Predictika · small-group medical quoting: group size, participation, plans, riders, commission and age-rated premium
An AI sales agent prepares a small-group medical quote for a fictional employer, with the total monthly premium it expects. Before the quote is released for enrollment, the agent sends it to Predictika’s validator, which checks it against group-size, participation, plan, rider and commission rules, compares the total the agent states with the one it computes, and returns a verdict with every reason.
This validator models small-group medical quotes for six sample areas and six plans, with dental and vision riders. It handles any combination of group, census, plan, rider and commission choices the model supports, not just the scenarios shown below.
It does not cover large-group or self-funded plans, other carriers’ rules, areas beyond the six modeled, real UnitedHealthcare rates or underwriting decisions, or any real employer.
7 scenarios in 3 groups · each group runs from the agent’s first attempt to the outcome · click one to switch
Illustrative agent statement. The validator receives the structured request below.
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 or Revenue Cloud) does with the same cases. It is a judgment about effort and reliability, not a claim that nothing can be built.
| What the validator catches | Typical rules-based CPQ | Predictika |
|---|---|---|
| Eligibility that depends on several choices together | Only with workarounds Group size, participation, contribution, plan and rider rules vary by area, and each combination tends to become a separate rule. | All conditions are evaluated together on every call, whatever order the choices arrive in. |
| Area limits and minimums | Only with care Limits and participation minimums are lookups by area that must be kept complete and read by several rules. | The area row supplies the limit and the minimum, and the same value drives the check and the message. |
| Age-rated premium | Only with care A census by age band, with spouse, child, tobacco, dental and vision factors, is manageable in a price rule but grows with every new band or rider. | Each premium figure is computed once for every check and line item to read. |
| Participation with waivers and the enrollment window | Only with workarounds Net-of-waiver participation and an exception that turns a block into an approval need several coordinated rules. | The participation test, the waiver credit and the window exception are evaluated together and returned with the reason. |
| Commission as a rate load and an approval | Only with care Commission changes the rate, needs an approval above a standard and is blocked above a maximum, which means price rules and validation rules must agree. | The load, the approval and the block come from one commission figure. |
| The total the agent states | Only with workarounds Comparing a stated total with a computed one means a separate rule per quote layout, and price rules rarely run on stated figures. | The stated total is a field in the request and is checked against the computed total. |
| Every problem returned in one answer | Only with workarounds Rules tend to fire as the quote is saved, so a rep 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 whatever order the choices arrive, and one problem never hides another. Blocking findings stop the quote; approval findings need a person to sign off; everything else is computed.
| Rule | Effect | What it checks |
|---|---|---|
| 1 | block | The area sets the small-group limit on eligible employees (50 in Texas and Florida, 100 in California, New York and Colorado) |
| 2 | block | At least one enrolling employee must not be an owner or owner spouse, and the census must be between 1 and the eligible count |
| 3 | block, or approval | Enrolling employees, net of valid waivers, must meet the area participation minimum, unless the quote is in the guaranteed-issue window, which needs approval |
| 4 | block | The employer must pay at least 50 percent of the employee-only premium, and no more than 100 percent |
| 5 | block | An HMO plan needs the HMO network in the area; an HSA needs an HSA-qualified plan |
| 6 | block | A tobacco surcharge is blocked where tobacco rating is prohibited, and tobacco users cannot exceed enrolling employees plus spouses |
| 7 | block | Dental needs at least 2 enrollees, no more than the medical enrollees, and the dental HMO only where it is offered |
| 8 | approval, then block | Broker commission above 5 percent needs a compensation override; above 8 percent is blocked |
| 9 | computed | Employee premium is the area rate times the age-band rating units, with the commission load applied |
| 10 | computed | Spouses and children are rated on their own factors; tobacco, dental and vision are added to the total |
| 11 | block | The total monthly premium the agent states must match the validator total within $1 |
The recorded result of the validator for each scenario on this page: the request the AI agent sent, the verdict, and every finding, in the order they appear above.
The agent's request. A small-group quote for a Dallas, Texas employer with 60 eligible employees, 45 enrolling, 8 spouses and 10 children, on Choice Plus Gold 1000 with PPO dental for 30 and vision, 60 percent employer contribution. Total monthly premium $54,232.00. Ready to release.
Verdict: Blocked.
The agent's request. A small-group quote for a Dallas, Texas employer with 50 eligible employees, 45 enrolling, 8 spouses and 10 children, on Choice Plus Gold 1000 with PPO dental for 30 and vision, 60 percent employer contribution. Total monthly premium $54,232.00. Ready to release.
Verdict: Allowed.
The agent's request. A small-group quote for a Dallas, Texas employer with 12 eligible employees, 5 enrolling, 2 spouses and 3 children, on Choice Plus Gold 1000 with PPO dental for 4 and vision, 60 percent employer contribution. Total monthly premium $7,362.55. Ready to release.
Verdict: Blocked.
The agent's request. A small-group quote for a Dallas, Texas employer with 12 eligible employees, 9 enrolling (8 of them non-owner employees), 2 spouses and 3 children, on Choice Plus Gold 1000 with PPO dental for 4 and vision, 60 percent employer contribution. Total monthly premium $10,201.05. Ready to release.
Verdict: Allowed.
The agent's request. A small-group quote for a Denver, Colorado employer with 10 eligible employees, 8 enrolling, 3 spouses and 4 children, on Choice Plus Bronze HSA 7000 with an HSA, a tobacco surcharge for 2 employees, PPO dental for 6 and vision, 75 percent employer contribution. Total monthly premium $5,512.18. Ready to release.
Verdict: Blocked.
The agent's request. A small-group quote for a Denver, Colorado employer with 10 eligible employees, 8 enrolling, 3 spouses and 4 children, on Choice Plus Bronze HSA 7000 with an HSA, a tobacco surcharge for 2 employees, PPO dental for 6 and vision, 75 percent employer contribution. Total monthly premium $6,890.22. Ready to release.
Verdict: Allowed.
The agent's request. A small-group quote for a Miami, Florida employer with 20 eligible employees and 16 enrolling, on Navigate HMO Gold 1500, 60 percent employer contribution, with a 7 percent broker commission. Compensation override approved. Total monthly premium $13,254.70. Ready to release.
Verdict: Needs approval.
The text of the narrated walkthrough, step by step.