| Business Data Model Data Model |
| Description | An association between a plan member and an insurance policy. Indicates a membership with the insurance policy. |
| Relationship | |
 Plan Member / Insurance Policy_Plan Member_FK |
|
| Plan Member / Insurance Policy_Insurance Policy_FK |
|
| Dependencies | |
 NONE |
|
| Reverse Dependencies | |
| |
|
| Attribute Details |
Late Enrollment Ind
| Description | Indicates whether the member is considered to have been continuously enrolled in a plan for a specified period or has switched plans during the criteria period, since their enrollment date or notification date, whichever is later. 1 enrolled late 0 not late |
| Data Type | Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership End Date
| Description | The date upon which the membership of the policy ended. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Date [DATE] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Lifetime Benefit Accumulator
| Description | The total benefits ever paid to date for this member for the agreement. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Notification Date
| Description | The date upon which the organization became aware of a membership. This may occur prospectively, i.e. before the enrollment date or retrospectively, i.e. after the enrollment date has passed. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Date [DATE] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Start Date
| Description | The date upon which the membership of the policy commenced. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Date [DATE] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Status
| Description | Indicates the current status of the membership. For example, if Mary separates from her husband, she may no longer elect to include spouse coverage on her individual policy, so while her policy and resulting membership will remain active her husbands will be terminated. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Status Reason
| Description | Indicates the reason for the current membership status or why it has changed. For example: Divorced Employment Opted out Overage Dependent Retired Terminated |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Year To Date Benefit Accumulator
| Description | The total benefits paid year-to-date for this agreement for this member for the given agreement. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Year To Date Deductible Accumulator
| Description | Amount of deductible on the agreement already paid by the member during the current contract year. Applies to benefits in-network, where applicable. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Year To Date Deductible Accumulator Out-of-Network
| Description | Amount of deductible on the agreement already paid by the member during the current contract year for benefits received out-of-network. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Year To Date Out-of-Pocket Accumulator
| Description | Amount of deductibles and co-payments on the agreement already paid by the member during the current contract year. Applies to benefits in-network, where applicable. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Membership Year To Date Out-of-Pocket Accumulator Out-of-Network
| Description | Amount of deductibles and co-payments on the agreement already paid by the member during the current contract year. Applies to benefits out-of-network. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Pre-existing Condition Waiver
| Description | Indicates whether enrolment occurred without consideration for pre-existing conditions. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Type of Membership
| Description | Indicates the type of membership under which benefits are paid. For example: Consolidated Omnibus Budget Reconciliation Act (COBRA) Standard Surviving Insured Tax Equity and Fiscal Responsibility Act (TEFRA) |
| Data Type | Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
| Relationship Details |
Plan Member / Insurance Policy_Plan Member_FK
| Is Identifying Relationship | true |
| Child Table | Plan Member / Insurance Policy |
| Child Role Name | has for left parent |
| Child Multiplicity | ZERO_TO_MANY |
| Child Referential Integrity: On Delete | NONE |
| Child Referential Integrity: On Insert | NONE |
| Child Referential Integrity: On Update | NONE |
| Parent Table | Plan Member |
| Parent Role Name | is left parent of |
| Parent Multiplicity | ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Plan Member / Insurance Policy_Insurance Policy_FK
| Is Identifying Relationship | true |
| Child Table | Plan Member / Insurance Policy |
| Child Role Name | has for right parent |
| Child Multiplicity | ZERO_TO_MANY |
| Child Referential Integrity: On Delete | NONE |
| Child Referential Integrity: On Insert | NONE |
| Child Referential Integrity: On Update | NONE |
| Parent Table | Insurance Policy |
| Parent Role Name | is right parent of |
| Parent Multiplicity | ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
| Business Data Model Data Model |