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Inheritance pattern 2

Updated on April 12, 2021

Inheritance for a benefit that works with the Lifetime maximum, Out-of-pocket, Annual maximum, and Deductible items, configured at the product or plan network level, follows Inheritance pattern 2.

Pega Product Composer for Healthcare

The Lifetime maximum, Out-of-pocket, Annual maximum, and Deductible items are accumulators or containers that store and track a total amount of money or benefit limits.

For example, the value of Lifetime maximum at the network level means that every benefit at the network level contributes to the Lifetime Maximum accumulator, unless you configure benefits to specifically not apply to this accumulator. For example, if you have a Dental Lifetime Maximum, a dental service such as a root canal or a tooth filling contributes to this accumulator.

Inheritance pattern 2

You configure these accumulators in the Cost shares and accumulators step of the product or plan wizard. The fields in the Network cost shares step inherit the values. You can also change these items on the specific network in the Network cost shares step.

Notice that for these items, the inheritance tree in the figure above starts at the network. Benefits groupers for products or plans do not inherit the values from these items configured at the network level.

To find the source of the items that use Inheritance pattern 2, PCS follows the numerical order in the tree and reviews the entity configuration to find where a value (an override) has been entered. For example, to find the value for Lifetime Maximum, review the configuration of Plan network (5 in the tree). If the value is not there, review the configuration Prod Network (6 in the tree), and so on.

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