CMS-10407 CMS-10407_Appendices_Part_7_(D-1)-F

Appendix D-1

Blank Template for Coverage Examples

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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 samp le care cost categories in the Coverage Example label on the "Label and Assumptions" tab. This faci litates consistency between the
Category

What services are covered under this Category and other notes:

Office visits & procedures

Includes services by all physicians (primary care, specia list, 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
Hospita I cha rges
Hospital charges (baby)

Facility charges for inpatient/outpatient services; discharge management
Applies to maternity scenario only; other scenarios wou ld use "Hospital charges"

Hospital charges (mother)

Applies to maternity scenario only; other scenarios wou ld use " Hospital charges"

Inpatient medical care
laboratory tests
Medical equipment & supplies

Services by physicians, surgeons, anesthesiologists, etc.
Includes blood work
Includes durable medica l equipment, orthotics, prosthetics

Mental hea lth
Outpatient surgery

PhysiCian and facility charges
Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not ad ministered in a hospital,

Pharmacy
Radiation therapy
Radiology

physician's office or other facility

Rehabilitation services
Routine obstetric care

Includes provision of treatment at any facility
Applies to maternity scenario only; typically a bundled payment

Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays

Skilled nursing care
Vaccines, other preventive

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