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Summary of Benefits and Coverage template

Updated on April 12, 2021

The Summary of Benefits and Coverage (SBC) is a snapshot of a health plan’s costs, benefits, covered healthcare services, and other features that are important to consumers. An SBC also explains the unique features of health plans such as cost-sharing rules and includes significant limits and exceptions to coverage in easy-to-understand terms. This document helps users to compare health plans.

Pega Product Composer for Healthcare

The SBC is mandated by the Affordable Care Act (ACA) as a requirement for healthcare plans. Payers must follow a prescriptive format of the regulations, which proves difficult for them to complete the documents with a level of quality within the specified time frames.

With Pega Product Composer for Healthcare, you can create templates that can be reused within your products or plans to create SBC documents for multiple products or plans. The template lets you merge specific fields, for example, benefit coverage with the corresponding copayment from a product or plan so that you create a Summary of Benefits and Coverage document that is specific to the product or plan.

With the integration of the SBC document with Pega Product Composer for Healthcare, the SBC documents are accurate because they are populated with the benefit values and text descriptions from the application, which is the system of record. The SBC document is attached to the entity.

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