| Category | Issuer Id | Product Smart Id | 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 Medical Out-of-Pocket Limit In Network |
Annual Medical 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 | Mental/ Behavioral health inpatient services | 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 | |
| Instructions and possible responses | Enter the Issuer ID | Enter the Product Smart ID | 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 annual medical out of pocket maximums, separated by commas. | Enter what elements are calculated for OOP in column L | Enter the highest annual max benefit | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | Covered, Not Covered, Available for Additional Premium, Covered with Limitations | |
| sample data | 11111 | 11111FL001 | PPO | N | None | 250, 500, 1000, 2500, 3000 | None | 15, 50 | 10%, 20% | 10%, 50% | 4000, 5000, 6000 | Deductible + Coinsurance | None | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Not Covered | Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | |
| sample data | 22222 | 22222GA991 | PPO | Y | 250, 500, 1000, 2500, 3000 | 200, 300, 1000, 5000 | 100, 200 | 0, 250 | 20%, 30% | 20%, 60% | 2500, 3000, 3500 | Deductible + Coinsurance + Copay | 670 | Covered | Covered | Available for Additional Premium | Covered | Covered | Covered | Covered | Covered | Covered with Limitations | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Covered | Not Covered | Available for Additional Premium | Covered with Limitations | Covered | Covered | Covered | Covered | Available for Additional Premium | Not Covered | Not Covered | Available for Additional Premium | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | Not Covered | |
| PLAN_TYPE | Choice | Availability | Deductible_List | Copay_Range | Coinsurance_Range | Annual Medical Out of Pocket | OOP_Includes | Annual Max Benefit | Cost_Combo | ||
| INDEMNITY | Y | Covered | None | None | None | None | None | None | $X Deductible/ $X Copay/ X% Coinsurance/ $X Max Annual Out of Pocket | ||
| PPO | N | Not Covered | X, X, X, X,… | x, y | x%, y% | x, y | Deductible | x | |||
| POS | Covered with Limitations | Copay | |||||||||
| Available for Additional Premium | Coinsurance | ||||||||||
| Coinsurance + Copay | |||||||||||
| Deductible + Copay | |||||||||||
| Deductible + Coinsurance | |||||||||||
| EPO | Deductible + Coinsurance + Copay | ||||||||||
| HMO | |||||||||||
| Instructions | Instructions | Instructions | Instructions | Instructions | Instructions | Instructions | |||||
| Covered, Not Covered, Available for Additional Premium, Covered with Limitations | 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 coinsurance separated by commas (ex 0%, 40%) | Enter the annual medical out of pocket maximums, separated by commas. | Enter what elements are calculated for OOP in column L | Enter the highest annual max benefit | |||||
| Copays range from $X to $Y | Coinsurance ranges from X% to Y% |
| File Type | application/vnd.ms-excel |
| Author | CGI |
| Last Modified By | CMS |
| File Modified | 2011-08-16 |
| File Created | 2011-07-22 |