Social Insurance

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Publicly supported social insurance programs provide financial assistance and protection for constituents who experience life events that reduce their income or increase their expenses. For example, pensions provide income to retired individuals. Workers’ compensation provides replacement wages, medical treatment, and other benefits to employees who become injured or ill on the job. And Social Security provides retirement income to almost every American worker.

Employees, including self-employed individuals, typically fund social insurance programs through regular contributions such as paycheck deductions. In addition, employers contribute to some social insurance programs on behalf of their employees. Contribution to some social insurance programs, such as workers’ compensation, is mandatory.

Public Sector Solutions provides these objects to enable you to manage social insurance programs and administer social insurance benefits to constituents.

• Set up social insurance benefits programs by using the Program, Benefit Type, and Benefit objects.
• Use the Insurance Policy object to define social insurance policies. Manage enrollments by relating constituents’ person accounts to policies. Track contributions by using the Insurance Policy Transaction object.
• Capture compensation classes in the Worker Compensation Coverage Class object. Workers’ compensation classes represent the category of work that employees perform, such as welder, computer engineer, or sales executive.
• Use the Payment Request and Payment Request Line objects to capture required contributions that constituents or employers make to social insurance policies. For example, create a payment request for a pending contribution from an employer for a workers’ compensation policy.
• When constituents file claims, store details in the Claim object. Relate constituents to a claim by using the Claim Participant object. Use the Claim Item object to capture details of items related to a claim. After reviewing a claim, record its approval status in the Claim object.
• For approved claims, create a support plan by using the Care Plan object.

Circumstances can make it difficult for constituents to get the care or services they need. For example, an injured worker needs physiotherapy sessions but cannot commute to the healthcare facility because the injury limits their mobility. To address the care barrier, you can assign the worker physiotherapy sessions at home.

Public Sector Solutions provides these objects to help you identify care barriers.

• Define the obstacles or circumstances that make it difficult for constituents to get the care and services they need by using the Care Barrier Type object.
• Use the Code Set and Code Set Bundle objects to store diagnostic codes for medical conditions. Map care barrier types for medical conditions to the corresponding diagnostic codes.
• Capture details of an obstacle or circumstance that affects a particular constituent by using the Care Barrier object.
• Relate a care barrier to a constituent’s care plan by using the Care Plan Detail object.

Public Sector Solutions provides these objects to help you assign constituents benefits and goals to address their economic hardship and care barriers.

• Assign goals to constituents to track their progress by using the Goal Assignment object. Relate a goal assignment to a care barrier by using the Goal Assignment Detail object.
• Assign eligible benefits to constituents by using the Benefit Assignment object. To adjust the amount of the benefit, use the Benefit Assignment Adjustment object. Track the delivery of assigned benefits by using the Benefit Disbursement object.

• Social Insurance Prerequisites
  Before you set up social insurance in Public Sector Solutions, complete the prerequisites.
• Social Insurance Claim Flows
  Constituents can file claims for social insurance benefits through guided flows on your Experience Cloud site. They can provide the required details, upload supporting documents, and preview and submit their claims. They can also track the status of the claims on the site.
• Build a Social Insurance Experience Cloud Site in Public Sector Solutions
  Create an Experience Cloud site where constituents can file and track claims for social insurance benefits.