CMS-10407 CMS-10407_Blank_Template_of_Coverage-Example_Condition-F

BCBSF Individual PPO Plan

A

Description of condition
1 (brief description of major services)
2
3 Sample care costs:
4 Office visits & procedures
5 Radiology
6 Laboratory tests
7 Hospital charges
8 Inpatient medical care
9 Outpatient surgery
10 Chemotherapy
11 Radiation therapy
12 Prostheses (wig)
13 Pharmacy
14 Mental health
15 Total
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

Breast Cancer - Plan Year 2 (2009)

B

DRAFT

C

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.

Instructions for HHS:
$0 * HHS to provide this label exactly as they want it to appear on the Summary of Coverage.
$0 * HHS to reuse existing sample care cost categories unless a new category is required.
$0 * HHS to specify no more than 11 sample care cost categories as space on the page with 12 point font dictates.
$0 * All of these costs roll up from the Scenario tab; HHS to confirm these totals match to the Scenario tab.
$0
$0
$0
$0
$0
$0
$0
$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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