Benefit Plan Configuration Guide

End-to-end guide to configuring benefit plans in Cloud Health Office — plan hierarchies, coverage tiers, cost sharing rules, accumulator tracking, and network assignment. Covers commercial, Medicaid, Medicare Advantage, and Exchange (QHP) plan types.

Overview

Cloud Health Office benefit plan configuration is organized around four interconnected areas that define how members are covered and how claims are adjudicated:

Each area feeds directly into the claims adjudication pipeline. When a claim is processed, the adjudication engine looks up the member's benefit plan to determine covered services, applies cost sharing rules, updates accumulators, and validates provider network participation — all driven by the configuration described in this guide.

1. Plan Structure

Benefit plans in Cloud Health Office follow a three-level hierarchy that mirrors how health plans are designed in the real world: the Plan is the top-level product, which contains one or more Benefit Packages (sets of covered services), each offered at multiple Coverage Tiers (employee-only, family, etc.).

Plan (top-level product) → one or more Benefit Packages (covered service sets) → multiple Coverage Tiers (Employee Only, Employee + Spouse, Employee + Children, Family)

Plan Fields

Each plan record contains the following core fields:

Field	Type	Description
PlanId	String	Unique identifier for the plan (system-generated or user-defined)
PlanName	String	Display name (e.g., "Gold PPO 2026", "Medicaid Standard")
LineOfBusiness	Enum	Medicaid, Medicare Advantage, Commercial, or Exchange (QHP)
EffectiveDate	Date	Date the plan becomes active and can accept enrollments
TermDate	Date	Date the plan is terminated (null for open-ended plans)
PlanStatus	Enum	Current lifecycle status (see lifecycle table below)
RegulatoryType	Enum	HMO, PPO, EPO, POS, HDHP, Indemnity — drives network and cost sharing rules

Plan Status Lifecycle

Plans progress through a defined lifecycle that controls enrollment eligibility and claims processing behavior:

Status	Description	Enrollment Allowed	Claims Processed
Draft	Plan is being designed; rates and benefits are editable	No	No
Active	Plan is live; members can be enrolled and claims adjudicated	Yes	Yes
Grandfathered	Plan is closed to new enrollment but existing members retain coverage	No (new)	Yes
Closed	Plan is closed; no new enrollments, existing members being transitioned	No	Yes (runout)
Terminated	Plan is fully terminated; no enrollment or claims processing	No	No

Lines of Business

The Line of Business (LOB) assigned to a plan drives significant downstream behavior throughout the platform:

• Medicaid — State-specific prompt-pay rules (typically 30 days clean claim), nominal copay limits, Medicaid-specific NCCI edits, state regulatory reporting requirements
• Medicare Advantage — CMS prompt-pay (30 days clean claim), MA-specific fee schedules, CMS STAR quality reporting, risk adjustment (HCC) integration
• Commercial — Employer-sponsored plans with contractual prompt-pay terms, commercial fee schedules, state DOI reporting
• Exchange (QHP) — ACA marketplace plans with Essential Health Benefit requirements, actuarial value calculations, risk corridor/reinsurance programs, 90-day grace period rules

Benefit Package Configuration

A Benefit Package defines the set of service categories covered under a plan. Each package specifies which services are covered, and the cost sharing rules for each category are configured separately (see Section 2: Cost Sharing Rules).

Standard service categories:

Service Category	Description	Typical Claim Types
Inpatient	Hospital admissions, skilled nursing facility stays	837I (Institutional)
Outpatient	Hospital outpatient services, ambulatory surgery centers	837I, 837P
Professional	Physician office visits, specialist consultations	837P (Professional)
Pharmacy	Prescription drugs (retail, mail-order, specialty)	NCPDP D.0
Behavioral Health	Mental health and substance use disorder services	837P, 837I
DME	Durable medical equipment (wheelchairs, CPAP, prosthetics)	837P
Lab	Laboratory testing (blood work, pathology, genetic testing)	837P
Imaging	Radiology, MRI, CT, ultrasound, PET scans	837P, 837I
Emergency	Emergency department visits and urgent care	837I, 837P
Preventive	Wellness exams, immunizations, screenings (ACA first-dollar coverage)	837P

Coverage Tiers

Each benefit package is offered at multiple coverage tiers that determine the number of covered individuals and the associated premium:

Coverage Tier	Covered Members	Typical Premium Ratio	Example Monthly Premium
Employee Only	Subscriber only	1.0x	$650
Employee + Spouse	Subscriber + spouse/domestic partner	2.0x	$1,300
Employee + Children	Subscriber + child dependents	1.7x	$1,100
Family	Subscriber + spouse + children	2.8x	$1,800

2. Cost Sharing Rules

Cost sharing rules define the member's financial responsibility for each covered service. For every combination of service category, place of service, and network tier, the plan specifies copay amounts, coinsurance percentages, deductible applicability, and prior authorization requirements.

Cost Sharing by Service Category

Example cost sharing configuration for a typical Commercial PPO plan (Gold tier):

Service Category	In-Network Copay	In-Network Coinsurance	Deductible Applies	Prior Auth Required
PCP Visit	$25	0%	No	No
Specialist Visit	$50	0%	No	No
Emergency Room	$250	20%	Yes	No
Inpatient Admission	$500/day	20%	Yes	Yes
Outpatient Surgery	$200	20%	Yes	Yes
Lab	$0	10%	Yes	No
Imaging (Advanced)	$100	20%	Yes	Yes
Pharmacy — Tier 1 (Generic)	$10	0%	No	No
Pharmacy — Tier 2 (Preferred Brand)	$35	0%	No	No
Pharmacy — Tier 3 (Non-Preferred)	$60	0%	Yes	No
Pharmacy — Tier 4 (Specialty)	N/A	30%	Yes	Yes
Behavioral Health	$25	0%	No	No (outpatient) / Yes (inpatient)

Service Category Lookup → Network Tier Check (in-network / out-of-network / OON emergency) → Deductible Application (has member met deductible?) → Copay / Coinsurance Calculation → Out-of-Pocket Maximum Check

HDHP / HSA-Specific Rules

High Deductible Health Plans (HDHPs) paired with Health Savings Accounts (HSAs) have IRS-mandated parameters that the plan configuration must enforce:

• Minimum deductible — Individual: $1,650 (2026); Family: $3,300 (2026). The plan deductible must meet or exceed these thresholds.
• Maximum out-of-pocket — Individual: $8,300 (2026); Family: $16,600 (2026). Total member cost sharing cannot exceed these limits.
• Preventive care exception — ACA-compliant preventive services must be covered at 100% before the deductible is met (first-dollar coverage). This is the only exception to the deductible-first rule.
• No copays before deductible — Unlike standard plans, HDHPs cannot apply copays until the full deductible is satisfied (except preventive care).

Pediatric Dental & Vision (ACA EHB)

Exchange (QHP) plans must cover the ten ACA Essential Health Benefit categories, including pediatric dental and pediatric vision for members under age 19. Cloud Health Office automatically applies these coverage rules when LineOfBusiness = Exchange:

• Pediatric dental and vision services are covered at the plan's standard cost sharing rates
• If the plan does not include an embedded dental/vision package, the system references the state's benchmark EHB plan
• Pediatric dental/vision accumulators can be tracked separately or combined with medical accumulators (configurable)

Medicaid-Specific Cost Sharing

Medicaid plans have unique cost sharing constraints mandated by federal and state regulation:

• Nominal copays — Federal regulation limits Medicaid copays to nominal amounts (typically $1–$4 per service). Cloud Health Office enforces the state-specific copay schedule.
• Copay-exempt services — Certain services are exempt from any cost sharing: preventive care, pregnancy-related services, emergency services, family planning, and services for children under 18.
• Income-based copay caps — Total member cost sharing in a quarter cannot exceed 5% of the member's household income. Cloud Health Office tracks quarterly copay accumulation against the income-based cap.
• No balance billing — Medicaid members cannot be balance-billed; provider must accept the Medicaid allowed amount as payment in full.

3. Accumulators

Accumulators track member cost sharing over time and determine when deductibles are met, out-of-pocket maximums are reached, and visit limits are exhausted. Cloud Health Office uses Redis-backed real-time accumulator tracking to support sub-millisecond lookups during claims adjudication.

Accumulator Types

Accumulator Type	Description	Typical Threshold	Effect When Met
Individual Deductible	Amount the member must pay before the plan begins paying coinsurance	$1,500 – $8,300	Plan pays coinsurance; copays still apply
Family Deductible	Combined deductible for all family members	$3,000 – $16,600	All family members' deductibles considered met
Individual OOP Max	Maximum total cost sharing for one member in a period	$8,300 (ACA max)	Plan pays 100%; no further member cost sharing
Family OOP Max	Combined OOP max for all family members	$16,600 (ACA max)	Plan pays 100% for all family members
Lifetime Maximum	Total plan benefits over member's lifetime (grandfathered plans only)	$1,000,000+	No further plan payments; ACA-compliant plans prohibit this
Visit Limits	Maximum number of visits per service category per period	20 PT visits/year, 30 BH visits/year	Additional visits denied or require auth override

Accumulator Periods

Accumulators reset based on the configured accumulator period:

• Calendar Year — Resets January 1; most common for commercial and Exchange plans
• Plan Year — Resets on a custom start date (e.g., October 1 for employers with fiscal-year-aligned benefit years)
• Rolling 12-Month — Resets 12 months from the member's enrollment effective date; used by some Medicaid programs

Family Accumulator Models

For family coverage tiers, Cloud Health Office supports two accumulator models:

Model	How It Works	Typical Use
Embedded	Each family member has an individual deductible within the family deductible. A single member's deductible is met when their individual threshold is reached, even if the family deductible is not yet met.	Most PPO and commercial plans
Aggregate	All family members' claims count toward a single family deductible. No individual member's deductible is met until the total family deductible is satisfied.	HDHP/HSA plans (IRS requirement), some HMO plans

Cross-Plan Accumulation

When a member changes plans mid-year (e.g., during a Special Enrollment Period or open enrollment with a different plan), accumulators can optionally carry over to the new plan:

• Full carry-over — All accumulated amounts transfer to the new plan's accumulators
• Partial carry-over — Only specific accumulator types carry over (e.g., deductible carries over but visit limits reset)
• No carry-over — Accumulators reset to zero on the new plan (default for cross-LOB plan changes)

Cross-plan accumulation is configured at the plan level and can be restricted to same-LOB transfers only.

Accumulator Reversals

When a claim is reversed, voided, or adjusted, the associated accumulator entries are automatically decremented. This ensures accumulator balances remain accurate after:

• Claim payment reversals (overpayment recovery)
• Claim adjustments that change the member responsibility amount
• Retroactive eligibility changes that invalidate previously processed claims
• Coordination of benefits (COB) corrections where the other payer's payment changes

Redis-Backed Real-Time Tracking

During claims adjudication, accumulator lookups must be instantaneous to avoid blocking the auto-adjudication pipeline. Cloud Health Office uses a dual-layer architecture:

• Redis cache — Current accumulator balances are cached in Redis for sub-millisecond read access. Every claim adjudication reads from and writes to Redis in real time.
• Core admin system — The health plan's core admin system (QNXT, Facets, or Cloud Health Office's own member database) is the system of record. A periodic reconciliation job (configurable — typically every 4 hours) syncs Redis with the source of truth.
• Conflict resolution — If Redis and the source of truth diverge during reconciliation, the source of truth wins. A reconciliation exception report is generated for manual review.

Accumulator Lifecycle

Status	Description
Initialized	Accumulator created at the start of the accumulator period with a balance of $0
Accumulating	Claims are being processed and member cost sharing is being tracked
Met	Threshold reached — deductible satisfied or OOP max hit
Reset	Accumulator period ended; balance reset to $0 for the new period

4. Network Assignment

Every benefit plan must be assigned to one or more provider networks. The network assignment determines which providers are considered in-network for the plan's members and drives cost sharing tier selection during claims adjudication.

Plan-to-Network Linking

Network assignment is configured at the plan level. A plan can be linked to:

• Single network — One provider network for all services (typical for HMO and EPO plans)
• Multiple networks — Different networks for different service categories (e.g., a separate behavioral health network, a carve-out pharmacy network)
• Tiered network — Multiple network tiers with different cost sharing at each tier (typical for PPO and POS plans)

Network Tiers

Tiered networks allow plans to incentivize members to use preferred providers through lower cost sharing:

Network Tier	Description	Typical Cost Sharing	Example Providers
Tier 1 — Preferred	High-value providers with negotiated rates and quality metrics	Lowest copays, lowest coinsurance	Centers of Excellence, ACO partners
Tier 2 — Standard	In-network providers with standard contracted rates	Standard copays, standard coinsurance	Most contracted physicians and facilities
Tier 3 — Out-of-Network	Non-contracted providers; highest member cost sharing	Highest copays/coinsurance, balance billing possible	Non-participating providers

Out-of-Network Rules

When a member receives care from an out-of-network provider, the plan's OON rules determine the allowed amount and member responsibility:

• Allowed amount calculation — Configurable per plan:
  • Medicare Rate % — A percentage of the Medicare fee schedule rate (e.g., 150% of Medicare)
  • UCR Percentile — Usual, Customary, and Reasonable charges at a configured percentile (e.g., 80th percentile of FAIR Health data)
  • Billed Charge % — A percentage of the provider's billed amount (least common, highest cost)
• Balance billing protection — Under the No Surprises Act (NSA), emergency services and certain non-emergency services at in-network facilities cannot be balance-billed to the member. Cloud Health Office flags NSA-protected claims and applies the appropriate allowed amount methodology.
• Surprise billing — For NSA-protected claims, the member cost sharing is calculated as if the provider were in-network. The difference between the provider's charge and the in-network allowed amount is resolved through the independent dispute resolution (IDR) process.

Network Adequacy

State regulators require health plans to maintain adequate provider networks. Cloud Health Office tracks network adequacy metrics per plan per county:

• Time/distance standards — Members must be within X miles or Y minutes of a provider for each required specialty
• Appointment wait times — Maximum days to next available appointment by provider type (PCP: 10 days, specialist: 15 days, urgent: 48 hours)
• Provider-to-member ratios — Minimum ratio of providers per 1,000 members by specialty (e.g., 1 PCP per 2,000 members, 1 OB/GYN per 5,000 members)

Network adequacy reports can be exported for state DOI filing or CMS MA network adequacy submissions.

Plan Type Network Rules

The plan's RegulatoryType determines how network rules are enforced:

Plan Type	In-Network Required	OON Coverage	PCP Referral Required	Typical Networks
HMO	Yes (except emergency)	No (except emergency)	Yes	Single narrow network
EPO	Yes (except emergency)	No (except emergency)	No	Single network, no referrals
PPO	No	Yes (higher cost sharing)	No	Tiered network (Tier 1/2/3)
POS	No	Yes (higher cost sharing)	Yes (for in-network tier)	HMO-like in-network + PPO-like OON

Getting Started

Recommended setup order for a new health plan implementation:

1. Create Line of Business entries — Define the LOBs your organization operates (Medicaid, MA, Commercial, Exchange)
2. Configure provider networks — Set up network definitions and load provider rosters
3. Create benefit plans with packages and tiers — Define the plan hierarchy: Plan → Benefit Package → Coverage Tier
4. Define cost sharing rules per service category — Configure copays, coinsurance, deductible applicability, and prior auth requirements
5. Configure accumulators — Set deductible and OOP max thresholds, select accumulator period and family model
6. Assign networks to plans — Link plans to provider networks and configure tier-based cost sharing
7. Test with a sample claim — Submit a test claim through the adjudication pipeline to verify benefit lookup, cost sharing, and accumulator behavior

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