and out-of-network.

Limits

Another accumulator type is a limit. For example, an eyeglasses benefit could have a limit of one pair per year in-network and one pair every two years out-of-network.

Benefit-grouper limits

A limit that is defined for a benefit-grouper includes all the benefits within the grouper. This means that the accumulator applies collectively to all the benefits within the grouper.

For example, a rehabilitation therapy grouper has a limit of 60 visits per year. Physical, occupational, and speech therapy benefits are associated with the rehabilitation therapy grouper. The maximum number of 60 visits per year can include any combination of speech therapy visits, occupational therapy visits, and physical therapy visits that do not exceed 60 visits in total.

Cross-network accumulators

When you configure an accumulator in a network, the accrual applies to that specific network. If a product template, product, or plan has multiple networks, you can define accruals to accumulate across networks.

For example, a plan has two networks with a $500 individual annual deductible for In-network and $1,000 individual annual deductible for Out-of-network. You can specify that the In-network individual annual deductible also accumulates to the Out-of-network individual annual deductible.

Another example is an orthodontic benefit with a $2000 lifetime maximum that accumulates across both networks.

  • Previous topic Pega Product Composer for Healthcare 8.2 Data Model Overview
  • Next topic Removal of properties from the default display in Pega Product Composer for Healthcare
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