Summary of Benefits and Coverage

The University is required under the Health Care Reform Act to provide you with a Summary of Benefits and Coverage (SBC), an easy-to-understand summary about the health plan’s benefits and coverage. It is designed to help you understand and evaluate your health insurance choices. The SBCs for July 1, 2018 are listed below:

Summary of Benefits and Coverage FAQ

The Panther Plus plan has a $750 individual deductible.  Why does the example show $800?

We are required to “round up” to the nearest $100 in the SBC example.  This was mandated by the government.

The Panther Advocate (PPO/HIA) does not provide any details about the $200/$400 available to earn. Why is that?

Since the HIA credits must be earned, and therefore are not guaranteed, we cannot reference them in the SBC.

On the Panther Advantage, Panther Gold, and PA Child SBCs, the basic radiology co-payments should be $20 but the SBC says “no cost.”

This field on the SBC is actually covering both basic radiology (e.g., X-rays and sonograms) as well as lab tests (e.g., blood work). Because the SBC does not differentiate these benefits, they must be combined into a single field on the document. As a result, we used the coverage calculator to determine which benefit was represented here, and only the lab work (blood tests in particular) appear in the coverage calculator. Therefore, that is the information that goes in this field, and the radiology information goes in the limit and exception field.

On all of the PPO maternity examples (Advocate, Plus, Basic) the math does not work out for me. I think they are based on embedded deductibles and not aggregate?

The Coverage calculator on the document does not take into account embedded vs. aggregate deductibles. The assumptions inherent to the plan are that the coverage is for only an individual and that there is no family coverage at all, so there would never be a need to meet a family deductible. Aggregate vs. embedded only comes into effect when there is more than one member on the plan.

Why do we show limits and exclusions in the examples for maternity, and diabetes is covered without limitation?

We are required to account for the fact that a member might seek services or care above and beyond what is covered by the plan, i.e. prenatal vitamins.