This topic describes how to set the fields of a decision support configuration in Benefits Setup > Benefits Decision Support. The way that you set these fields should be based on the benefit design of the medical plan that the configuration is for.
The descriptions in this topic are intended to help you interpret the benefit design of the medical plan that you are working with. Some of the descriptions include a link to more detailed information with visual examples; you can see a full list of these in Descriptions of Benefits Coverage Examples. You might also want to consult the descriptions of the coverage categories in Benefits Decision Support Coverage Categories. However, if after consulting this information, you still have questions about specific fields as they relate to a particular benefit design, you should contact your Dayforce representative or your plan provider.
This topic is divided into seven sections, each describing a section of the configuration. Click the links below to go to each section:
- General
- Option Configuration
- HSA Configuration
- FSA Configuration
- HRA Configuration
- Coverage Thresholds
- Required Coverage Details / Optional Coverage Details
| Field | Action |
|---|---|
|
Effective From |
Enter or select the start date for the decision support configuration. The default selection is today. If you have multiple configurations for a plan, ensure that you don’t have overlapping effective dates. |
|
Reimbursement Account Applicable |
Select one of the following options in the drop-down list to indicate the type of reimbursement account or accounts that are included with the plan:
By default, the option None is selected. |
|
Accumulation Method |
Select an option in the drop-down list to indicate how the plan treats deductibles and out-of-pocket (OOP) maximums for an individual within a family coverage level:
|
|
Referral Required |
Select the checkbox if an authorization by a primary care physician is required before the member can seek treatment or a consultation from a specialty provider. |
|
Out-of-Network Coverage Included |
Select the checkbox if an out-of-network benefit design is available for the plan. |
The following fields determine which options are included in your configuration and indicate how they should be mapped to the coverage tiers used by Dayforce in the Benefits Decision Support questionnaire.
You might need to choose more than one coverage tier for certain options. For example, for an "Employee + Child(ren)" option, you should select the Employee + 1 Child and Employee + Children checkboxes.
| Field | Action |
|---|---|
|
Include |
Select one of the following options in the drop-down list to set whether the option is included in, excluded from, or only has its premiums included in the decision support:
|
| Include Drop-Down List Options | |
| Exclude: The option is excluded from decision support recommendations in employee enrollments. When you select Exclude, enrollment data for the option is reflected in Actual Enrollment charts in Benefits Intelligence, but the option is excluded from forecasting information. If you want to see enrollment data for an entire plan in Benefits Intelligence without having that plan included in forecasts, add a decision support configuration for the plan and exclude all of its options. | |
|
Include: The option is included in decision support recommendations in employee enrollments. Note: For options that you include in your decision support configuration, confirm that the Suppress Costs field (found in the General tab of option setup in Benefits Setup > Plans and Options) isn’t enabled. If this field is enabled, Dayforce cannot deliver decision support results during enrollment. |
|
| Premiums Only: Only the premiums for the option are included in decision support recommendations in employee enrollments. Also, the Include Premiums with Option drop-down list shows next to the option. This selection is typically used for post-tax domestic partner options that are bundled with a pre-tax option in enrollments. Selecting this option allows you to exclude the post-tax option from decision support recommendations but still have the premiums for the option reflected with the pre-tax option in decision support results, providing the employee with more accurate cost information. If the bundled options have multiple rates (premiums), the amount shown for employees is a weighted average of those rates based on enrollment in the included option. | |
|
Include Premiums with Option |
This drop-down list shows if you selected Premiums Only in the Include drop-down list. Select the option that the premiums of this option should be included with. Typically, the option that you select in this drop-down list is the pre-tax option that is bundled (in enrollments) with the post-tax option you've set to Premiums Only. The "premiums only" option and the option that you select in this drop-down list must have the same rate structure configured in Benefits Setup > Plans and Options. That is, the effective dates of the rates must be the same, and in the case of multiple rates, the rate qualifiers must be the same. If you update the rate structure for one of the options so that they no longer match, then Dayforce only shows the rates for the included option in decision support results after that. |
|
Employee Only |
Select this checkbox if the option only allows coverage of the employee and no other dependents. |
|
Employee +Spouse |
Select this checkbox if the option allows coverage of the employee and their spouse, domestic partner, or both. |
|
Employee +1 Child |
Select this checkbox if the option allows coverage of the employee and one child. |
|
Employee +Children |
Select this checkbox if the option allows coverage of the employee and multiple children. |
|
Full Family |
Select this checkbox if the option allows coverage of the employee, spouse (or domestic partner, or both), and one or more children. |
For each tier that has an associated option, enter employer Health Savings Accounts (HSA) information in this section, if applicable. Typically, this applies to high-deductible plans. This information will come from someone in your organization or your broker; it's not found in the SBC.
If there is one HSA amount, enter it for all of the options. If a plan has one amount for individuals and another amount for families, enter the individual amount for options mapped to the Employee Only tier and enter the family amount for all of the options mapped to multi-person tiers.
| Field | Action |
|---|---|
|
Enable Employee HSA Recommendations |
Select the checkbox and, during enrollment, Dayforce includes a question related to HSA contributions in the decision support questionnaire and provides recommendations for employee contributions in the decision support results. Keep the checkbox cleared, and neither the question nor any recommendations are included. |
|
HSA Type |
Select an option in the drop-down list to indicate the contribution structure of the HSA that's associated with the tier. The options are:
Your selection determines which fields are enabled in this section. |
|
Employer HSA Amount |
Enter the amount contributed by the employer annually. This field is enabled if you selected Automatic or Both in the HSA Type drop-down list. |
|
Employer HSA Max |
Enter the maximum matching contribution made by the employer annually. This field is enabled if you selected Both or Contingent in the HSA Type drop-down list. |
|
Employer HSA Percent |
Enter the percentage of the employee's contribution that the employer contributes annually. This field is enabled if you selected Both or Contingent in the HSA Type drop-down list. |
If a tier isn’t mapped to any plan options, or if all of the options mapped to a tier are subsequently excluded from the configuration, the settings for that tier in the HSA Configuration section aren't enabled and cannot be edited. Field values are cleared, and the HSA Type selection is set to No Employer Contribution.
For each tier that has an associated option, enter employer Flexible Spending Account (FSA) information in this section, if applicable. This information will come from someone in your organization or your broker; it's not found in the SBC.
If there is one FSA amount, enter it for all of the options. If a plan has one amount for individuals and another amount for families, enter the individual amount for options mapped to the Employee Only tier and enter the family amount for all of the options mapped to multi-person tiers.
| Field | Action |
|---|---|
|
Enable Employee FSA Recommendations |
Select the checkbox and, during enrollment, Dayforce includes a question related to FSA contributions in the decision support questionnaire and provides recommendations for employee contributions in the decision support results. Keep the checkbox cleared, and neither the question nor any recommendations are included. |
|
Employer FSA Amount |
Enter the amount contributed by the employer annually. |
|
Employer FSA Max |
Enter the employer-set annual limit for the combined employee and employer contributions to the FSA. When set, this amount must not override the federal limit for the tax year in question. This field can be left blank when the FSA or FSA and HRA options are selected in the Reimbursement Account Applicable drop-down list. |
If a tier isn’t mapped to any plan options, or if all of the options mapped to a tier are subsequently excluded from the configuration, the settings for that tier in the FSA Configuration section aren't enabled and cannot be edited. Also, any existing field values are cleared.
For each tier that has an associated option, enter employer Health Reimbursement Account (HRA) information in this section, if applicable. This information will come from someone in your organization or your broker; it's not found in the SBC.
If there is one HRA amount, enter it for all of the options. If a plan has one amount for individuals and another amount for families, enter the individual amount for options mapped to the Employee Only tier and enter the family amount for all of the options mapped to multi-person tiers.
| Field | Action |
|---|---|
| HRA Type |
Select an option in the drop-down list to indicate when the employer begins contributing to the HRA that's associated with the tier. The options are:
|
|
Employer HRA Amount |
Enter the number representing the total potential amount of the employer's reimbursement in the HRA. |
|
Employer HRA Starting Amount |
Enter the total out-of-pocket expense the employee must incur before the employer reimbursement begins. This field is enabled if you selected Middle in the HRA Type drop-down list. |
If a tier isn’t mapped to any plan options, or if all of the options mapped to a tier are subsequently excluded from the configuration, the settings for that tier in the HRA Configuration section aren't enabled and cannot be edited. Also, field values and the HRA Type selection are cleared.
| Field | Action |
|---|---|
|
Medical Deductible |
Enter a value in the field. This value represents the amount a member must pay for covered medical expenses each plan year, before the plan begins to pay its share. An SBC will usually present only two amounts for in-network coverage: "Individual" and "Family." In general, the “Family” deductible amount in an SBC corresponds to all four of the multi-person tiers. |
|
Rx Deductible Type |
If there is a prescription medication (Rx) deductible or out-of-pocket maximum (OOP max) separate from the medical deductible or OOP max, select Separate from Medical in the drop-down list. If the prescription medication deductible and OOP max are both included in the medical deductible and OOP max, select Included in Medical in the drop-down list. If there is a prescription medication deductible separate from the medical deductible, it will appear separately on the SBC. |
|
Rx Deductible |
If there is a prescription medication (Rx) deductible separate from the medical deductible, enter a value in the Rx Deductible field. This value represents the amount a member must pay for covered prescription medication expenses each plan year, before the plan begins to pay its share. If there is a single amount applicable to all tiers, enter it for all five tiers. Alternatively, there might be two amounts, for "Individual" and "Family," in which case the “Family” amount corresponds to all of the multi-person tiers. If there is no separate prescription medication deductible, leave this field empty. |
|
OOP Max |
Enter a value in the field. This value represents the maximum out-of-pocket amount an individual or family will pay (in deductibles, copays, coinsurance, and other patient pay categories) during a plan year. |
| Rx OOP Max |
If there is an out-of-pocket maximum (OOP max) for prescription medication (Rx) separate from the medical OOP max, enter a value in the field. This value represents the maximum out-of-pocket amount an individual or family will pay for covered prescription medication during a plan year. If there is a single amount applicable to all tiers, enter it for all five tiers. Alternatively, there might be two amounts, for "Individual" and "Family," in which case the “Family” amount corresponds to all of the multi-person tiers. If there is no separate prescription medication OOP max, leave this field empty. |
Required Coverage Details / Optional Coverage Details
This table describes the fields that you set in both the Required Coverage Details and Optional Coverage Details sections of the configuration. In these sections, you select the benefit design type (for example, co-pay, coinsurance, or dual) that applies to each benefit service and then enter the details of that design. The fields listed in the table can appear for any benefit service; Dayforce shows the appropriate fields based on the benefit design that you select for that service.
You must set these details for all of the benefit services listed in the Required Coverage Details section. You don’t have to set them for any of the services listed in the Optional Coverage Details section, but doing so increases the accuracy of the out-of-pocket cost calculations generated by Benefits Decision Support for your employees.
The following two tables list:
- Benefit designs
- Fields to set for those benefit designs
Select a benefit design for each benefit service included in the plan. Then set the fields for that design.
| Benefit Design | Definition / Action |
|---|---|
|
Not Covered |
Select this benefit design if the benefit service isn’t covered by the plan. |
|
Copay |
Select this benefit design if the member pays a fixed amount for the benefit service. |
|
Coinsurance |
Select this benefit design if the member pays share, or percentage, of the cost of the benefit service. |
|
Combo |
Select this benefit design if the plan uses a combination of copays and coinsurance for the benefit service. |
|
Greater of maximum |
Select this benefit design if the cost share is either a copay amount or a percentage-based coinsurance payment (depending on which is the greater amount), and a per-service maximum is specified. This benefit design is typically applied to non-preferred or high cost prescription drugs. For example, the member pays the greater of $50 or 20% of a prescription cost up to a maximum of $200 for a high cost drug. |
|
Dual |
Select this benefit design if the plan uses one component (initial) for a certain number of units of service, then switches to the other component (secondary) after that number of units of service has been used. For example, a member initially pays a coinsurance amount of 50% until they've used 20 units of the benefit service; for the 21st unit of service and all units after that, the member has a copay of $25. Typically, the copay portion of a dual benefit design isn’t applicable to the medical deductible, but the coinsurance portion is. |
|
No Charge |
Select this benefit design if the benefit service is fully covered by the plan and requires no out-of-pocket contribution from the member. |
Note: The fields in the following table are listed alphabetically.
| Field | Action |
|---|---|
|
Applicable Deductibles |
Select the appropriate checkboxes if the costs that members incur for this benefit service apply towards the medical and / or Rx deductibles. Dayforce shows Medical and Rx checkboxes for all options except No Charge, for which it only shows the Medical checkbox. |
|
Applicable Units of Service |
Select an option in the drop-down list. Dayforce shows the Applicable Units of Service drop-down list when the benefit design selection for the service is Dual. Enter the units of service for which the initial component of the dual benefit design is applicable before the secondary component is applied for this benefit service. |
|
Coinsurance% |
Enter a value in the field. Don’t enter a percentage symbol. This value represents the individual or family share of the costs for this benefit service. |
|
Copay Amount |
Enter a value in the field. This value represents the dollar amount that the individual or family pays for this benefit service. |
|
Initial Component |
Dayforce shows the Initial Component drop-down list when the benefit design selection for the service is Dual. Select from the following options to designate the benefit design that will apply initially for this benefit service:
|
|
Max Days |
Enter a value in the field. This value represents the maximum number of days the copay applies to this benefit service or prescription. |
|
Per Day |
Select the checkbox if the copay applies to a specific number of days for the benefit or service. When the checkbox is selected, Dayforce shows the Max Days field. |
|
Per Service Max |
Enter a value in the field. This value represents the maximum that an insured member can spend, per unit of service, in a greater of maximum benefit design. |
|
Secondary Component |
Dayforce shows the Secondary Component drop-down list when the benefit design selection for the service is Dual. Select from one of the following options to designate the benefit design that will apply secondarily for this benefit service:
|