Review this extract of a larger knowledge guide to learn the definition of accelerated products (medical, dental, vision, etc.) and yearly pricing strategies. See how these products are sold to customers (i.e. plan sponsors, individuals, groups, etc.). Also learn about the high-level pain points faced by health insurers and their partners related to product lines, product components, product packages, and the product shelf.

1. Fundamentals of
Health Payor
Product
Management:
An Introduction to
Accelerated Product and
Pricing
www.salusoneed.com

2. |
All information in this course is subject to change without notice. This document is
provided for informational and knowledge purposes only and SO Health, Inc. makes no
guarantees, representations or warranties, either expressed or implied, about the
information contained within the document or about the document itself. SO Health®,
Salus One, Inc.™ are trademarks of Salus One, Ltd.
Copyright © 2017 Salus One, Ltd. All rights reserved.
Created in the United States of America.
www.salusoneed.com

3. Section One:
Definition of Health Payor
Product and Pricing
www.salusoneed.com

4. | 3
For the purposes of this Accelerated Product and Pricing Knowledge
Guide extract, we have developed a few definitions to guide us:
www.salusoneed.com

5. | 4www.salusoneed.com
Products are a set of offerings (Medical, Dental, Vision, etc.) combined with network
configuration (PPO, HMO, POS, etc.) sold to plan sponsors, groups or individuals to
substantiate a contract related to a specific under which the group/member has
coverage and financial obligations. (An example of this would be a Medical Insurance
policy).
An offering may be sold individually or combined and does not always require a
Certificate to be filed.
Product

6. | 5
Plan
A plan is defined as a set of healthcare
components/services (example -
Hospitalization under Medical or
Orthodontic under Dental) sold under
specific Product. A grouping of products
and specific contracts offered to a group,
including all riders, buy-up, ancillary or
specialty products (Incentive Programs,
Dental, Life and Disability (otherwise
known as L&D)).
www.salusoneed.com

7. | 6
Contract
• A Contract – often referred to as a Product – is a Plan purchased by Plan sponsor, group,
employer or individual.
• A Contract represents the specific instance of the insurance plan with the associated cost,
deductible, out of pocket, etc.. values and other additional variables defined related to
provider services (e.g., in/out of network).
• The contract is the source of truth for benefit data, cost shares including provider and
coverage.
www.salusoneed.com

8. | 7
Benefits
Benefits are a list of component
coverage and financial obligations
included in a Contract or Plan that are
considered benefits to the members.
www.salusoneed.com

9. Section Two:
What are the most
common payor product
management pain points?
www.salusoneed.com

10. | 9
Health Insurance Product Definition
Before moving forward about today’s current state product
management pain points, let’s define the term “Product”…
www.salusoneed.com
…a discrete package of health insurance coverage benefits that
are offered using a particular product network type (such as
health maintenance organization, preferred provider
organization, exclusive provider organization, point of service,
or indemnity) within a service area.
In the case of a product that has been modified, transferred, or
replaced, the resulting new product will be considered to be the
same as the modified, transferred, or replaced product if the
changes to the modified, transferred, or replaced product meet
the standards of 45 CFR § 146.152(f), § 147.106(e), or §
148.122(g) (relating to uniform modification of coverage), as
applicable.
According to the Centers for Medicare and Medicaid
Services (CMS), a product is:

11. | 10
Product Line
Product Management
Product
Components
Product Package Product Shelf
Current state Product Management pain points include:
www.salusoneed.com
Product Lines
are a catalog of items sold
by a health insurance
company to its current and
potential customers and
consist of many products
Product Components
are the services, activities,
premium calculation,
shared accumulation
determination and other
required activities related to
composition of Products
Product Packages
are offerings to members
(group, large plan and
individuals) for sale or
renewals (i.e. health,
dental, vision, etc.)
Product Shelf
are essentially an inventory
of products that can be sold
to potential and current
contractees. The more
products offered, the better
likelihood that sales will
occur and length of
retention rises.

12. | 11
Current state Product Management pain points:
Product Line
Product Line
▪ Product Lines are not managed holistically
across Lines of Business (e.g., IBU, Small
Group, Mergers and Acquisitions)
▪ Product Line identifiers are not available
▪ Some Product Lines are not managed like a
product (e.g., Wellness)
▪ Administrative services are not managed like a
Product Line (e.g., setup, open enrollment,
etc..)
www.salusoneed.com

13. | 12
Current state Product Management pain points:
Product Component
Product Component
▪ Difficult to manage / retire certificates & riders
▪
▪ Products are not broken into well-defined
components
▪ Difficult to determine wheat already exists (e.g.
could be configured) vs. what is new that
requires new investment to be able to
administer and implement
▪ Product is not represented or managed as a
unique component configuration
www.salusoneed.com

14. | 13
Current state Product Management pain points:
Product Package
Product Package
▪ Requires manually managed crosswalks to
administer the product across multiple
business segments ( e.g., IBU, Small Group,
Large)
▪ Since it is not independently managed,
Explanations and Summaries are created
downstream, increasing volume of material
that must be managed
▪ Limited ability to perform Product Book of
Business analysis
www.salusoneed.com

15. | 14
Current state Product Management pain points:
Product Shelf
Product Shelf
▪ Products are not managed in unique
configurations (e.g., by Product Line) that
would ensure available selection choices /
options
▪ Managing product IDs is difficult and
cumbersome (e.g., re-purposed identifiers) –
adds complexity in administering benefits
▪ Each downstream platform adopts unique way
to represent product – adds operational
complexity
www.salusoneed.com

16. Section Three:
What product management
capabilities are required to
successfully and efficiently
implement and maintain
health insurance products
for viability and increased
revenue?
www.salusoneed.com

17. | 16
Product Line
Product Management
Product Components Product Package Legal / Approval Product Shelf
Regulatory / Legal
Product Strategy
Product Owner
Actuary
Products offered via channel
▪ Only ‘valid’ Product Packages are available across all Product Lines
▪ Provides foundation for marketing / sales / service operations processes
▪ Options (value) change triggers new coverage period
▪ Product Shelf IDs are managed independently of the downstream processes (e.g.,
quoting, underwriting, installation, etc..)
Formal filing with Federal, State and other regulatory agencies
▪ Submits Product Package material (e.g. product composition , legal description, rates, etc..) for approval
▪ Provide foundation for Underwriting process (e.g., rating, pricing)
▪ Once approved, flags Product Packages and approved rates are promoted to the Product Shelf
▪ Creates initial product market availability period (how long it would be available)
Product package (s) are constructed
▪ Establishes foundational product view – creates valid Product Line and Product Component combination(s)
▪ Actuarial value / value ranges developed prior to approval process
▪ Reflects submissions to for legal/ regulatory approval to be sold in the market
▪ Baseline Explanations and Summaries are created (e.g., legal, marketing / sales, account mgmt.)
▪ Has unique way to identify and version (e.g., master IDs, internal definition, etc..) each combination
▪ Creating new Product Package requires set-up effort in downstream solutions
▪ Managed independently from marketing / sales / service operations processes
Manages components (building blocks) that could be used to assemble a product offering
▪ Certificates & Riders that represent coverage (SMBs???)
▪ Modification options and Financial tiers for each
▪ Baseline actuarial value / value ranges can be established by actuaries
▪ New instances reflect a need to invest to implement
▪ Has unique way to identify and version (e.g., master IDs, internal definition, legal r/ regulatory representation, etc..) components
Establishes a basis for the product type
▪ Independent of the business segment or line of business (e.g., Medical, Dental, Pharma, Vision, L&D, Admin Services, Data Services, etc..)
▪ Creates ability to create an umbrella for selection / offering
▪ New instances reflect a need for new processes, platforms, partners
▪ Has unique way to identify and version (e.g., master IDs, definition, representation, etc..)
Industry Product Management capabilities goals:
www.salusoneed.com

18. Section Four:
Solid case products and
benefits
www.salusoneed.com

19. | 18
Product
Marketing
Commercial
Sales
Online
Representations
Pricing
Contract
Components/
Details
Product Management
Product Name
Other Identities
Customer
Rules
Certs
Riders
Medical Policy
Other
Human
System
Human
System
Human
System
Human
System
Rules
Underwriting
Product Benefit
Actuarial
Actuarial
What is included in the product? What are the actual benefits?
www.salusoneed.com

20. | 19
Product
Marketing
Internal
Agents
Direct
Representations
Pricing
Contract
Components/
Details
Product Management
Product Name
Other Identities
Customer
Rules
Certs
Riders
Network
Other (e.g.
Deductible, OOP,
Copay, etc.)
Human
System
Contract
Human
System
Contract
Human
System
Rules
Underwriting (rating)
Product Benefit
Actuarial (Pricing/Risk)
Attributes
Product Family
Business Segment
Contract
Human
System
Product and Benefit - is an alignment of component parts;
riders, coverage types and amounts, etc.. underneath a single
identifier that is used to identify the offering for consumption by
the marketplace. A product may have one or more component
parts that make it uniquely identifiable from other products.
Component parts may have assigned variations that don’t
warrant a differentiated product.
Product and Benefit Activity Flows
www.salusoneed.com

21. | 20
Sold Case / Case Installation / Benefit Summary
Sold Case (Plan)
Product Shelf
▪ Only ‘valid’ Product
Packages are available
across all Product Lines
▪ Provides foundation for
marketing / sales / service
operations processes
▪ Options (value) change
triggers new coverage
period
▪ Product Shelf IDs are
managed independently
of the downstream
processes (e.g., quoting,
underwriting, installation,
etc..)
▪ Product Package component material (e.g., Certificates, Riders, Rules) are
available
▪ Final Quote is available from Underwriting
▪ Coverage Agreement defines Product Package based on available
options (Contract)
▪ Group structure is defined an d applied to the Product Package
▪ Initial Roster / Census is available
▪ BAAG material is generated material based on group structure and
Product Package configuration
▪ Benefit Configurator is used to configure the selected benefits and
configure core systems
▪ Should be used to generate Secondary Solution feeds
▪ Sold record is created and appropriate ID is assigned – manages customer
ID, group setup, contract / plan reference, Product Package and selected
options, configured benefits, rate structure, census, effective dates, target
renewal date, etc..
▪ Sold record is persisted in a centralized repository
▪ New record or an updates are sent to SMART as required
Solid Case/Case Installation/Benefit Summary
www.salusoneed.com

22. |21www.salusoneed.com
Please use the discount code shown below on your next
purchase:

23. | 22
www.salusoneed.com
22