Summary of Benefits and Coverage

Summary of Benefits and Coverage (SBC)

As a result of the Affordable Care Act, The Panama Canal Area Benefit Plan will provide a summary document detailing information about health plan benefits and coverage on the Plan’s website. This Summary of Benefits and Coverage (SBC) document will help FEHB enrollees better understand their coverage and allow them to easily compare different plans and plan options. The SBC contains information on the following:

  • Cost - deductibles, copayments, coinsurance, and out-of-pocket limits.
  • Coverage - covered services, examples of covered services, and excluded services. 
  • Rights - rights to continue coverage and grievance and appeal rights.

 

Please note that the SBC is only a summary of the features of the Panama Canal Area Benefit Plan. Before making a final decision, please read the Plan’s Federal brochure (RI 72-004). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.

We will provide information in your Open Season materials about where to find this plan’s SBC as well as how to obtain a paper copy of the SBC. We will have the Plan’s SBC available at the Panama Canal area Benefit Plan offices, through various organizations for retirees, among others.

What’s New?

•  Effective January 1, 2014, the SBC will need to state whether the plan provides "minimum essential coverage" (MEC) as required by the "individual mandate."  

•  It will also need to state whether the plan meets the "minimum value" (MV) requirement. Minimum value means the plan pays at least 60% of allowed charges for covered services, as required by the "employer mandate."

Coordinating of Benefits

Coordination of benefits (COB) is a way of determining the order in which benefits are paid and the amounts which are payable when you are covered under more than one health care plan or Medicare. Coordination of benefits determines which plan pays first, which plan pays second, and which plan pays third. It also ensures that the total payments from all plans do not exceed 100 percent of the total covered charge. All benefits of this plan are subject to coordination of benefits. These coordination of benefits provisions are subject to change as new rules and regulations arise.

Order of Benefit Payment

The most common rules for determining the order of payment are the Non-Dependent / Dependent Rule, the Active/ Inactive Rule and the Birthday Rule.

  • Non-dependent / Dependent Rule: The plan that covers an individual as an enrollee or subscriber is the primary payer over a plan that covers an individual as a dependent, for example, as a spouse.
  • Active/ Inactive Rule: The plan that covers an individual as an active employee or as the dependent of an active employee is the primary payer over the plan that covers the individual as a retired or laid off employee or as the dependent of such an employee.
  • Birthday Rule: This rule determines whether a plan is primary or secondary for a dependent child who is covered by both parents' benefit plans and those parents live together. The plan covering the parent whose birthday (month and day only) falls first in a calendar year provides primary coverage for the child. If both parents have the same birthday, then the plan that has been in effect the longest pays as primary.

A different set of rules applies to a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married: 

(1) If a court decree states that one of the parents is responsible for the child’s health care expenses / coverage (“health care coverage responsibility”) and the plan covering that parent has actual knowledge of those terms, that plan is primary. If the responsible parent has no coverage for the child’s health care expenses, but that parent’s spouse does, that parent’s spouse’s plan is the primary plan.

(2) If a court decree states that both parents are responsible for the child’s health care expenses /coverage, the Birthday Rule determines the order of benefits;

(3) If a court decree states that the parents have joint custody without specifying that one parent has health care coverage responsibility, the Birthday Rule determines the order of benefits; or

(4) If there is no court decree allocating health care coverage responsibility for the child, the order of benefits for the child is as follows:

    (a) The plan covering the custodial parent;

    (b) The plan covering the custodial parent’s spouse;

    (c) The plan covering the non-custodial parent; and then

    (d) The plan covering the non-custodial parent’s spouse. 

For additional information on NAIC rules regarding the coordinating of benefits, visit the NAIC website at www.NAIC.org.

You can download the SBC below:

2019

Download SBC 2019 English

2018

Download SBC 2018 English


Download SBC Glossary English