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.
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Before you begin: 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 Configuration
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.
The following figure shows the Coverage examples tab in the SBC template.
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.
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.
To edit an example:
Click in the dark blue example box.
In the right pane, to edit the corresponding text to the example, click
the Click here to edit icon, and modify the
text.
For each benefit type (Specialist, Hospital (facility), and Other) that
is listed, select a benefit from the drop-down list.
Click Apply.
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.
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.
The following figure shows the Coverage example calculation sheet that you use to
calculate the coverage examples.
Coverage example calculation sheet
On the Coverage examples tab, click Configure
examples data.
On the Coverage example calculation sheet, click
one of the three tabs.
For each line item, in the Benefit column, enter
and click a benefit.
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.
Repeat step 1 for the other tabs.
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.
To modify the rules that are listed in the following table, in Dev Studio,
enter the rule name in the search box.
Click the rule name.
On the Data Transform page, click Save
as and save the rule to your implementation layer.
Make your changes and click Save.
For more information about data transforms, see Data transforms.
Repeat steps 1 through 4 for each rule that you are modifying.
Action
Rule 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".
