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Editing the Coverage examples tab

Updated on January 26, 2021

All SBC documents include examples of how a plan might cover a hypothetical consumer’s healthcare costs for sample health conditions, such as pregnancy or Type 2 diabetes. Consumers should not use these coverage examples to estimate their actual costs under a plan because actual services and costs depend on consumers’ individual medical needs when they consult with a provider. Instead, consumers should use the examples to understand how much financial protection the plan is generally expected to provide for common health conditions. These standardized, hypothetical coverage examples can help consumers facilitate apples-to-apples comparisons between plans.

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Before you begin: Ensure that you complete the steps in Configuring data for coverage examples in this section.

The following list describes how values are calculated for the Coverage Examples:

  • Deductible values are populated from the selected product or plan. The deductible logic for In-network is different for each calculation method.
  • For Number of family members, the value of the Individual deductible is used.
  • For Policy type, ranking is applied for each and the deductible value of the lowest ranked displayed on the coverage example page. For more information about modifying this setting, see Configuring settings for the SBC template.
  • For Subscriber salary, the value for the Individual lowest deductible value is used.
  • For Specialist, the value is populated from the copay. If the copay is N/A, then it uses the value from coinsurance. If both the copay and the coinsurance have values of N/A, then the SBC template displays N/A from the In-network configuration.
  • For Hospital (facility), the value is populated from the copay. If the copay is N/A, then it uses the coinsurance. If both the copay and coinsurance are N/A, then the SBC template displays N/A from the In-network configuration.
  • For Other coinsurance, the value is populated from the copay. If the copay value is N/A, then it uses the coinsurance. If both the copay and coinsurance have values of N/A, then the SBC template displays N/A from the In-network configuration.
  • If the mapped benefit for any of the above values is not found for In-network list, then the SBC template displays the Benefit does not exist. (In-network) error.
  • The cost sharing text is replaced with cost share name (copy or coinsurance) per the selected benefit.
  • You can change the benefit mapping for the above values at the product or plan. For example, in the template coverage examples section, you mapped a benefit to hospital facility. Because this is a custom plan and you want to use a different benefit than you had on the template, you can change it specifically for this plan. The available values in the Benefit mapping list come from the benefits contained in the product or plan.

Coverage examples tab

The following items describe the calculation of final cost shares that appear in the product- or plan-specific SBC document that is based on the contents of the SBC template:

  • Final cost shares for each example are displayed from the auto-calculation results.
  • Auto-calculation does not occur if there is any benefit mismatch error in the calculation sheet.
  • You can continue SBC generation without the auto-calculation process and instead manually override the cost share.
  1. On the Coverage examples tab of the Document template page, to edit the text in the disclaimer section, click in the box. In the right pane, edit the text, and then click Apply.
  2. To edit an example:
    1. Click in the dark blue example box.
    2. In the right pane, to edit the corresponding text to the example, click the Click here to edit icon, and modify the text.
    3. For each benefit type (Specialist, Hospital (facility), and Other) that is listed, select a benefit from the drop-down list.
    4. Click Apply.
  3. Click Save if you have not completed the template or Finish.
    An error icon appears in the Common medical events tab for any service that you did not complete.
  4. Click Save when you complete the information on this tab, click the Addendum tab, and then follow the steps in Using the Addendum tab of the SBC template.

Configuring data for coverage examples

You configure data on the Coverage example calculation sheet as required to drive the calculation of each coverage example. CMS provides each line for every service for each coverage example. You must map the service in each line to a valid benefit so that when the SBC document is generated for the product or plan, it uses the corresponding values for each benefit that is mapped to populate the coverage example.

Coverage example calculation sheet

  1. On the Coverage examples tab, click Configure examples data.
    1. On the Coverage example calculation sheet, click one of the three tabs.
    2. For each line item, in the Benefit column, enter and click a benefit.
    3. In the Copay indicator and the Coinsurance indicator fields, select the option.
      When you select No Charge on the Coverage example calculation sheet page, you are specifying to the system that it should not use the copay or coinsurance in the calculation for the product or plan even if there is a copay or coinsurance on the benefit.
  2. Repeat step 1 for the other tabs.
  3. Click Submit when you are finished.

Optional: Extending the rules in the Coverage examples

As an administrator, you can extend rules that are related to the Coverage examples tab by modifying the data transforms to meet your business needs.

  1. To modify the rules that are listed in the following table, in Dev Studio, enter the rule name in the search box.
  2. Click the rule name.
  3. On the Data Transform page, click Save as and save the rule to your implementation layer.
  4. Make your changes and click Save.
    For more information about data transforms, see Data transforms.
  5. Repeat these steps for each rule that you are modifying.

    ActionRule name
    Overwrite the labels or types that are used in the coverage examples on the Coverage Examples tab.InitializeCommonDataForCoverageExampleEXT
    Overwrite the labels, description, and header of the first example, "Peg is Having a Baby". InitializeDataForCoverageExample1EXT
    Overwrite the labels, description, and header of the second example "Managing Joe's type 2 Diabetes".InitializeDataForCoverageExample2EXT
    Overwrite the labels, description, and header of the third example "Mia's Simple Fracture".InitializeDataForCoverageExample3EXT

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