CMS-10448 EHB Benefits Template

Benefit

Primary Care Visit to Treat an Injury
or Illness
Specialist Visit
Other Practitioner Office Visit (Nurse,
Physician Assistant)
Outpatient Facility Fee (e.g.,
Ambulatory Surgery Center)
Outpatient Surgery
Physician/Surgical Services
Hospice Services
Non-Emergency Care When Traveling
Outside the U.S.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home
Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Home Health Care Services
Emergency Room Services
Emergency
Transportation/Ambulance
Inpatient Hospital Services (e.g.,
Hospital Stay)
Inpatient Physician and Surgical
Services
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Prenatal and Postnatal Care
Delivery and All Inpatient Services for
Maternity Care
Mental/Behavioral Health Outpatient
Services
Mental/Behavioral Health Inpatient
Services
Substance Abuse Disorder
Outpatient Services
Substance Abuse Disorder Inpatient
Services
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Diagnostic Test (X-Ray and Lab
Work)
Imaging (CT/PET Scans, MRIs)
Preventive
Care/Screening/Immunization
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Eye Glasses for Children
Dental Check-Up for Children
Other

Covered*

Benefit Description

Quantitative
Limit on
Service?

Limit Quantity

Required:
Is benefit Covered or
Not Covered

Required if Benefit is Covered:
Enter Description

Required if Covered:
Select "Yes" if
Quantitative Limit
applies

Required if
Quantitative Limit is
"Yes":
Enter Limit Quantity

Limit Units

Other Limit Units
Description

Required if Quantitative Limit Required if "Other" Limit Unit:
If a Limit Unit of "Other" was
is "Yes":
Double-click the cell to select the selected in Limit Units, enter a
description
correct limit units

Minimum
Stay

Exclusions

Explanation

Are there additional
Limitations or Exclusions
for this benefit?

Optional:
Enter the
Minimum Stay
(in hours) as a
whole number

Optional:
Enter any Exclusions for
this benefit

Optional:
Enter an Explanation for
anything not listed

Required if Covered:
Select "Yes" if there are additional
limitations or exclusions that need to
be described