Implementing the Summary of Benefits and coverage (SBC) feature

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Implementing the Summary of Benefits and coverage (SBC) feature

Description Implementing the Summary of Benefits and coverage (SBC) feature
Version as of 8.5
Application Pega Product Composer for Healthcare
Capability/Industry Area Healthcare and Life Sciences

Implementing the SBC feature

Pega Product Composer for Healthcare supports the configuration and generation of the Summary of Benefits and Coverage (SBC) document. This article discusses the process of configuring an SBC template and then using the SBC template in the product and plan flows. The SBC feature allows PCS users to leverage the cost share data from their existing product repository to automatically generate the SBC document. The calculations for coverage examples are also automated and the complete process of SBC generation is embedded in the product and plan configuration flows.

This information can help you leverage the out-of-the-box SBC feature for your existing portfolio and can also help you gain an understanding of the process that is involved in updating the mappings and the data in the SBC templates. As your product repository changes, you can update and regenerate the affected SBC documents by using this feature.

The two steps to leverage the SBC feature in PCS are:

  1. Create the SBC template.
  2. Update the product and plan flows to reference the SBC template.

Create the SBC template

With the PCS 8.5 release, the new Document management portal allows you to configure SBC templates. For more details, see Accessing the Document management portal.

Within this portal, create a new SBC template. The SBC template is a document template with configurable tabs. The SBC document is divided into five functional sections. Each section is represented by a tab in the SBC template: Plan overview, Common medical details, Excluded services, Coverage examples, and Addendum. For more information, see Creating an SBC template.

SBC template tabs

Each of the tabs displays pre-configured static text which is based on the guidance for the SBC document from Centers for Medicare & Medicaid Services (CMS). There are also placeholders for the values of copay, coinsurance, and other cost shares. These values are automatically populated when the SBC template is referenced as part of the product and plan flows.

On the Common medical event tab, you map the benefits that correspond to the common medical events. The cost shares for those benefits are populated from the product or plan. Similarly, on the Coverage examples tab, several benefits are mapped. The goal is to ensure that the correct language and benefit mappings are configured in the SBC template.

After the manager approves the SBC template, it is eligible for selection in the product and the plan flows. For more information, see Life cycle for the SBC template.

Update the product and plan flows to reference the SBC template

With the PCS 8.5 release, the standard flows (wizards) for products and plans are updated to include two new steps:

Step 6 for selecting the SBC template and networks

In Step 6, you can select up to a maximum of 3 networks and an approved SBC template that matches the metadata of the product. The matching criteria include insurance line, market segment, and effective dates between the product or plan and the SBC template.

Step 7 for configuring the SBC document

In Step 7, you see all the cost shares from the product populated across the different tabs of the SBC document.

You are responsible for carefully reviewing these values on each of the tabs. By default, the mappings for each tab are directly inherited from the SBC template. If needed, you can edit any one of these tabs and make any local changes to either the benefit mapping or the static text. However, this results in breaking the standard inheritance between the SBC template and the product for the respective tab. For example, if you want to change the language for the Why this matters column on the Plan overview tab, you can edit the tab and make the changes. The content on the rest of the tab continues to inherit directly from the SBC template. For more information about inheritance, see SBC inheritance.

Troubleshooting the validation errors

The application displays an error when any of the mapped benefits in the SBC template are missing from the product. When this occurs, you can choose one of the following options to fix the issue:

  • Choose a different SBC template where the benefit mappings match the list of benefits available in the product.
  • Add the missing benefits to the product.
  • Make a local change at the product or plan level to the benefit mapping by editing the content on the respective tab and pointing the mapping to an existing benefit.

The best practice for configuring the SBC template is to have the most generic set of benefit mappings, which is present across the product and plan repository in the majority of the cases. This reduces the chances of errors and any rework at the product or plan layers.

Having a single source of truth for both benefit configuration and associated compliance document generation such as SBC has multifold benefits for the healthcare payers. The SBC feature in PCS enables them in achieving that automation.