Having a Baby

Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the

Having a baby

Scenario tab.

Sample Care Costs
Inpatient Hospital Care (Facility)
Professional Services: Primary Care
Professional Services: Obstetric Care (Bundle
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Over-the-counter Drugs
Preventive Services & Vaccines
Total (unrounded)

$8,959
$198
$2,394
$164
$882
$36
$60
$37
$12,731

Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
These assumptions are standard across all scenarios.
Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
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.
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.
If the plan has a wellness program that varies the deductibles, copayments, coinsurance, or coverage for any of the services listed in a treatment scenario, the plan or issuer
must complete the calculations for that treatment scenario assuming that the patient is NOT participating in the wellness program.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Medical Condition:

Having a baby

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 group health plans and health insurance issuers. However, some plans or issuers may classify an item or service under
another category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs" section.
Examples of cost sharing and benefit features include, but are not limited to:
• Payment of services based on the location such as inpatient, outpatient, or office; and
• Payment of items as prescription drugs vs. medical equipment.
Explanation of Scenario:
Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded.
Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered.
ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service.
ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service.
CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC.
Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider.
Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab.
Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code.
Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing.
CPT copyright 2010 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Totals:
ICD-9
ICD-10
Date of
Diagnosis
Diagnosis
CPT©, HCPCS, or Other Billing Code
Service
Code
Code

07-Jan

$
Provider Type

Category

Description

Allowed Amount

OTC

Pharmacy Retail

Over-the-counter
Drugs

Prenatal Vitamins (OTC Bottle of 100) [1 pill daily;
30 pills/month]

$12.21

Obstetric Panel

$42.75

Detect agnt mult dna ampli

$94.00

Cytopath TBS C/V Manual

$12.64

HIV-1

$15.48

Routine Venipuncture

$4.17

Urine Pregnancy Test

$9.06

Obstetrical Care

$2,394.18

01-Apr

V22.0

Z3400

80055

OBGYN

01-Apr

V22.0

Z3400

87801

OBGYN

01-Apr

V22.0

Z3400

88164

OBGYN

01-Apr

V22.0

Z3400

86701

OBGYN

01-Apr

V22.0

Z3400

36415

OBGYN

01-Apr

V72.42

Z3201

81025

OBGYN

59400

OBGYN

01-Apr

650, V27.0,
O80, Z370
Proc: 73.59

12,731.28

Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Professional Services:
Obstetric Care
(Bundled)

07-Apr

V22.0

Z3400

07-Apr

59400

OBGYN

Professional Services:
Obstetric Care
(Bundled)

Office/Outpatient Visit Est

-

OTC

Pharmacy Retail

Over-the-counter
Drugs

Prenatal Vitamins (OTC Bottle of 100) [1 pill daily;
30 pills/month]

$12.21

Office/Outpatient Visit Est

-

Alpha-fetoprotein serum

$17.53

Assay of estriol

$23.82

Chorionic gonadotropin
test

$16.40

Inhibin A

$17.43

CFTR gene analysis,
common variants

$561.73

Routine Venipuncture

$4.17

Office/Outpatient Visit Est

-

Prenatal Vitamins (OTC Bottle of 100) [1 pill daily;
30 pills/month]

$12.21

27-May

V22.0

Z3400

59400

OBGYN

24-Jun

V22.0

Z3400

82105

OBGYN

24-Jun

V22.0

Z3400

82677

OBGYN

24-Jun

V22.0

Z3400

84702

OBGYN

24-Jun

V22.0

Z3400

86336

OBGYN

24-Jun

V22.0

Z3400

81220

OBGYN

24-Jun

V22.0

Z3400

36415

OBGYN

24-Jun

V22.0

Z3400

59400

OBGYN

OTC

Pharmacy Retail

06-Jul

22-Jul

V22.0

Z3400

59400

OBGYN

22-Jul

V22.0

Z3400

76805

Radiology

19-Aug

V22.0

Z3400

59400

OBGYN

16-Sep

V22.0

Z3400

82947

OBGYN

16-Sep

V22.0

Z3400

85025

OBGYN

16-Sep

V22.0

Z3400

82950

OBGYN

Professional Services:
Obstetric Care
(Bundled)
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Professional Services:
Obstetric Care
(Bundled)
Over-the-counter
Drugs

Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Diagnostic Services:
OB US >/= 14 WKS SNGL
Radiology
FETUS
Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Diagnostic Services:
Assay Glucose Blood Quant
Laboratory
Diagnostic Services:
Complete cbc w/auto diff
Laboratory
wbc
Diagnostic Services:
Glucose Test
Laboratory

$163.99
$5.73
$11.14
$5.14

16-Sep

V22.0

Z3400

36415

OBGYN

16-Sep

V22.0

Z3400

59400

OBGYN

30-Sep

V22.0

Z3400

59400

OBGYN

OTC

Pharmacy Retail

59400

OBGYN

20-Oct

S9442

Alternative Provider

27-Oct

S9442

Alternative Provider

04-Oct

14-Oct

V22.0

Z3400

28-Oct

V22.0

Z3400

87653

OBGYN

28-Oct

V22.0

Z3400

59400

OBGYN

28-Oct

V04.81

Z23

90471

OBGYN

28-Oct

V04.81

Z23

90656

OBGYN

01-Nov

S9442

Alternative Provider

08-Nov

S9442

Alternative Provider

11-Nov

V22.0

Z3400

59400

OBGYN

18-Nov

V22.0

Z3400

59400

OBGYN

25-Nov

V22.0

Z3400

59400

OBGYN

Diagnostic Services:
Laboratory
Professional Services:
Obstetric Care
(Bundled)
Professional Services:
Obstetric Care
(Bundled)
Over-the-counter
Drugs

Routine Venipuncture

$4.17

Office/Outpatient Visit Est

-

Office/Outpatient Visit Est

-

Prenatal Vitamins (OTC Bottle of 100) [1 pill daily;
30 pills/month]

$12.21

Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Preventive Services &
Birthing class
Vaccines
Preventive Services &
Birthing class
Vaccines
Diagnostic Services:
Strep B DNA Amp Probe
Laboratory
Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Preventive Services &
Immunization Admin
Vaccines
Preventive Services & Flu Vaccine N0 Preserv 3 &
Vaccines
>
Preventive Services &
Birthing class
Vaccines
Preventive Services &
Birthing class
Vaccines
Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Professional Services:
Obstetric Care
Office/Outpatient Visit Est
(Bundled)

$36.78
$23.00
$14.27
-

-

-

02-Dec

V22.0

Z3400

59400

09-Dec

09-Dec
09-Dec

OBGYN

Inpatient Facility

V22.0

Z3400

650, V27.0 O80, Z370

59400

OBGYN

S9443

Inpatient Facility

Professional Services:
Obstetric Care
(Bundled)

Office/Outpatient Visit Est

Inpatient Hospital Care Inpatient Maternity Bundle
(Facility)
(Bundled line items 4, 5, 34)
Professional Services:
Obstetric Care
(Bundled)
Preventive Services &
Vaccines

-

$8,959.38

Office/Outpatient Visit Est

-

Lactation class

-

Initial hospital or birthing
center care, per day, for
$99.00
10-Dec
99460
E/M of normal newborn
infant
Initial hospital or birthing
Inpatient
Professional Services:
center care, per day, for
$99.00
11-Dec
99460
Professional
Primary Care
E/M of normal newborn
infant
Over-the-counter
Docusate sodium (OTC) [1
$11.20
11-Dec
OTC
Pharmacy Retail
Drugs
pill QD]
Prescription Drugs: Ibuprofen 800mg (Rx) [1 pill
$11.69
11-Dec
591346601
Pharmacy Retail
Generic
Q8H PRN; 60 pills]
Oxycodone/APAP
Prescription Drugs:
$6.45
5mg/325mg (Rx) [1 pill Q6H
11-Dec
378710401
Pharmacy Retail
Generic
PRN; 15 pills]
Professional Services:
23-Dec
V24.2
Z392
59400
OBGYN
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
Prescription Drugs: Ibuprofen 800mg (Rx) [1 pill
$11.69
11-Dec
V24.2
Z392
591346601
Pharmacy Retail
Generic
Q8H PRN; 60 pills]
Oxycodone/APAP
Prescription Drugs:
$6.45
5mg/325mg (Rx) [1 pill Q6H
11-Dec
V24.2
Z392
378710401
Pharmacy Retail
Generic
PRN; 15 pills]
Professional Services:
23-Dec
V24.2
Z392
59400
OBGYN
Obstetric Care
Office/Outpatient Visit Est
(Bundled)
** Inpatient costs were calculated based on national averages using the indicated DRG codes. Additional variances may occur based on how health plan hospital contracts are structured (e.g., case rate, per diems, percentage of billed charges, etc.)
Inpatient
Professional

Professional Services:
Primary Care

The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids group
health plans and health insurance issuers in applying benefits to each item and service.
Provider Type
Pharmacy Retail
OBGYN
Radiology
Alternative Provider
Inpatient Facility
Inpatient Professional

What providers are covered under this Provider Type and other notes:

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to
the same category 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:
Over-the-counter Drugs
Diagnostic Services: Laboratory
Professional Services: Obstetric Care (Bundled)
Diagnostic Services: Radiology
Preventive Services & Vaccines
Inpatient Hospital Care (Facility)
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146