Form CMS-10407 Blank

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Overview

Label and Assumptions
Scenario
Provider Types
Sample Care Cost Categories

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Sheet 1: Label and Assumptions

Description of condition (brief description of major services)		Instructions to Insurers: Do not modify this tab. The numbers shown here roll up from the Scenario tab. Transfer this label to the Summary of Coverage exactly as shown here.
Sample care costs:		Instructions for HHS:
Office visits & procedures	$0	* HHS to provide this label exactly as they want it to appear on the Summary of Coverage.
Radiology	$0	* HHS to reuse existing sample care cost categories unless a new category is required.
Laboratory tests	$0	* HHS to specify no more than 11 sample care cost categories as space on the page with 12 point font dictates.
Hospital charges	$0	* All of these costs roll up from the Scenario tab; HHS to confirm these totals match to the Scenario tab.
Inpatient medical care	$0
Outpatient surgery	$0
Chemotherapy	$0
Radiation therapy	$0
Prostheses (wig)	$0
Pharmacy	$0
Mental health	$0
Total	$0	* This total must match the total on the Scenario tab; HHS to confirm it matches before issuing to insurers.
Assumptions
The following are assumptions that all health plan carriers make to calculate the scenario.
Standard Assumptions
These assumptions are standard across all scenarios. (HHS to apply these assumptions regardless of scenario.)
Costs do not include premiums.
Condition was not an excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan.
All care is in-network. No out-of-network charges or any other variation in Sample Care Costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundred dollars.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest ten dollars.
All medications are covered as generic equivalents if available.
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks.
Special Assumptions
These assumptions are specific to this scenario only. (HHS to specify special assumptions.)
[HHS to supply any assumptions that are specific to this scenario]

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Sheet 2: Scenario

Medical Condition:					Condition Name
Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into that category in the "Sample care costs" section so that those costs are uniform across all carriers and plans. However, some plans may classify that service under another category. The insurer should apply their cost sharing and benefit features for each policy in order to complete the “You pay” section, but must leave the "Sample care costs" section as is. Examples of cost sharing and benefit features include, but are not limited to: • Payment of services based on the location where they are provided (inpatient, outpatient, office, etc.) • Payment of items as prescription drugs vs. medical equipment Instructions to HHS for Completing the Columns: Date of Service - include Month/Day of service so insurers understand the order in which services are rendered. Do not include year. Diagnosis Code - include the ICD code for each service CPT code - include the CPT code for each service Provider Type - use one of the types listed on the "Provider Types" tab to classify each service by provider Category - use one of the categories listed on the "Sample Care Cost Categories" tab to classify each service so they roll up into the broader cost categories on the "Label and Assumptions" tab Notes - freeform field to include any special notes for that service Allowed Amount - include the total cost for each service that would be owed to providers that insurers will use to calculate cost-sharing
Date of Service	Diagnosis Code	CPT Code	Provider Type	Category	Notes	Allowed Amount
Total						0.00	*this amount must match the total first tab.

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Sheet 3: Provider Types

Provider Type
The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids the insurers in applying benefits to each service.
Provider Type	What providers are covered under this Provider Type and other notes:
Primary	Primary Care Physician or non-Specialist
Specialist	Cardiology, Dermatology, Neurology, etc.
Alternative Provider	Chiropractor, Acupuncturist, etc.
Outpatient Facility
Inpatient Facility
Pharmacy Retail
Pharmacy Mail Order
Pharmacy Administered	All prescriptions reimburseable under a Pharmacy plan that are administered in a provider's office or hospital
Emergency Room
Home Health
Skilled Nursing Facility
Ambulance

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Sheet 4: Sample Care Cost Categories

Sample Care Cost Categories
The following are the sample care cost categories to use on the "Scenario" tab ~ "Category" column to classify each service so that they roll up to the same sample care cost categories in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" tab and Coverage Example label.
Category	What services are covered under this Category and other notes:
Office visits & procedures	Includes services by all physicians (primary care, specialist, etc.) and alternative providers (chiropractor, acupuncture, etc.)
First office visit	Applies to maternity scenario only; other scenarios would use "Office visits & procedures"
Anesthesia
Chemotherapy
Circumcision
Emergency care	Includes emergency room facility charges, physician services, ambulance transportation
Home health care
Hospital charges	Facility charges for inpatient/outpatient services; discharge management
Hospital charges (baby)	Applies to maternity scenario only; other scenarios would use "Hospital charges"
Hospital charges (mother)	Applies to maternity scenario only; other scenarios would use "Hospital charges"
Inpatient medical care	Services by physicians, surgeons, anesthesiologists, etc.
Laboratory tests	Includes blood work
Medical equipment & supplies	Includes durable medical equipment, orthotics, prosthetics
Mental health
Outpatient surgery	Physician and facility charges
Pharmacy	Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not administered in a hospital, physician's office or other facility
Radiation therapy
Radiology	Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays
Rehabilitation services	Includes provision of treatment at any facility
Routine obstetric care	Applies to maternity scenario only; typically a bundled payment
Skilled nursing care
Vaccines, other preventive