20110815_SG_BenefitFields

Small Group Benefit Template Fields: HealthCare.gov Planfinder October 2011
Field
Issuer Id
Product Smart Id
Effective Date
Expiration Date
Doctor Choice
HSA Eligible
Annual Deductible
In Network
Annual Deductible
Out of Network
Copay
In Network
Copay
Out of Network
Coinsurance
In Network
Coinsurance
Out of Network
Annual Out-of-Pocket Limit
In Network Elements
Annual Out-of-Pocket Limit
In Network
Annual Max Benefit
In Network
Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Preventive care/screening/immunization
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs (e.g., chemotherapy)
Outpatient facility fee (example, ambulatory
surgery center)
Outpatient Physician/ surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
Hospitalization facility fee (example: hospital
room)
Hospitalization Physician/surgeon fee
Mental/Behavioral health outpatient services

Instruction
Enter the Issuer ID
Enter the Product Smart ID
Enter the Effective Date
Enter the Expiration Date
Enter one of the following:
Indemnity, PPO, HMO, POS, EPO
Enter Y or N
Enter the available deductibles separated by commas (ex
1000, 2000, 2500, etc.)
Enter the available deductibles separated by commas (ex
1000, 2000, 2500, etc.)
Enter the minimum and maximum copay separated by
commas (ex 0, 50)
Enter the minimum and maximum copay separated by
commas (ex 0, 50)
Enter the minimum and maximum coinsurance separated
by commas (ex 0%, 40%)
Enter the minimum and maximum coinsurance separated
by commas (ex 0%, 40%)
Enter the maximum annual out of pocket net of
deductibles, copay and coinsurance.
Enter what elements are calculated for OOP in column L
Enter the highest annual max benefit

Typically Covered, Not Covered, Covered for Additional
Premium, Limited Coverage
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Mental/ Behavioral health inpatient services

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Substance use disorder outpatient services
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
Eye exam
Glasses
Dental check-up
Acupuncture
Bariatric Surgery
Non-emergency care when travelling outside
the U.S.
Chiropractic Care
Cosmetic Surgery
Dental care (adult)
Hearing aids
Infertility treatment
Long-term care
Private-duty nursing
Routine eye care (adult)
Routine foot care
Weight loss programs

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