CMS-10407 CMS-10407_Diabetes

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Overview

Label and Assumptions
Scenario
Provider Types
Sample Care Cost Categories

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Sheet 1: Label and Assumptions

Managing Diabetes (routine maintenance of existing condition)		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	$1,200	* HHS to provide this label exactly as they want it to appear on the Summary of Coverage.
Laboratory Tests	$200	* HHS to reuse existing sample care cost categories unless a new category is required.
Medical Equipment and Supplies	$900	* HHS to specify no more than 11 sample care cost categories as space on the page with 12 point font dictates.
Pharmacy	$1,600	* All of these costs roll up from the Scenario tab; HHS to confirm these totals match to the Scenario tab.
Total	$3,900	* 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 hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
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:					Diabetes
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 CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Date of Service	Diagnosis Code	CPT©, HCPCS, or Other Billing Code	Provider Type	Category	Notes	Allowed Amount
Total						3786.33
3-Jan	250.0, V58.76	36415	Primary	Laboratory tests	Routine Venipuncture	$6.00
3-Jan	250.0, V58.75	80053	Primary	Laboratory tests	Comprehen Metabolic Panel	$14.87
3-Jan	250.0, V58.74	80061	Primary	Laboratory tests	Lipid panel	$16.97
3-Jan	250.0, V58.71	80069	Primary	Laboratory tests	Renal Function Panel	$24.44
3-Jan	250.0, V58.70	81003	Primary	Laboratory tests	Urinalysis Auto W/O Scope	$6.32
3-Jan	250.0, V58.72	82043	Primary	Laboratory tests	Microalbumin Quantitative	$8.14
3-Jan	250.0, V58.73	82570	Primary	Laboratory tests	Assay of Urine Creatinine	$7.28
3-Jan	250.0, V58.68	82947	Primary	Laboratory tests	Assay Glucose Blood Quant	$11.04
3-Jan	250.0, V58.69	83036	Primary	Laboratory tests	Glycosylated Hemoglobin Test	$27.32
3-Jan	250.0, V58.67	99214	Primary	Office visits & procedures	Office Visit/Outpatient Visit Est	$102.27
3-Jan	250.0, V58.87	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
3-Jan	250.0, V58.85	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
3-Jan	250.0, V58.86	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
3-Jan	250.0, V58.80	J1610	Pharmacy Retail	Pharmacy	Glucagon Kit	$94.15
3-Jan	250.0, V58.83	A4253	Pharmacy Retail	Medical equipment and supplies	Blood glucose/reagent strips [usage = 2 strips per day; 60 per month; 1,080 per year]	$565.05
3-Jan	250.0, V58.79	A4256	Pharmacy Retail	Medical equipment and supplies	Calibrator solution/chips	$12.00
3-Jan	250.0, V58.78	A4258	Pharmacy Retail	Medical equipment and supplies	Lancet device	$32.64
3-Jan	250.0, V58.81	A4259	Pharmacy Retail	Medical equipment and supplies	Lancet device each (100 per box) [usage = 60 lancets per month; 720 per year]	$97.92
3-Jan	250.0, V58.77	E0607	Primary	Medical equipment and supplies	Blood glucose monitor home	$70.65
3-Jan	250.0, V58.82	S8490	Pharmacy Retail	Medical equipment and supplies	100 insulin syringes [usage = 30 syringes per month; 360 per year]	$61.72
3-Jan	250.0, V58.88		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
4-Jan	250.0, V58.89	97803	Alternative Provider	Office visits & procedures	Med Nutrition Indiv Subseq	$111.44
4-Jan	250.0, V58.90	G0108	Alternative Provider	Office visits & procedures	Diab manage trn per indiv	$109.40
6-Jan	250.0, V58.92	99214	Alternative Provider	Office visits & procedures	Office Visit/Outpatient Visit Est	$102.27
7-Jan	250.0, V58.93	92014	Alternative Provider	Office visits & procedures	Eye Exam & Treatment	$115.86
31-Jan	250.0, V58.95	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
31-Jan	250.0, V58.94	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
31-Jan	250.0, V58.96		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
21-Feb	250.0, V58.97	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
28-Feb	250.0, V58.99	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
28-Feb	250.0, V58.98	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
28-Feb	250.0, V58.100		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
28-Mar	250.0, V58.101	99214	Primary	Office visits & procedures	Office Visit/Outpatient Visit Est	$102.27
28-Mar	250.0, V58.103	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
28-Mar	250.0, V58.102	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
28-Mar	250.0, V58.104		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
11-Apr	250.0, V58.105	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
25-Apr	250.0, V58.107	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
25-Apr	250.0, V58.106	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
25-Apr	250.0, V58.108		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
23-May	250.0, V58.110	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
23-May	250.0, V58.109	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
23-May	250.0, V58.111		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
30-May	250.0, V58.112	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
20-Jun	250.0, V58.114	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
20-Jun	250.0, V58.113	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
20-Jun	250.0, V58.115		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
27-Jun	250.0, V58.121	36415	Primary	Laboratory tests	Routine Venipuncture	$6.00
27-Jun	250.0, V58.120	80069	Primary	Laboratory tests	Renal Function Panel	$24.44
27-Jun	250.0, V58.119	81003	Primary	Laboratory tests	Urinalysis Auto W/O Scope	$6.32
27-Jun	250.0, V58.117	82947	Primary	Laboratory tests	Assay Glucose Blood Quant	$11.04
27-Jun	250.0, V58.118	83036	Primary	Laboratory tests	Glycosylated Hemoglobin Test	$27.32
27-Jun	250.0, V58.116	99214	Primary	Office visits & procedures	Office Visit/Outpatient Visit Est	$102.27
27-Jun	250.0, V58.122	A4256	Pharmacy Retail	Medical equipment and supplies	Calibrator solution/chips	$12.00
28-Jun	250.0, V58.123	97803	Alternative Provider	Office visits & procedures	Med Nutrition Indiv Subseq	$111.44
28-Jun	250.0, V58.124	G0108	Alternative Provider	Office visits & procedures	Diab manage trn per indiv	$109.40
30-Jun	250.0, V58.126	99214	Alternative Provider	Office visits & procedures	Office Visit/Outpatient Visit Est	$102.27
18-Jul	250.0, V58.129	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
18-Jul	250.0, V58.127	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
18-Jul	250.0, V58.128	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
18-Jul	250.0, V58.130		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
15-Aug	250.0, V58.132	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
15-Aug	250.0, V58.131	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
15-Aug	250.0, V58.133		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
5-Sep	250.0, V58.134	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
12-Sep	250.0, V58.136	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
12-Sep	250.0, V58.135	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
12-Sep	250.0, V58.137		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
26-Sep	250.0, V58.138	99214	Primary	Office visits & procedures	Office Visit/Outpatient Visit Est	$102.27
3-Oct	250.0, V58.139	90656	Pharmacy Retail	Pharmacy	Flu Vaccine No Preserv 3 & >	$30.99
10-Oct	250.0, V58.141	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
10-Oct	250.0, V58.140	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
10-Oct	250.0, V58.142		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
24-Oct	250.0, V58.143	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59
7-Nov	250.0, V58.145	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
7-Nov	250.0, V58.144	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
7-Nov	250.0, V58.146		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
5-Dec	250.0, V58.148	261962	Pharmacy Retail	Pharmacy	Ramipril 10 mg oral capsule	$34.90
5-Dec	250.0, V58.147	861004	Pharmacy Retail	Pharmacy	Metformin hydrochloride 1000 mg oral tablet	$19.33
5-Dec	250.0, V58.149		Pharmacy Retail	Pharmacy	Aspirin (81 mg) [usage = 1 per day; 30 per month]	$2.68
12-Dec	250.0, V58.150	285018	Pharmacy Retail	Pharmacy	Insulin glargine 100 unt/l injectable solution [Lantus]	$87.59

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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