CMS-10407.RBIS_IFP_Benefits_Template_SBC Addition

IFP Benefits Template v1.0

Voluntary Coverage Example Reporting for Deemed Compliance with SBC Requirements

Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance, well-controlled)

Issuer ID

Product Smart ID

Plan ID

Plan Name

Plan Effective Date

Plan Expiration Date

Product Type

HSA-Eligible

Same-Sex Partners

Domestic Partners

Annual Deductible (IN)

Annual Deductible (OON)

PCP Copay (IN)

PCP Copay (OON)

Coinsurance (IN)

Coinsurance (OON)

Annual Out-of-Pocket Limit (IN)

Annual Out-of-Pocket Limit Elements (IN)

Annual Max Benefit (IN)

Primary Care Visit to Treat Injury or Illness (IN)

Primary Care Visit to Treat Injury or Illness (OON)

Primary Care Visit to Treat Injury or Illness Exceptions

Specialist Visit (IN)

Specialist Visit (OON)

Specialist Visit Exceptions

Other Practitioner Office Visit (Nurse,Physician Assistant) (IN)

Other Practitioner Office Visit (Nurse,Physician Assistant) (OON)

Other Practitioner Office Visit (Nurse,Physician Assistant) Exceptions

Preventive Care/Screening/Immunization (IN)

Preventive Care/Screening/Immunization (OON)

Preventive Care/Screening/Immunization Exceptions

Diagnostic Test (X-Ray and Lab Work) (IN)

Diagnostic Test (X-Ray and Lab Work) (OON)

Diagnostic Test (X-Ray and Lab Work) Exceptions

Imaging (CT/PET Scans, MRIs) -(IN)

Imaging (CT/PET Scans, MRIs) -(OON)

Imaging (CT/PET Scans, MRIs) Exceptions

Generic Drugs

Generic Drugs Exceptions

Preferred Brand Drugs

Preferred Brand Drugs Exceptions

Non-Preferred Brand Drugs

Non-Preferred Brand Drugs Exceptions

Specialty Drugs

Specialty Drugs Exceptions

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) (IN)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) (OON)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center) - Exceptions

Outpatient Surgery Physician/Surgical Services (IN)

Outpatient Surgery Physician/Surgical Services (OON)

Outpatient Surgery Physician/Surgical Services - Exceptions

Emergency Room Services (IN)

Emergency Room Services (OON)

Emergency Room Services Exceptions

Emergency Transportation/Ambulance (IN)

Emergency Transportation/Ambulance (OON)

Emergency Transportation/Ambulance Exceptions

Urgent Care (IN)

Urgent Care (OON)

Urgent Care Exceptions

Inpatient Hospital Services (e.g., Hospital Stay) (IN)

Inpatient Hospital Services (e.g., Hospital Stay) (OON)

Inpatient Hospital Services (e.g., Hospital Stay) Exceptions

Inpatient Physician and Surgical Services (IN)

Inpatient Physician and Surgical Services (OON)

Inpatient Physician and Surgical Services Exceptions

Mental/Behavioral Health Outpatient Services (IN)

Mental/Behavioral Health Outpatient Services (OON)

Mental/Behavioral Health Outpatient Services Exceptions

Mental/Behavioral Health Inpatient Services (IN)

Mental/Behavioral Health Inpatient Services (OON)

Mental/Behavioral Health Inpatient Services Exceptions

Substance Abuse Disorder Outpatient Services (IN)

Substance Abuse Disorder Outpatient Services (OON)

Substance Abuse Disorder Outpatient Services Exceptions

Substance Abuse Disorder Inpatient Services (IN)

Substance Abuse Disorder Inpatient Services (OON)

Substance Abuse Disorder Inpatient Services Exceptions

Prenatal and Postnatal Care (IN)

Prenatal and Postnatal Care (OON)

Prenatal and Postnatal Care Exceptions

Delivery and All Inpatient Services for Maternity Care (IN)

Delivery and All Inpatient Services for Maternity Care (OON)

Delivery and All Inpatient Services for Maternity Care Exceptions

Home Health Care Services (IN)

Home Health Care Services (OON)

Home Health Care Services Exceptions

Inpatient Rehabilitation Services (IN)

Inpatient Rehabilitation Services (OON)

Inpatient Rehabilitation Services Exceptions

Outpatient Rehabilitation Services (IN)

Outpatient Rehabilitation Services (OON)

Outpatient Rehabilitation Services Exceptions

Habilitation Services

Habilitation Services Exceptions

Skilled Nursing Facility (IN)

Skilled Nursing Facility (OON)

Skilled Nursing Facility Exceptions

Durable Medical Equipment (IN)

Durable Medical Equipment (OON)

Durable Medical Equipment Exceptions

Hospice Services (IN)

Hospice Services (OON)

Hospice Services Exceptions

Routine Eye Exam for Children (IN)

Routine Eye Exam for Children (OON)

Routine Eye Exam for Children Exceptions

Eye Glasses for Children (IN)

Eye Glasses for Children (OON)

Eye Glasses for Children Exceptions

Dental Check-Up for Children (IN)

Dental Check-Up for Children (OON)

Dental Check-Up for Children Exceptions

Acupuncture

Bariatric Surgery

Non-Emergency Care when Travelling Outside the U.S.

Chiropractic Care

Cosmetic Surgery

Routine Dental Services (Adult)

Hearing Aids

Infertility Treatment

Long-Term/Custodial Nursing Home Care

Private-Duty Nursing

Routine Eye Exam (Adult)

Routine Foot Care

Weight Loss Programs

Routine Hearing Tests

Plan Brochure

Deductibles

Co-pays

Co-insurance

Limits or Exclusions

Total

Deductibles

Co-pays

Co-insurance

Limits or Exclusions

Total

Enter the Issuer ID.

Enter the Product Smart ID.

Enter the Plan ID.

Enter the Plan Name.

Enter the Plan Effective Date.

Enter the Plan Expiration Date.

Enter one of the following Plan Types: Indemnity, PPO, POS, EPO, HMO, or Other/Describe.

Enter Y or N. Enter Y if this plan qualifies as an HSA-Eligible HDHP.

Does this plan allow enrollment of same-sex partners?

Does this plan allow enrollment of domestic partners?

Enter the Annual In-Network Deductible for this plan.

Enter the Annual Out-of-Network Deductible for this plan.

Enter the In-Network PCP Copay for this plan.

Enter the Out-of-Network PCP Copay for this plan.

Enter the In-Network Coinsurance amount for this plan.

Enter the Out-of-Network Coinsurance amount for this plan.

Enter the In-Network Out-of-Pocket Maximum amount for this plan.

Enter what elements are calculated the for the Annual Out-of-Pocket Limit (IN).

Enter the Annual In-Network Maximum Benefit amount for this plan.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable Fixed Cost or Co-Insurance amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable Fixed Cost or Co-Insurance amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable Fixed Cost or Co-Insurance amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable Fixed Cost or Co-Insurance amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Enter the applicable In-Network amount.

Enter the applicable Out-of-Network amount.

Enter the applicable Limitations or Exceptions.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Select the applicable coverage.

Enter the Plan Brochure URL.

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount

Enter the dollar amount