Summary of Benefits and Coverage

Summary of Benefits and Coverage and Uniform Glossary Required Under the Affordable Care Act

Having a baby April 2017.xlsx

Summary of Benefits and Coverage

OMB: 1210-0147

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Overview

Label and Assumptions
Scenario
Provider Types
Categories


Sheet 1: Label and Assumptions

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



Sample Care Costs

Inpatient Hospital Care (Facility) $8,959
Professional Services: Primary Care $198
Professional Services: Obstetric Care (Bundled) $2,394
Diagnostic Services: Radiology $164
Diagnostic Services: Laboratory $882
Prescription Drugs: Generic $36
Over-the-counter Drugs $60
Preventive Services & Vaccines $37
Total (unrounded) $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


Sheet 2: Scenario

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:





$12,731.28
Date of Service ICD-9 Diagnosis Code ICD-10 Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Description Allowed Amount
7-Jan

OTC Pharmacy Retail Over-the-counter Drugs Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] $12.21
1-Apr V22.0 Z3400 80055 OBGYN Diagnostic Services: Laboratory Obstetric Panel $42.75
1-Apr V22.0 Z3400 87801 OBGYN Diagnostic Services: Laboratory Detect agnt mult dna ampli $94.00
1-Apr V22.0 Z3400 88164 OBGYN Diagnostic Services: Laboratory Cytopath TBS C/V Manual $12.64
1-Apr V22.0 Z3400 86701 OBGYN Diagnostic Services: Laboratory HIV-1 $15.48
1-Apr V22.0 Z3400 36415 OBGYN Diagnostic Services: Laboratory Routine Venipuncture $4.17
1-Apr V72.42 Z3201 81025 OBGYN Diagnostic Services: Laboratory Urine Pregnancy Test $9.06
1-Apr 650, V27.0, Proc: 73.59 O80, Z370 59400 OBGYN Professional Services: Obstetric Care (Bundled) Obstetrical Care $2,394.18
7-Apr V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
7-Apr

OTC Pharmacy Retail Over-the-counter Drugs Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] $12.21
27-May V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
24-Jun V22.0 Z3400 82105 OBGYN Diagnostic Services: Laboratory Alpha-fetoprotein serum $17.53
24-Jun V22.0 Z3400 82677 OBGYN Diagnostic Services: Laboratory Assay of estriol $23.82
24-Jun V22.0 Z3400 84702 OBGYN Diagnostic Services: Laboratory Chorionic gonadotropin test $16.40
24-Jun V22.0 Z3400 86336 OBGYN Diagnostic Services: Laboratory Inhibin A $17.43
24-Jun V22.0 Z3400 81220 OBGYN Diagnostic Services: Laboratory CFTR gene analysis, common variants $561.73
24-Jun V22.0 Z3400 36415 OBGYN Diagnostic Services: Laboratory Routine Venipuncture $4.17
24-Jun V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
6-Jul

OTC Pharmacy Retail Over-the-counter Drugs Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] $12.21
22-Jul V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
22-Jul V22.0 Z3400 76805 Radiology Diagnostic Services: Radiology OB US >/= 14 WKS SNGL FETUS $163.99
19-Aug V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
16-Sep V22.0 Z3400 82947 OBGYN Diagnostic Services: Laboratory Assay Glucose Blood Quant $5.73
16-Sep V22.0 Z3400 85025 OBGYN Diagnostic Services: Laboratory Complete cbc w/auto diff wbc $11.14
16-Sep V22.0 Z3400 82950 OBGYN Diagnostic Services: Laboratory Glucose Test $5.14
16-Sep V22.0 Z3400 36415 OBGYN Diagnostic Services: Laboratory Routine Venipuncture $4.17
16-Sep V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
30-Sep V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
4-Oct

OTC Pharmacy Retail Over-the-counter Drugs Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] $12.21
14-Oct V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
20-Oct

S9442 Alternative Provider Preventive Services & Vaccines Birthing class -
27-Oct

S9442 Alternative Provider Preventive Services & Vaccines Birthing class -
28-Oct V22.0 Z3400 87653 OBGYN Diagnostic Services: Laboratory Strep B DNA Amp Probe $36.78
28-Oct V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
28-Oct V04.81 Z23 90471 OBGYN Preventive Services & Vaccines Immunization Admin $23.00
28-Oct V04.81 Z23 90656 OBGYN Preventive Services & Vaccines Flu Vaccine N0 Preserv 3 & > $14.27
1-Nov

S9442 Alternative Provider Preventive Services & Vaccines Birthing class -
8-Nov

S9442 Alternative Provider Preventive Services & Vaccines Birthing class -
11-Nov V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
18-Nov V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
25-Nov V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
2-Dec V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
9-Dec


Inpatient Facility Inpatient Hospital Care (Facility) Inpatient Maternity Bundle (Bundled line items 4, 5, 34) $8,959.38
9-Dec V22.0 Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
9-Dec 650, V27.0 O80, Z370 S9443 Inpatient Facility Preventive Services & Vaccines Lactation class -
10-Dec

99460 Inpatient Professional Professional Services: Primary Care Initial hospital or birthing center care, per day, for E/M of normal newborn infant $99.00
11-Dec

99460 Inpatient Professional Professional Services: Primary Care Initial hospital or birthing center care, per day, for E/M of normal newborn infant $99.00
11-Dec

OTC Pharmacy Retail Over-the-counter Drugs Docusate sodium (OTC) [1 pill QD] $11.20
11-Dec

591346601 Pharmacy Retail Prescription Drugs: Generic Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60 pills] $11.69
11-Dec

378710401 Pharmacy Retail Prescription Drugs: Generic Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H PRN; 15 pills] $6.45
23-Dec V24.2 Z392 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
11-Dec V24.2 Z392 591346601 Pharmacy Retail Prescription Drugs: Generic Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60 pills] $11.69
11-Dec V24.2 Z392 378710401 Pharmacy Retail Prescription Drugs: Generic Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H PRN; 15 pills] $6.45
23-Dec V24.2 Z392 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
** 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.)







Sheet 3: Provider Types

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 What providers are covered under this Provider Type and other notes:
Pharmacy Retail
OBGYN
Radiology
Alternative Provider
Inpatient Facility
Inpatient Professional
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Sheet 4: Categories

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
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
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