Predictika · Health plan enrollment
An AI sales agent enrolls a household in a Community Health Choice Marketplace plan: Premier, Select or Ultra Select, Bronze, Silver or Gold, with the household members, county, premium tax credit, cost-sharing reduction, enrollment period and the premium and out-of-pocket maximum it quotes. Before the enrollment goes out, the agent sends it to Predictika, which checks it against a declarative model of the plans Community Health Choice publishes and returns a verdict, every reason, a monthly premium schedule and the figures it computed. The households are fictional.
This validator models the enrollment of a household in a Community Health Choice individual Marketplace plan for plan year 2026, as described in the public Community Health Choice plan documents, not just the scenarios shown below. Where a rule is published by Community Health Choice or follows federal Marketplace rules it says so; the premiums, the cost-sharing reduction caps and the approvals are labeled as invented.
Any enrollment of a household in these plans is in scope — not only the scenarios pictured here. Not covered: Medicaid STAR and CHIP enrollment (CHIP appears only as an approval), Medicare Advantage and D-SNP plans, employer and group plans, dental and vision, tobacco rating, and the exact federal subsidy formulas (the tax credit is an input taken from the Marketplace eligibility result). The households are fictional.
7 scenarios in 3 groups · each group runs from the agent’s first attempt to the outcome · click one to switch
Proposing agent: AI sales agent (scripted)
Before sending, the agent must call Recorded run
What this means
Our assessment of what a typical rules-based CPQ (product rules, price rules and validation rules, as in Salesforce CPQ) does with the same cases. It is a judgment about effort and reliability, not a claim that nothing can be built.
| What the validator caught | Typical rules-based CPQ | Predictika |
|---|---|---|
| A premium built from age, county and the three-child rule | Only with workarounds Each member pays the plan base rate times an age factor times a county factor, and only the three oldest children under 21 are charged. A rules engine needs a ranking of the children and a rule for each slot, and the free child changes the total only in large families. | The ranking, the child with no premium and every member's line are computed together, and the lines add up to the total. |
| Plans that are offered in some counties only | Only with care Premier plans are offered in all 20 counties, two Select plans in Harris and Fort Bend, the rest in Harris only. A product-availability rule is needed for every plan and county, and adding a county touches many of them. | The availability of each plan is one table, checked against the county in the same pass as everything else. |
| Subsidies that depend on the plan, the channel and the income | Only with workarounds A premium tax credit applies only on the Marketplace, starts at 100 percent of the poverty level and cannot exceed the premium; a cost-sharing reduction applies only to a Silver plan on the Marketplace, in three income bands. Each rule reads several fields and the exceptions pile up. | Every condition is checked together and each finding names the one that failed. |
| Enrollment periods | Only with care Open enrollment has fixed dates; a special enrollment period needs a qualifying event within 60 days. The dates and the event are fields that rules must read together. | The window and the event are checked in the same pass as the plan and the household. |
| A stated premium and out-of-pocket maximum that must match | Only with workarounds The agent states a net premium and an out-of-pocket maximum that depend on the credit, the free child and the cost-sharing reduction cap. Comparing them means recomputing both in a validation rule. | Both figures are computed and compared with what the agent stated; a difference blocks. |
| Every problem returned in one answer | Only with workarounds Rules tend to fire as the application is saved or a step is completed, so a person often fixes one error and meets the next. | All findings come back together, whatever order the choices arrived in. |
Every rule is checked on every call, in any order the choices arrive; one problem never hides another. Blocking findings stop the enrollment; approval findings need a person to sign off; everything else is computed.
| 1 | The selected plan is not sold the way the application asks; Premier Gold 001 and Ultra Select Gold 001 are sold off the Marketplace only, the Silver plans are sold both on and off the Marketplace, and every other plan is sold on the Marketplace only. |
| 2 | A premium tax credit of $400 a month is claimed on a plan bought off the Marketplace; premium tax credits apply only to plans bought on the Marketplace. |
| 3 | The household lives outside the 20-county Community Health Choice service area (Austin, Brazoria, Chambers, Galveston, Fort Bend, Hardin, Harris, Jasper, Jefferson, Liberty, Matagorda, Montgomery, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller and Wharton counties). |
| 4 | The selected plan is not offered in the household county; Premier plans are offered in all 20 counties, Select Silver 019 and Select Gold 022 in Harris and Fort Bend counties, and the other Select and Ultra Select plans in Harris County only. |
| 5 | An open enrollment application must be dated from November 1, 2025 through January 15, 2026; outside those dates a special enrollment period is needed. |
| 6 | The qualifying event was 61 days ago; a special enrollment period lasts 60 days from the event. |
| 7 | A special enrollment application names no qualifying life event. |
| 8 | The subscriber is 17 years old; the subscriber on a Marketplace application must be at least 18. |
| 9 | The spouse is 17 years old; a spouse on the application must be at least 18. |
| 10 | The oldest child on the application is 26 years old; a child can be covered as a dependent only up to age 26, so a child aged 26 or older needs a separate application. |
| 11 | The application asks for the 73 percent cost-sharing reduction variant, but at 251 percent of the federal poverty level the household does not qualify; the variants cover 100 to 250 percent. |
| 12 | A premium tax credit is claimed at 99 percent of the federal poverty level; the credit starts at 100 percent. |
| 13 | No household income is given, so premium tax credit and cost-sharing reduction eligibility cannot be checked. |
| 14 | A premium tax credit is claimed at 401 percent of the federal poverty level, above 400 percent, where credit eligibility depends on the federal rules for the plan year, so a person should confirm. |
| 15 | At 140 percent of the federal poverty level the household qualifies for the 94 percent cost-sharing reduction variant of a Silver plan, but the application selects none. |
| 16 | The application asks for the 87 percent cost-sharing reduction variant; at 140 percent of the federal poverty level the household qualifies for the 94 percent variant. |
| 17 | A cost-sharing reduction variant is requested, but cost-sharing reductions come only with a Silver plan bought on the Marketplace. |
| 18 | The household qualifies for a 94 percent cost-sharing reduction variant, which only Silver plans offer, so a person should confirm the household means to choose a Bronze or Gold plan. |
| 19 | The monthly premium tax credit of $623 is more than the total monthly premium of $622; the credit cannot exceed the premium. |
| 20 | The household has at least one child under 19 at 201 percent of the federal poverty level, at or below the Texas CHIP limit of 201 percent, so a person should confirm whether the children belong in CHIP instead of this Marketplace plan. |
| 21 | The quote states a net monthly premium of $621; the validator computes $622. |
| 22 | The quote states a household out-of-pocket maximum of $8,899; the validator computes $8,900. |
The text of the narrated walkthrough, step by step.