CMS-10433 Plans and Benefits Template

To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required

HIOS Issuer ID*

You will need to save the latest version of the add-in file (PlansBenefitsAddIn.xlam) on your machine.

Issuer State*

To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro.

Market Coverage*

To create additional Benefits Package worksheets, use the Create New Benefits Package macro.

Dental Only Plan*

To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro.

TIN*

Plan Identifiers

Plan Attributes

Stand Alone Dental Only

Plan Dates

Geographic Coverage

Plan Level URLs

HIOS Plan ID* (Standard Component)

Plan Marketing Name*

HIOS Product ID*

HPID

Network ID*

Service Area ID*

Formulary ID*

New/Existing Plan?*

Plan Type*

Level of Coverage*

Design Type*

Unique Plan Design?*

QHP/Non-QHP*

Notice Required for Pregnancy*

Is a Referral Required for Specialist?*

Specialist(s) Requiring a Referral

Plan Level Exclusions

Limited Cost Sharing Plan Variation - Est Advanced Payment

Does this plan offer Composite Rating?*

Child-Only Offering*

Child Only Plan ID

Tobacco Wellness Program Offered*

Disease Management Programs Offered

EHB Percent of Total Premium*

EHB Apportionment for Pediatric Dental

Guaranteed vs. Estimated Rate

Plan Effective Date*

Plan Expiration Date

Out of Country Coverage*

Out of Country Coverage Description

Out of Service Area Coverage*

Out of Service Area Coverage Description

National Network*

URL for Enrollment Payment

Benefit Information

General Information

Out of Pocket Exceptions

Benefits

EHB

Is this Benefit Covered?

Quantitative Limit on Service

Limit Quantity

Limit Unit

Exclusions

Benefit Explanation

EHB Variance Reason

Excluded from In Network MOOP

Excluded from Out of Network MOOP

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

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

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

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical Therapy

Well Baby Visits and Care

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Basic Dental Care – Child

Orthodontia – Child

Major Dental Care – Child

Basic Dental Care – Adult

Orthodontia – Adult

Major Dental Care – Adult

Abortion for Which Public Funding is Prohibited

Transplant

Accidental Dental

Dialysis

Allergy Testing

Chemotherapy

Radiation

Diabetes Education

Prosthetic Devices

Infusion Therapy

Treatment for Temporomandibular Joint Disorders

Nutritional Counseling

Reconstructive Surgery