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pdfCoverage Examples Cost Sharing Calculator
Information Packet
March 29, 2016
Revision: 02.07.02
Document Number: RTI.CCIIO.CECSC.02.07.02
Contact Number:
Prepared for:
Centers for Medicare & Medicaid Services (CMS)
Center for Consumer Information & Insurance Oversight
Prepared by:
RTI International
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
ii
Revision History
Revision
Date
02.04.XX.02 2/9/2016
02.05.XX.01 2/19/2016
2.07.02
3/29/2016
Revisions
Changed references to “beneficiary” to “subscriber”
Changed revision number to conform to version 02.05 of the
calculator
Updated figure in §3.4 to reflect relabeling of buttons in tool
Added material to §
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Table of Contents
Revision History ............................................................................................................................................ ii
Table of Contents ......................................................................................................................................... iii
1.0
Purpose and Construction ................................................................................................................ 1
2.0
Using the Coverage Examples Cost Sharing Calculator..................................................................... 2
3.0
Technical Overview .......................................................................................................................... 2
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4.0
4.1
4.2
4.3
4.4
5.0
5.1
5.2
The WELCOME worksheet ............................................................................................................ 3
The MANUAL_INPUT Worksheet .................................................................................................. 4
The MULTIPLE_PLAN_MODE worksheet ...................................................................................... 6
The RESULTS_SUMMARY worksheet ............................................................................................ 7
The MATERNITY_SUMMARY, DIABETES_SUMMARY and FRACTURE_SUMMARY worksheets ... 9
The TIMELINE worksheets ............................................................................................................ 9
The LINE_ITEM worksheets......................................................................................................... 15
Plan Benefit Parameters and the BENEFIT_DESIGN worksheet ..................................................... 16
Benefit Categories ....................................................................................................................... 17
Cost Sharing Options ................................................................................................................... 18
Coverage limits............................................................................................................................ 20
Out-of-pocket Limits ................................................................................................................... 20
Multi-Plan Mode ............................................................................................................................. 23
Browsing and reviewing Multi-Plan Mode input data ................................................................ 24
Generating output in Multi-Plan Mode ...................................................................................... 24
Appendix A: Overview of the Coverage Examples Calculator Logic ........................................................... 25
Phase 1: Obtain the allowed amount ..................................................................................................... 25
Phase 2: Determine whether the claim is for a covered service ............................................................ 25
Phase 3: Apply the monthly and annual coverage limits ........................................................................ 25
Phase 4: Apply the required Co-payment or Co-insurance .................................................................... 26
Phase 5: Apply the required deductible.................................................................................................. 26
Phase 6: Apply the out-of-pocket limit ................................................................................................... 26
Phase 7: Calculate the subscriber and the plan payment ....................................................................... 27
Phase 8: Allocate the subscriber payment to summary aggregation categories ................................... 27
Appendix B: PLAN_INPUT_DATA external data file specifications ............................................................. 29
Appendix C: PLAN_OUTPUT_DATA external data file................................................................................. 35
Coverage Examples Cost Sharing Calculator
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Coverage Examples Cost Sharing Calculator
1.0
Purpose and Construction
The Coverage Examples Cost Sharing Calculator (CECSC) is a tool that can be used by health plans to
estimate the out-of-pocket expenditure under a benefit package for treatment of three stylized
examples: management of stable type 2 diabetes; an uncomplicated pregnancy with a vaginal birth; and
a simple foot fracture.
This coverage example calculator makes several assumptions which may not be valid for all plan designs.
The coverage example calculator makes the following assumptions:
The benefit package covers maternity care, diabetes care, and simple fracture care. If the plan does
not cover these conditions, the coverage example calculator cannot be used for the non-covered
condition;
Consumer out-of-pocket costs do not include premiums.
The condition was not excluded as a pre-existing condition.
The only medical expense incurred by the subscriber was for treatment of the specified condition.
There are no medical expenses for any member covered under the plan or policy other than those
listed.
The calculator treats each condition independently of the others. (For example, the calculator does
not calculate the subscriber’s out-of-pocket cost if she is both diabetic and experiences an
uncomplicated fracture.)
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.
All services occur in same policy period.
All prior authorizations are obtained.
All services are deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the
nearest hundred dollars.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the
nearest ten dollars.
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 benefit design that is applied
reflect the cost-sharing required assuming that the patient does NOT participate in the wellness
program.
If your plan design differs significantly from these assumptions, the estimated consumer out-of-pocket
cost may be inaccurate. In such a case, the user can alter the coverage calculator to make it more
accurate. For example, if your plan covers diabetes supplies under the prescription drug benefit, a user
can modify the calculator to apply prescription drug cost sharing to those items. Alternatively, the plan
can use a coverage calculator that it develops using as inputs the schedules of services provided and the
schedule of allowed amounts that are included in the cost sharing calculator.
The CECSC is a macro-enabled Excel™ workbook. The user must enable macros.
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Using the Coverage Examples Cost Sharing Calculator
2.0
Using the Coverage Examples Cost Sharing Calculator
2
The CECSC can be used in two different modes. When the workbook is first opened, the WELCOME
worksheet is displayed and Mode is selected.
In the Single Plan Mode a user enters the characteristics of a single plan, and then runs the results of
the calculator. In Single Plan Mode a user can also add plans one at a time and then export an output file
for all of the plans that the user has entered.
In the Multi-Plan Mode a user imports (or copies) data from an external file for a set of plans and then
runs the calculator to produce an output file. In Multi-Plan Mode a user can also browse and review the
results for each plan before creating the output file.
3.0
Technical Overview
The CECSC has 4 core worksheets that the user interacts with:
The WELCOME worksheet in which the user chooses either the Single Plan or Multi-Plan mode.
The MULTIPLE_PLAN_MODE worksheet in which the user chooses the method that will be used to
enter data for multiple plans.
The BENEFIT_DESIGN worksheet in which the user enters the benefit design parameters (i.e., type of
cost sharing, deductible amounts, coinsurance rates, copayment amounts, coverage limits, etc.)
The RESULTS_SUMMARY worksheet which displays the estimated cost-sharing under the specified
benefit design for each of the standardized coverage examples.
From the RESULTS_SUMMARY worksheet, the user can navigate to a set of three worksheets for each of
the coverage examples. Specifically, from the Maternity Example section of the RESULTS_SUMMARY
worksheet the user can navigate to:
The MATERNITY_SUMMARY worksheet which shows the allowed amount, the amount of the plan
payment, and the amount of the subscriber payment for the maternity coverage example.
The MATERNITY_TIMELINE worksheet which shows the claim-by-claim development of the
consumer cost sharing amount.
The MATERNITY_LINE_ITEM worksheet which shows the allowed amount for each of the items and
services that are included in the coverage example.
From the Diabetes Type 2 section of the RESULTS_SUMMARY worksheet the user can navigate to:
The DIABETES_SUMMARY worksheet which shows the allowed amount, the amount of the plan
payment, and the amount of the subscriber payment for the Type 2 Diabetes coverage example.
The DIABETES_TIMELINE worksheet which shows the claim-by-claim development of the consumer
cost sharing amount.
The DIABETES_LINE_ITEM worksheet which shows the allowed amount for each of the items and
services that are included in the coverage example.
From the Foot Fracture Example section of the RESULTS_SUMMARY worksheet the user can navigate to:
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Technical Overview
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The FRACTURE_SUMMARY worksheet shows the allowed amount, the amount of the plan payment,
and the amount of the subscriber payment for the foot fracture coverage example.
The FRACTURE_TIMELINE worksheet which shows the claim-by-claim development of the consumer
cost sharing amount.
The FRACTURE_LINE_ITEM worksheet which shows the allowed amount for each of the items and
services that are included in the coverage example.
In addition to these worksheets, the CECSC has two worksheets that are used to store the input and
output data when the tool is being used in multi-plan mode.
The PLAN_INPUT_DATA worksheet which holds the benefit design parameters for each of the plans
that have been entered.
The PLAN_OUTPUT_DATA worksheet which holds the output data for each of the plans that have
been entered.
Each of these worksheets is described in the following sections.
3.1
The WELCOME worksheet
Welcome to the Coverage Examples Cost Sharing Calculator
All insurer data entry fields are highlighted in orange.
The Cost Sharing Calculator operates in two modes.
Click the button that corresponds to the mode you want to use.
Single Plan Mode
The user enters data for an individual plan and views the results.
Multi-Plan Mode
The user loads data for multiple plans and runs the calculator.
The user can then browse the results for the individual plans, save
the results to an external file, or copy and paste the results for
the individual plans to a separate worksheet.
On the WELCOME worksheet, which displays when the tool is opened, the user will select either the
Single Plan Mode or the Multi-Plan Mode.
To select the Single Plan Mode, click the Single Plan Mode button. The BENEFIT_DESIGN worksheet will
then be displayed, allowing the user to enter the parameters for a single plan or multiple plans one at a
time.
To select the Multi-Plan Mode, click the Multi-Plan Mode button. The MULTIPLE_PLAN_MODE
worksheet will then be displayed, allowing the user to select the method that will be used to load data
for multiple plans.
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3.2
The MANUAL_INPUT Worksheet
Prev Plan1
Single Plan Mode
Enter or modify data for each plan.
Data entry fields are highlighted in orange.
Clear
Plan 1
Benefit category
Inpatient Hospital Care (Facility)
Other Facility Services
Emergency Department (Facility)
Ambulance
Professional Services: Primary Care
Professional Services: Emergency Department
Professional Services: Specialist
Professional Services: Obstetric Care (Bundled)
Professional Services: Procedures & Other
Professional Services: Physical Therapy
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Prescription Drugs: Branded
Over-the-counter Drugs
Preventive Services & Vaccines
Durable Medical Equipment
Medical Supplies
Over-the-counter Medical Supplies
Other Items & Services
Plan Deductible
Rx Deductible
Deductible C
Deductible D
Individual Out-of-Pocket (OOP) Limit
Type of cost sharing that
applies
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
1 of 3
Next Plan
Multi-Plan Mode
Update
Save As
Run Calculator
Cost sharing¹
Benefit
CoCoDeductible payment insurance
Coverage Limits
OOP
per
limit
month per year applies?
$0
¹ The benefit-specific deductible, copayment amount, or coinsurance rate that determines consumer liability.
² Outpatient services include non-professional Emergency Department services. Professional services fall under the Professional Services benefit categories.
The BENEFIT_DESIGN worksheet is used to enter the benefit design parameters for a plan.
At the top of the worksheet are several navigation buttons that allow a user to navigate between plans
(if more than one plan has been created and saved), to clear or reset the benefit parameters for the
displayed plan, to update the benefit parameters for the displayed plan, or to save the displayed plan as
a new plan.
The Prev Plan and Next Plan buttons allow a user to navigate between plans (if more than one plan has
been created and saved). If any changes were made to the parameters of the plan after it was loaded
into the BENEFIT_DESIGN worksheet, a dialog box will prompt the user to save the changed parameters:
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Clicking the Yes button will save the updated parameters for the plan. Clicking the No button will discard
the changes to the parameters to the current plan and load the parameters for the next plan into the
BENEFIT_DESIGN worksheet. Clicking the Cancel button will allow the user to continue reviewing or
editing the updated parameters for the current plan before deciding to load a different plan.
Clicking the Clear button will reset the parameters for the plan that is currently loaded into the
BENEFIT_DESIGN worksheet to the default parameters.
Clicking the Update button will save the parameters for the plan that is currently loaded into the
BENEFIT_DESIGN worksheet.
Clicking the Save As button will save the parameters for the plan that is currently loaded into the
BENEFIT_DESIGN worksheet as a new plan, increment the number of plans that are available, and load
the parameters for the newly created plan.
Clicking the Run Calculator button will display the RESULTS_SUMMARY worksheet.
The Multi-Plan Mode button in the upper right corner of the worksheet allows a user to switch to MultiPlan Mode.
Section 4.0 discusses the entry of plan parameter data into the BENEFIT_DESIGN worksheet.
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Technical Overview
3.3
The MULTIPLE_PLAN_MODE worksheet
6
Multiple Plan Mode
In multiple plan mode you load data for multiple plans into the calculator.
The calculator will check your plan benefit design data for errors and calculate
subscriber cost sharing for each plan.
After loading plan data you can browse the output and review the benefit design
parameters for each plan. You can also correct any errors that were identfied
and update your input data by switching to Single Plan Mode.
You have three options for loading plan-level data.
Select the option you want to use by clicking the appropriate button.
Option 1
Import data from external file.
Option
2
Option2:
Copy and paste data from an external file into the plan input data worksheet.
Option
3
Option3:
Enter data for each plan in Single Plan Mode and save the data to the input data worksheet.
Single Plan Mode
Click the button to the left to switch to Single Plan Mode
Multi-Plan Mode allows a user to load data for multiple plans into the calculator, run the calculator for
all loaded plans, and generate an output file that contains the calculated cost sharing for each of the
scenarios for each of the plans.
The MULTIPLE_PLAN_MODE worksheet allows the user to select the method that will be used to load
data for multiple plans. The three options are:
1. To import data from an external file to be used in the calculator. This data must be of a form
readable to the program. Text files (.txt) should be delimited by tabs in order to be read into the
program.
2. To copy and paste data from an external data file (such as an Excel worksheet) into the
PLAN_INPUT_DATA worksheet.
3. To enter data for each plan, one at a time, in Single Plan Mode and save the data to the input
data worksheet.
The Single Plan Mode button in the lower left corner of the worksheet allows a user to switch to Single
Plan Mode. (This will also occur if the user clicks the Option 3 button.)
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3.4
The RESULTS_SUMMARY worksheet
Summary of Subscriber & Plan Payments
View Input Data
Plan Parameters
Prev Plan
3 of 3
View Output Data
Export Data
Next Plan
Summary for Plan 3
Maternity Example
Plan Pays:
$11,575
Patient Pays:
Deductibles
Copayments
Coinsurance
Exclusions & Limits
Detail
Diabetes Type 2 Example
Timeline
$1,163
$1,003
$100
$0
$60
Line Item
Plan Pays:
$5,305
Patient Pays:
Deductibles
Copayments
Coinsurance
Exclusions & Limits
$2,095
$1,100
$940
$0
$55
Detail
Timeline
Line Item
Foot Fracture Example
Plan Pays:
$1,212
Patient Pays:
Deductibles
Copayments
Coinsurance
Exclusions & Limits
Detail
Timeline
$713
$713
$0
$0
$0
Line Item
The RESULTS_SUMMARY worksheet displays for a plan the estimated cost sharing that is calculated by
the CECSC.
Several navigation buttons are provided at the top of the worksheet. The View Input Data button will
display the PLAN_INPUT_DATA worksheet, which lists the benefit parameters for each of the plans that
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Technical Overview
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has been loaded into to CECSC. The View Output Data button will display the PLAN_OUTPUT_DATA
worksheet.
The Plan Parameters button will navigate to the BENEFIT_DESIGN worksheet which will display the
benefit design parameters for the plan shown on the RESULTS_SUMMARY worksheet.
The Prev Plan and Next Plan buttons allow a user to navigate between plans (if more than one plan has
been created and saved).
The Export Data button will run the calculator and export the output data for all loaded plans to an
external file.
Within the section of the RESULTS_SUMMARY worksheet for each of the coverage examples, there are
three buttons.
Maternity Example
Plan Pays:
$11,653
Patient Pays:
Deductibles
Copayments
Coinsurance
Exclusions & Limits
Detail
Diabetes Type 2 Example
Timeline
$1,078
$1,018
$0
$0
$60
Line Item
The Detail button will display more detailed data on the calculated cost sharing amounts. For example,
in the Maternity Example:
Clicking the Detail button will display the MATERNITY_SUMMARY worksheet.
Clicking the Time Line button will display the MATERNITY_TIMELINE worksheet which shows the
claim-by-claim development of the consumer cost sharing amount.
Clicking the Line Item button will display the MATERNITY_LINE_ITEM worksheet which shows the
allowed amount for each of the items and services that are included in the coverage example.
Each of the buttons in the other examples works in a similar way.
If the RESULTS_SUMMARY worksheet displays “ERROR” in the calculated cost sharing amounts, it means
that there is an uncorrected error in the BENEFIT_DESIGN. To identify the error click the Plan
Parameters button, which will navigate to the BENEFIT_DESIGN worksheet. The benefit category or
other parameter containing the error will be identified on that worksheet.
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3.5
The MATERNITY_SUMMARY, DIABETES_SUMMARY and FRACTURE_SUMMARY worksheets
Maternity Example: Summary of Subscriber and Plan Payments
Plan 2
Benefit category
Inpatient Hospital Care (Facility)
Other Facility Services
Emergency Department (Facility)
Ambulance
Professional Services: Primary Care
Professional Services: Emergency Department
Professional Services: Specialist
Professional Services: Obstetric Care (Bundled)
Professional Services: Procedures & Other
Professional Services: Physical Therapy
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Prescription Drugs: Branded
Over-the-counter Drugs
Preventive Services & Vaccines
Durable Medical Equipment
Medical Supplies
Over-the-counter Medical Supplies
Other Items & Services
Total (unrounded)
Total (rounded)
Allowed Amount
Subscriber pays:
Allowed
Allowed
Plan
Total
Subscriber- Subscriber- Subscriber- Non-covered
Amount
Amount
payment
subscriber
paid
paid
paid
and
(unrounded) (rounded)
(unrounded) payment
deductible
copayment coinsurance exclusions
$8,959
$9,000
$8,959
$198
$200
$198
$2,394
$2,400
$1,572
$822
$822
$164
$200
$164
$882
$900
$704
$178
$178
$36
$40
$18
$18
$18
$60
$60
$60
$60
$37
$40
$37
$12,731
$11,653
$1,078
$1,018
$0
$0
$60
$12,840
$11,760
$1,080
$1,020
$0
$0
$60
The summary worksheets for each of the coverage examples (MATERNITY_SUMMARY worksheet,
DIABETES_SUMMARY worksheet and FRACTURE_SUMMARY worksheet) display a summary of the
calculated payment amounts including the allowed amounts. These data are informational.
The payment data are organized by the benefit category to which claims are assigned. (See section 4 for
additional information on benefit categories.)
3.6
The TIMELINE worksheets
Phase 1
Claim
Calendar
Item or
number Date
Month
Service Code
1
01/03/2011
1
25
2
01/03/2011
1
14
3
01/03/2011
1
5
4
01/03/2011
1
3
5
01/03/2011
1
7
6
01/03/2011
1
4
Description
Benefit Category
Cost-sharing type
Alcohol swabs (OTC - box of 100)
Over-the-counter
[usage = 3 wipes/day;
Drugs 90 wipes/month]
Not Covered
BD Ultrafine Insulin Syringes /Medical
30G/ 0.5cc
Supplies
[usage = 30 syringes per month]
Plan Deductible Only
OneTouch Delica Lancets (100Medical
per box)Supplies
[usage = 60 lancets per month]
Plan Deductible Only
OneTouch Delica Lancing Device
Medical Supplies
Plan Deductible Only
OneTouch Ultra 2 Blood Glucose
Medical
MeterSupplies
Kit
Plan Deductible Only
OneTouch Ultra Blue Test Strips
Medical
(Rx - box
Supplies
of 100) [usage = 2 strips/day; 60 per month]
Plan Deductible Only
Phase 2
Allowed
amount
Not covered
$2.61
$2.61
$42.66
$10.38
$16.12
$56.90
$125.26
-
The MATERNITY_TIMELINE worksheet, DIABETES_TIMELINE worksheet and FRACTURE_TIMELINE
worksheet are where the cost sharing amounts are calculated. The cost sharing amount is calculated in
an 8-stage process that is described in Appendix A. Row 1 of this worksheet identifies the stage
(described as a “phase”) that is implemented by the column.
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Columns A through G display the scenario’s data on the items and services that were provided to the
hypothetical subscriber. The remaining columns correspond to the 8 phases of the process that calculate
the consumer cost sharing.
Table 3.6. Descriptive information for the line-item claim
Column Column Heading
Description
A
Claim number
The claim number in chronological sequence of processing.
B
Date
The date the item or service was rendered.
C
Calendar Month
The calendar month in which the item or service was rendered
(Used to apply monthly limits).
D
Item or Service Code
The code for the item or service. Corresponds to the codes for
the item or service in column A of the corresponding
LINE_ITEM worksheet.
E
Description
The description for the item or service from column F of the
corresponding LINE_ITEM worksheet.
F
Benefit Category
The benefit category to which the item or service is assigned.
This is given in column E of the corresponding LINE_ITEM
worksheet where it can also be changed by the user by making
use of the drop-down menu in the relevant cell.
G
Cost-sharing type
The cost sharing type that is assigned to the item or service
based on its benefit category (column F) and the benefit
parameters for that benefit category that are given in the
BENEFIT_DESIGN worksheet.
Table 3.6.1. Phase 1. Obtain the allowed amount for the item or service
Column Column Heading
Description
H
Allowed amount
The allowed amount for the item or service as given in column
G of the corresponding LINE_ITEM worksheet. The allowed
amounts cannot be modified by the user.
Table 3.6.2. Phase 2. Determine whether the claim is for a covered service
Column Column Heading
Description
I
Not covered
The amount of the consumer’s liability (the allowed amount) if
the item or service is not covered.
J
Covered amount
The allowed amount, before application of coverage
limitations, cost sharing requirements, or out-of-pocket limits if
the item or service is covered. This is the starting point for the
calculation of the plan liability and the consumer’s out-ofpocket cost for a covered service.
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Table 3.6.3. Phase 3. Apply the monthly and annual coverage limits
Column Column Heading
Description
K
Monthly limit
The limit on the number of claims for the specified item or
service that the plan will cover if received in a single calendar
month. “None” if the plan does not have monthly coverage
limits that apply to the item or service.¹ The monthly limit is
determined by the benefit category to which the item or
service is assigned (column F) and the parameters for that
benefit category specified in the BENEFIT_DESIGN worksheet.
L
Prior use (month)
The number of claims for the specified item or service that have
already been submitted and covered by the plan for the month
in which the line-item was received.
M
subscriber pays because
The amount that the consumer is required to pay because the
monthly limit exceeded
monthly limit has already been reached. If the monthly limit
has been reached the consumer is responsible for the allowed
amount.
N
Annual limit
The limit on the number of claims for the specified item or
service that the plan will cover if received in a calendar year.
“None” if the plan does not have annual coverage limits that
apply to the item or service. The annual limit is determined by
the benefit category to which the item or service is assigned
(column F) and the parameters for that benefit category
specified in the BENEFIT_DESIGN worksheet.
O
Prior use (annual)
The number of claims for the specified item or service that have
already been submitted and covered by the plan for the year
which the line-item was received.¹
P
subscriber pays because
The amount that the consumer is required to pay because the
annual limit exceeded
monthly limit has already been reached. If the annual limit has
been reached the consumer is responsible for the allowed
amount.
¹
Note that coverage limits are applied as if the only services that a consumer has received are the services listed in each coverage example.
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Table 3.6.4. Phase 4. Apply the required co-payment or co-insurance
Column Column Heading
Description
Q
Co-payment amount
The copayment amount that applies to the item or service
based on the benefit category to which the item or service is
assigned (column F) and the parameters for that benefit
category specified in the BENEFIT_DESIGN worksheet. The
copayment amount is shown only if the item or service is
covered and the monthly or annual coverage limit has not been
reached.
R
Co-insurance rate
The coinsurance rate that applies to the item or service based
on the benefit category to which the item or service is assigned
(column F) and the parameters for that benefit category
specified in the BENEFIT_DESIGN worksheet.
S
Co-insurance amount
The coinsurance amount that applies to the item or service
which is equal to the product of the covered amount (column J)
and the co-insurance rate (column R) for the item or service.
The copayment amount is shown only if the item or service is
covered and the monthly or annual coverage limit has not been
reached.
Table 3.6.5. Phase 5. Apply the required deductible
Column Column Heading
Description
T
Allowed amount after
The difference between the allowed amount for the item or
co-payment or coservice if no coverage limit had been applied and after the
insurance
amount of any required copayment or cost sharing has been
deducted. The allowed amount after co-payment or coinsurance is zero if the required copayment exceeds the
allowed amount.
U
Plan deductible applies
Indicator of whether the plan-level deductible applies to the
item or service based on its benefit category (column F) and the
cost sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
V
remaining plan
The amount of the plan deductible that remains after all
deductible
previous charges against the plan deductible have been taken.
W
subscriber pays toward
plan deductible¹
X
Rx deductible applies
Y
remaining Rx deductible
Z
subscriber pays toward
Rx deductible¹
The difference between the remaining plan-deductible (column
V) and the allowed amount after co-payment or co-insurance
(column T).
Indicator of whether the Rx deductible applies to the item or
service based on its benefit category (column F) and the cost
sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
The amount of the Rx deductible that remains after all previous
charges against the plan deductible have been taken.
The difference between the remaining Rx deductible (column Y)
and the allowed amount after co-payment or co-insurance
(column T).
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Column Column Heading
AA
deductible C applies
¹
AB
remaining deductible C
AC
subscriber pays toward
deductible C¹
AD
deductible D applies
AE
remaining deductible D
AF
subscriber pays toward
deductible D¹
AG
benefit deductible
applies
AH
remaining benefit
deductible
AI
subscriber pays toward
benefit deductible¹
AJ
subscriber pays toward
any deductible¹
AK
Covered amount
remaining after
deductibles
13
Description
Indicator of whether Deductible C applies to the item or service
based on its benefit category (column F) and the cost sharing
parameters for that benefit category from the BENEFIT_DESIGN
worksheet.
The amount of Deductible C that remains after all previous
charges against the plan deductible have been taken.
The difference between the remaining Deductible C (column
AB) and the allowed amount after co-payment or co-insurance
(column T).
Indicator of whether Deductible D applies to the item or service
based on its benefit category (column F) and the cost sharing
parameters for that benefit category from the BENEFIT_DESIGN
worksheet.
The amount of Deductible D that remains after all previous
charges against the plan deductible have been taken.
The difference between the remaining Deductible D (column
AE) and the allowed amount after co-payment or co-insurance
(column T).
Indicator of whether a benefit-category deductible applies to
the item or service based on its benefit category (column F) and
the cost sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
The amount of any benefit-category deductible that remains
after all previous charges against the plan deductible have been
taken.
The difference between the remaining benefit-category
deductible (column AI) and the allowed amount after copayment or co-insurance (column T).
The amount of the consumer liability under any deductible.
Equal to the sum of the amount paid toward the plan
deductible, the Rx deductible, deductible C, deductible D, or
specific benefit-category deductibles.
The difference between the covered amount (column I) for
services not subject to annual or monthly coverage limits and
the amount of the subscriber’s deductible
Note that any given item or service is subject to one and only one deductible.
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Table 3.6.6. Phase 6. Apply the out-of-pocket limit
Column Column Heading
Description
AL
subscriber payment
The total year-to-date payments of the subscriber up to and
before OPL
including any payments related to the current claim.
AM
OPL applies
AN
amount subject to OPL
AO
remaining OPL after
subscriber payment
An indicator of whether the out-of-pocket limit applies to this
benefit category based on the benefit category to which the
item or service is assigned (column F) and the benefit
parameters specified for that benefit category in the
BENEFIT_DESIGN worksheet
The amount of the subscriber payment before OPL (column AL)
if the out-of-pocket limit applies to the item or service (column
AM)
The difference between the out-of-pocket limit and the amount
paid out-of-pocket by the subscriber for items and services that
are subject to the out-of-pocket limit
Table 3.6.7. Phase 7. Calculate the subscriber and the plan payment
Column Column Heading
Description
AP
subscriber payment after If the out-of-pocket limit applies to the item or service the
OOP limit
lesser of the amount subject to OPL (column AN) and the
subscriber payment before application of the OPL (column AL)
AQ
plan payment
The difference between the covered amount (column F) and
the subscriber payment after application of the out-of-pocket
limit (column AP)
Table 3.6.8. Phase 8. Allocate the subscriber payment to the summary aggregation categories
Column Column Heading
Description
AR
Not covered
The amount of the allowed charge if the item or service is not
covered
AS
Exclusions
The amount of the allowed charge if the item or service was
subject to coverage limitations
AT
Subscriber-paid
The lesser of the co-payment amount (column Q) and the
copayment
subscriber payment after application of the out-of-pocket limit
(column AP)
AU
Subscriber-paid
The lesser of the co-insurance amount (column S) and the
coinsurance
subscriber payment after application of the out-of-pocket limit
(column AP)
AV
Subscriber-paid
The greater of the payment toward deductibles (column AJ)
deductible
and the difference between the subscriber payment after
application of the out-of-pocket limit (column AP) and the
subscriber’s co-payment (column Q) and co-insurance amounts
(column S)
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3.7
The LINE_ITEM worksheets
Item or
Service
Code
Diagnosis Code
(ICD-9)
15
1
CPT©, HCPCS, or
Other Billing Code
378710401
Provider
Type
Pharmacy Retail
2
591346601
Pharmacy Retail
S9443
795
1967
59400
OTC
OTC
Inpatient Facility
Inpatient Facility
Anesthesiology
OBGYN
Pharmacy Retail
Pharmacy Retail
3
650, V27.0
4 650, V27.0, Proc: 73.59
5 650, V27.0, Proc: 73.59
6 650, V27.0, Proc: 73.59
7
8
Allowed
Description
Amount
Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H
6.45
PRN; 15 pills]
Prescription Drugs: Generic
Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60
11.69
pills]
Preventive Services & Vaccines
Lactation class
0.00
Inpatient Hospital Care (Facility)
Normal newborn
1,756.00
Professional Services: Procedures & Other
Anesth/analg vag delivery
1,008.00
Professional Services: Obstetric Care (Bundled)Obstetrical Care
2,394.18
Over-the-counter Drugs
Docusate sodium (OTC) [1 pill QD]
11.20
Over-the-counter Drugs
Prenatal Vitamins (OTC - Bottle of 100) [1 pill
12.21
daily; 30 pills/month]
Category
Prescription Drugs: Generic
The MATERNITY_LINE_ITEM worksheet, DIABETES_LINE_ITEM worksheet and FRACTURE_TIMELINE
worksheet contain the list of items and services that appear in the TIMELINE worksheets for each
coverage example. The LINE_ITEM worksheets describe each item and service, identify the benefit
category (which can be modified by the user by making use of the drop-down menus in column E), and
the allowed amount. Table 3.7 describes the columns in these worksheets.
Table 3.7. LINE_ITEM worksheet columns
Column Column Heading
Description
A
Item or Service Code
The code for the item or service. Corresponds to the codes for
the item or service in column D of the corresponding TIMELINE
worksheet
B
Diagnosis Code
When applicable an ICD-9 diagnosis code related to the item or
(ICD-9)
service. This is informational.
C
CPT©, HCPCS, or
The “standard” procedure code for the item or service. This is
Other Billing Code
informational.
D
Provider
Type
The type of provider that typically provides the service. This is
informational.
E
Benefit Category
F
Description
The benefit category to which the item or service is assigned by
default. The user can change the benefit category for individual
items or services using the drop down menu that is provided in
the cells in column E. Note that the user must select one of the
20 benefit categories used in the CECSC.
A brief description of the item or service.
G
Allowed
Amount
The allowed amount for the item or service.
H
Notes
Brief comments provided for information only.
I
Valid Benefit Category
J
Timeline Count
An indicator that shows whether the benefit category assigned
to the item or service in column E is one of the 20 allowed
benefit categories. Provided as a check if the user changes the
default benefit category assigned to an item or service.
A count of the number of times the item or service (identified
by Item or service code (column A) appears in the related
TIMELINE worksheet.
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Plan Benefit Parameters and the BENEFIT_DESIGN worksheet
16
In the BENEFIT_DESIGN worksheet, the coverage parameters for each coverage category are specified.
The coverage parameters include:
1. The type of cost sharing (cost sharing option) that applies to each benefit category. The CECSC
defines 19 standard cost sharing options (see §4.2).
2. The benefit-level deductible when a coverage option requiring a benefit-deductible is selected.
3. The co-payment amount when a coverage option requiring a co-payment is selected.
4. The co-payment amount when a coverage option requiring a co-payment is selected.
5. The monthly and annual coverage limit that applies to the benefit category.
6. Whether the benefit category falls under the plan’s out-of-pocket limit.
7. The plan-level deductibles that apply to the plan. Up to four plan-level deductibles may be
specified.
To select a cost sharing option for a benefit category, a user should make use of the drop-down menus
that are available when the cell specifying the type of cost sharing that applies is selected for that
benefit category. In Single Plan Mode only the allowed cost sharing options can be selected. (See figure
4.1.)
Figure 4.1. Use of drop-down menu to select cost sharing option
Trying to enter a cost sharing option that is not one of the 19 allowed options will trigger an error dialog
shown in Figure 4.2.
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17
Figure 4.2. Error dialog for selection of invalid cost sharing option
Clicking the Retry button will let the user modify the data that have been entered. Clicking cancel will
restore the value that existed before the user tried to enter new data.
Depending on the cost sharing option that is selected, certain parameters either must or must not be
specified. Initially these parameters will not have been specified and the BENEFIT_DESIGN worksheet
will identify the “warnings” that result. These warnings may include parameters that must be but have
not been specified or parameters have been but must not be specified. For example, figure 4.3 shows
the warnings that would appear if the cost sharing option for Inpatient hospital care had been changed
from Plan Deductible Only to Deductible C plus Co-payment.
Figure 4.3. Warnings associated with “incomplete” entry of benefit parameters
In this example, the user must specify a copayment amount for Inpatient Hospital Care and must specify
an amount for Deductible C.
Depending on the cost sharing option that is selected, the other parameters that are required will be
dark yellow. Parameters that are not permitted will be black and any data that has been entered will be
in red type. When the required data are entered or the prohibited data are deleted the warnings will
disappear.
4.1
Benefit Categories
The CECSC assigns claims to one of 20 benefit categories:
1. Inpatient Hospital Care (Facility)
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
18
Other Facility Services
Emergency Department (Facility)
Ambulance
Professional Services: Primary Care
Professional Services: Emergency Department
Professional Services: Specialist
Professional Services: Obstetric Care (Bundled)
Professional Services: Procedures & Other
Professional Services: Physical Therapy
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Prescription Drugs: Branded
Over-the-counter Drugs
Preventive Services & Vaccines
Durable Medical Equipment
Medical Supplies
Over-the-counter Medical Supplies
Other Items & Services
Each line item or service code on the LINE_ITEM worksheets is assigned to one of these benefit
categories (in column E). The benefit category determines whether a plan covers the item or service, the
cost sharing requirements for the item or service under the plan, and what limits the plan applies to
coverage for that item or service. A user can customize the benefit categories to which each item or
service is assigned and can redefine the benefit categories that are used by the calculator as described in
section 4.5.
4.2
Cost Sharing Options
The CECSC uses 19 standard coverage options as described in Table 4.2.
Table 4.2. Standard coverage options
Cost sharing option
Description
Not Covered
The benefit category is not covered by the plan.
No Cost Sharing
The benefit category identifies items and services that are
covered but that have no required cost sharing. An
example would be preventive services.
Plan Deductible Only
The benefit category identifies items and services that are
covered and that are subject to the plan-level deductible
but no coinsurance or copayment.
Rx Deductible Only
The benefit category identifies items and services that are
covered and that are subject to the prescription drug (Rx)
deductible but no coinsurance or copayment.
Deductible C Only
The benefit category identifies items and services that are
covered and that are subject to a third plan-level
deductible that applies to multiple benefit categories but
no coinsurance or copayment.
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Cost sharing option
Deductible D Only
Benefit Deductible Only
Copayment Only
Coinsurance Only
Plan Deductible+Co-pay
Rx Deductible+Co-pay
Deductible C+Co-pay
Deductible D+Co-pay
Benefit Deductible+Co-pay
Plan Deductible+Co-ins
Rx Deductible+Co-ins
Deductible C+Co-ins
Deductible D+Co-ins
19
Description
The benefit category identifies items and services that are
covered and that are subject to a fourth plan-level
deductible that applies to multiple benefit categories but
no coinsurance or copayment.
The benefit category identifies items and services that are
covered and that are subject to a deductible that applies
only to the benefit category with no coinsurance or
copayment.
The benefit category does not fall under any deductible
but does have a copayment.
The benefit category does not fall under any deductible
but does require a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to the plan-level deductible
and to a copayment.
The benefit category identifies items and services that are
covered and that are subject to the prescription drug (Rx)
deductible and to a copayment.
The benefit category identifies items and services that are
covered and that are subject to a third plan-level
deductible that applies to multiple benefit categories and
to a copayment.
The benefit category identifies items and services that are
covered and that are subject to a fourth plan-level
deductible that applies to multiple benefit categories and
to a copayment.
The benefit category identifies items and services that are
covered and that are subject to a deductible that applies
only to the benefit category and to a copayment.
The benefit category identifies items and services that are
covered and that are subject to the plan-level deductible
and to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to the prescription drug (Rx)
deductible and to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to a third plan-level
deductible that applies to multiple benefit categories and
to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to a fourth plan-level
deductible that applies to multiple benefit categories and
to a coinsurance payment.
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Cost sharing option
Benefit Deductible+Co-ins
20
Description
The benefit category identifies items and services that are
covered and that are subject to a deductible that applies
only to the benefit category and to a coinsurance
payment.
Deductible amounts (of any type) must be entered as dollars and cents. Copayment amounts must be
entered as dollars and cents. Coinsurance amounts must be entered as values greater than zero and less
than 1.00, i.e. 30% must be entered as 0.30 or 30%.
4.3
Coverage limits
Data for coverage limits must be entered for all services that are covered. (Coverage limits cannot be
entered for services that are not covered. Doing so will create a warning.)
If no coverage limit applies, “None” must be entered as the monthly and annual coverage limit.
If a monthly but not an annual coverage limit applies, an integer of 1 or greater must be entered in the
“per month” coverage limit column and “None” must be entered in the “per year” coverage limit
column.
If an annual but not a monthly coverage limit applies, an integer of 1 or greater must be entered in the
“per year” coverage limit column and “None” must be entered in the “per month” coverage limit
column.
If both monthly and annual coverage limits applies, an integer of 1 or greater must be entered in both
the “per month” coverage limit column and the “per year” coverage limit column.
4.4
Out-of-pocket Limits
If a benefit category contributes to the out-of-pocket limit, then “Yes” must be entered in the column
headed “OOP Limit applies?” If the benefit category does not contribute to the out-of-pocket limit, then
“No” must be entered in that column.
If the benefit category is not covered, the out-of-pocket limit column must be left blank.
4.5
Customizing the Benefit Categories
A user may customize the cost calculator to better reflect the way a specific plan covers the items and
services specified on the LINE_ITEM worksheets for the three coverage examples. A user can customize
the benefit categories to which each item or service is assigned, and can redefine the benefit categories
the calculator uses.
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4.5.1
Reassigning the Benefit Category for an item or service
21
The calculator allows each item or service listed in the LINE_ITEM worksheets for the three coverage
examples to be assigned to one of 20 benefit categories. A user can change the benefit category to which
an item or service is assigned on the LINE_ITEM worksheet.
For example, by default the coverage calculate assigns diabetic test strips to the Medical Supplies benefit
category. However, a user may change that category so that test trips are covered under the Over-thecounter Medical Supplies benefit category or under the Other Items & Services benefit category using
the drop-down list of benefit categories:
Note, a user must select one of the 20 listed benefit categories. These are the benefit categories that are
listed on the BENEFIT_DESIGN worksheet.
Note that the reassignment of an item or service to a benefit category using the LINE_ITEM worksheet
will apply only to the item or service in the coverage example. For example, influenza vaccination is a
line item in both the diabetes and maternity coverage examples. Changing the benefit category to which
influenza vaccination is assigned in the DIABETES_TIME_LINE will not change the benefit category to
which influenza vaccination is assigned in the MATERNITY_TIME_LINE.
4.5.2
Redefining the Benefit Categories
Any of the 20 benefit categories can be redefined in the calculator. The only limitation imposed by the
calculator is that the number of benefit categories cannot exceed 20. However, if a plan needs to define
a specific benefit category for Diabetic Supplies it can do so by following a two-step procedure.
Step one is to change the labels that are used to identify the benefit categories on the BENEFIT_DESIGN
worksheet. For example, a user might want to use the Other Items & Services benefit category:
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22
to identify Diabetes Supplies:
This changes makes the benefit category Diabetes Supplies available for use in the calculator. However,
it also means that the benefit category Other Items & Services is no longer available and any item or
service that is assigned to the Other Items & Services benefit category in a LINE_ITEM worksheet must
be re-assigned either to Diabetes Supplies or to another of the benefit categories listed on the
BENEFIT_DESIGN worksheet.
Step 2 is to change the benefit category for the items and services that are to be paid under the new
Diabetes Supplies benefit category. In this example, the user will modify the benefit categories to which
the items on the DIABETES_LINE_ITEM worksheet are assigned. These items and services may include
lancing devices, test strips, lancets, control solutions, and syringes. The user must change the benefit
category for each of those items to Diabetes Supplies using the drop-down menu.
The re-designated benefit category Diabetes Supplies will now be an available option in the drop-down
list.
A user can, in fact, redefine all 20 of the benefit categories to better match the categories that the plan
uses. However, in this case the user will need to make extensive revisions to the TIME_LINE worksheets
so that every item or service is correctly mapped to one of the newly defined benefit categories.
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23
CAUTION: If a user changes the designation for a benefit category that is used by multiple coverage
examples (for example, both the FRACTURE example and the DIABETES example), any item or service
in any of the LINE_ITEM schedules that was assigned to the benefit category as it was originally
designated will need to be reassigned either to the new category or to another available category.
5.0
Multi-Plan Mode
When used in Multi-Plan Mode, the CECSC allows a user to populate the PLAN_INPUT_DATA worksheet
with benefit parameters for multiple plans.
This worksheet may be populated by importing a tab-separated text file containing the benefit
parameter data (see Appendix B) or by directly entering data on the PLAN_INPUT_DATA worksheet.
(Directly entering data into the PLAN_INPUT_DATA worksheet is not recommended as 146 variables or
columns must be completed for each plan.)
Figure 5.0. PLAN_INPUT_DATA worksheet
Run Calculator
PLAN_ID
Plan 1
Plan 2
Plan 3
This worksheet contains the benefit parameters for multiple plans.
You can copy and paste data for individual plans from an external source starting on row 8.
Plan deductible Rx deductible
$1,000.00
$1,000.00
$100.00
Deductible C
$500.00
Deductible D
OOP Limit
$5,000.00
$5,000.00
The first 7 rows of the PLAN_INPUT_DATA worksheet contain a button that will run the calculator and
generate output for the plans whose parameters are listed starting on row 8. Rows 6 and 7 are the
“header” for the plan parameter data.
WARNING: Do NOT separate groups of plans by using a blank row. A blank row is interpreted by the
CECSC as signaling the end of the entered data. Any data below a blank row will be ignored by the
CECSC.
The plan parameter data are divided into 21 groups.
1. Plan-level parameters (Columns A through F): the plan identifier, the plan deductible, the Rx
deductible, Deductible C, Deductible D, and the out-of-pocket limit (if any) that applies to the
plan.
2. Inpatient hospital care coverage parameters (columns G through M):
a. The cost sharing option or type (column G)
b. Benefit deductible (if required by the cost sharing option) (column H)
c. Copayment amount (if required by the cost sharing option) (column I)
d. Coinsurance rate (if required by the cost sharing option) (column J)
e. The monthly coverage limit (if required by the cost sharing option) (column K)
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Multi-Plan Mode
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
24
f. The annual coverage limit (if required by the cost sharing option) (column L)
g. Whether the out-of-pocket limit applies(column M)
Other Facility Services coverage parameters (columns N through T)
Emergency Department (Facility) (columns U through AA)
Ambulance (columns AB through AH)
Professional Services: Primary Care (columns AI through AO)
Professional Services: Emergency Department (columns AP through AV)
Professional Services: Specialist (columns AW through BC)
Professional Services: Obstetric Care (Bundled) (columns BD through BJ)
Professional Services: Procedures & Other (columns BK through BQ)
Professional Services: Physical Therapy (columns BR through BX)
Diagnostic Services: Radiology (columns BY through CE)
Diagnostic Services: Laboratory (columns CF through CL)
Prescription Drugs: Generic (columns CM through CS)
Prescription Drugs: Branded (columns CT through CZ)
Over-the-counter Drugs (columns DA through DG)
Preventive Services & Vaccines (columns GH through DN)
Durable Medical Equipment (columns DO through DU)
Medical Supplies (columns DV through EB)
Over-the-counter Medical Supplies (columns EC through EI)
Other Items & Services (columns EJ through EP)
An external data file that will be imported using Multi-Plan Mode Option 1 must be a tab-separated
value file consisting of 146 “fields” or “variables” corresponding to the above.
5.1
Browsing and reviewing Multi-Plan Mode input data
Once the plan parameter data for multiple plans have been loaded into the PLAN_INPUT_DATA
worksheet, the BENEFIT_DESIGN worksheet can be used to browse and review the plan input data. As
each plan is loaded, error checking will be performed and any errors will be identified by “warning”
notices in the BENEFIT_DESIGN worksheet.
If errors exist in the input data for a plan, the output data will simply indicate ERROR.
5.2
Generating output in Multi-Plan Mode
To generate output in Multi-Plan Mode the user will click the Run Calculator button that is found on the
PLAN_INPUT_DATA worksheet or the PLAN_OUTPUT_DATA worksheet, or the user can click the View
Output Data button or the Export Data button on the RESULTS_SUMMARY worksheet.
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Appendix A: Overview of the Coverage Examples Calculator Logic
25
Appendix A: Overview of the Coverage Examples Calculator Logic
The Coverage Examples Cost Sharing Calculator (the Calculator) calculates the subscriber and plan
payment for a claim (i.e., the claim for a service provided on a specified date) for a subscriber with selfonly coverage in eight phases:
1.
2.
3.
4.
5.
6.
7.
8.
Phase 1: Obtain the allowed amount.1
Phase 2: Determine whether the claim is for a covered service.
Phase 3: Apply the monthly and annual coverage limits.
Phase 4: Apply the required Co-payment or Co-insurance.
Phase 5: Apply the required deductible.
Phase 6: Apply the out-of-pocket limit.
Phase 7: Calculate the subscriber and the plan payment.
Phase 8: Allocate the subscriber payment to summary aggregation categories.
The following sections describe the Calculator logic for each phase.
Phase 1: Obtain the allowed amount
For each line item in the so-called “timeline”, the Calculator looks up the allowed amount for the Item
or Service Code in the associated “line item” charge schedule.
Phase 2: Determine whether the claim is for a covered service
For the line item, the Calculator looks up the benefit category (broadly speaking, the benefit that the
line item falls under) that applies to the Item or Service Code in the associated “line item” charge
schedule. It then looks up the coverage that applies to the benefit category.
Phase 3: Apply the monthly and annual coverage limits
Based on the coverage that applies to the benefit category, the Calculator looks up the monthly limit
that applies to the line item. It calculates the total number of claims for the same service that have been
provided during the same month as the current claim. If the total number of claims is less than the
monthly limit or if the plan does not apply a monthly limit, the claim is covered by the plan and nothing
accrues to the subscriber. If the total number of claims equals or exceeds the monthly limit, the
allowable charge accrues to the subscriber.
Based on the coverage that applies to the benefit category, the Calculator looks up the annual limit that
applies to the line item. It calculates the total number of claims for the same service that have been
provided during the same year as the current claim. If the total number of claims is less than the annual
limit or if the plan does not apply an annuallimit, the claim is covered by the plan and nothing accrues to
1
The “allowed amount” is the maximum amount that the plan will pay for the item or service. Technically, a noncovered service would not have an “allowed amount”, and the subscriber’s out-of-pocket payment would be
whatever the provider or supplier of the item or service charges.
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Appendix A: Overview of the Coverage Examples Calculator Logic
26
the subscriber. If the total number of claims equals or exceeds the annual limit, the allowable charge
accrues to the subscriber.
Phase 4: Apply the required Co-payment or Co-insurance
If the line-item is covered by the plan and is not subject to the monthly or annual limit, the Calculator
looks up the co-payment that applies to the line item based on the coverage that applies to the benefit
category. If the copayment amount is greater than zero, the amount of the copayment accrues to the
subscriber.
If the line item is covered by the plan and is not subject to the monthly or annual limit, the Calculator
looks up the co-insurance rate that applies to the line item based on the coverage that applies to the
benefit category. If the insurance rate is greater than zero, the amount of the coinsurance that accrues
to the subscriber is calculated by multiplying the coinsurance rate by the allowable amount.
Phase 5: Apply the required deductible
The amount of the allowed amount that is subject to the deductible is equal to the allowed amount less
any copayment or coinsurance that has accrued to the subscriber.
The application of the appropriate deductible proceeds in five stages corresponding to each of the five
deductibles that may apply to a line item. The benefit design may subject each line item to one of five
deductibles or to no deductible. These five deductibles are:
1.
2.
3.
4.
5.
The overall plan deductible;
The prescription drug deductible;
An optional deductible (e.g., that applies to Emergency Services) referred to as deductible C;
An optional deductible (e.g., that applies to Physician Services) referred to as deductible D;
A deductible that applies only to the benefit category.
The calculator determines whether the overall plan deductible applies to the line item based on the
benefit category for the line item. If the overall plan deductible applies, the calculator obtains the plan
deductible and deducts any payments that counted toward the plan deductible for items and services
that were received prior to the line-item being adjudicated. If the remaining plan deductible is greater
than the allowed amount that is subject to the deductible, the amount subject to the deductible accrues
to the subscriber. If the remaining plan deductible is less than the allowed amount that is subject to the
deductible, the amount of the remaining plan deductible accrues to the subscriber.
This same procedure is repeated for each of the remaining deductibles.
Phase 6: Apply the out-of-pocket limit
The Calculator computes the amount of the subscriber’s out-of-pocket payment, which is equal to the
amount of any liability that accrued to the subscriber for the line item as a result of:
1. The application of the monthly and annual limits on coverage;
2. The application of copayment and coinsurance; and,
Coverage Examples Cost Sharing Calculator
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Appendix A: Overview of the Coverage Examples Calculator Logic
27
3. The application of the plan deductible, prescription drug deductible, optional deductible C,
optional deductible D, and benefit deductibles.
This is the amount of the subscriber’s out-of-pocket liability for the line item prior to the application of
the out-of-pocket limit.
The Calculator determines, based on the benefit category that applies to the line item, whether the
claim is subject to the out-of-pocket limit.
If the line-item is subject to the out-of-pocket limit, the calculator compares the subscriber liability prior
to application of the out-of-pocket limit to the remaining allowed out-of-pocket expenditure. The
subscriber’s liability for the claim is the lesser of the amount of the remaining allowed out-of-pocket
expenditure and the amount of the subscriber’s liability prior to the application of the out-of-pocket
limit.
Phase 7: Calculate the subscriber and the plan payment
The Calculator compares the amount of the subscriber’s liability after application of the out-of-pocket
limit to the allowed amount (see Phase 1). If the subscriber’s liability is less than the allowed amount,
the plan’s liability is equal to the difference between the allowed amount and the subscriber’s liability. If
the subscriber’s liability is equal to or greater than the allowed amount, the plan’s liability is zero.
Phase 8: Allocate the subscriber payment to summary aggregation categories
The amount of any subscriber liability is allocated to the reporting categories (i.e., not covered or
exclusions, coinsurance, copayment, or deductibles) by comparing the amount of the subscriber’s
liability that is determined at each step to the amount of the subscriber’s liability after application of the
out-of-pocket limit.
If the subscriber is liable for the claim because the monthly or annual limits have been exceeded, the
amount of the allowed amount up to the amount of the total subscriber liability after application of the
out-of-pocket limit is allocated to “exclusions”.
If the subscriber was not liable for the claim because the monthly or annual limits have been exceeded,
and the amount of copayment is less than or equal to the amount of the total subscriber liability after
application of the out-of-pocket limit, the amount of the copayment up to the total subscriber liability
after application of the out-of-pocket limit is allocated to “co-payments”.
If the subscriber was not liable for the claim because the monthly or annual limits have been exceeded,
and the amount of coinsurance is less than or equal to the amount of the total subscriber liability after
application of the out-of-pocket limit, the amount of the coinsurance up to the total subscriber liability
after application of the out-of-pocket limit is allocated to “co-insurance”.
If the subscriber was not liable for the claim because the monthly or annual limits have been exceeded,
and the amount of the allowed amount that was charged against deductibles is less than or equal to the
amount of the total subscriber liability after application of the out-of-pocket limit less the amount of any
Coverage Examples Cost Sharing Calculator
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Appendix A: Overview of the Coverage Examples Calculator Logic
28
coinsurance or deductible, the amount of the allowed amount that was charged against deductibles up
to the total subscriber liability after application of the out-of-pocket limit is allocated to “deductibles”.
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix B: PLAN_INPUT_DATA external data file specifications
29
Appendix B: PLAN_INPUT_DATA external data file specifications
Table B-1 specifies the required data elements and formats for an external data file of plan parameters.
This file must have no header and no trailer. It should contain only plan parameter data.
Table B-1. Layout of PLAN_INPUT_DATA external data file
Column Data category
Variable
1
Plan-level
PLAN_ID
parameters
2
Plan-level
Plan deductible
parameters
3
Plan-level
Rx deductible
parameters
4
Plan-level
Deductible C
parameters
5
Plan-level
Deductible D
parameters
6
Plan-level
OOP Limit
parameters
7
Inpatient Hospital
Cost sharing Type
Care (Facility)
8
Inpatient Hospital
Benefit Deductible
Care (Facility)
9
Inpatient Hospital
Co-payment
Care (Facility)
10
Inpatient Hospital
Co-insurance
Care (Facility)
11
Inpatient Hospital
Monthly Limits
Care (Facility)
12
Inpatient Hospital
Annual Limits
Care (Facility)
13
Inpatient Hospital
OOP Limit Applies
Care (Facility)
14
Other Facility
Cost sharing Type
Services
15
Other Facility
Benefit Deductible
Services
16
Other Facility
Co-payment
Services
17
Other Facility
Co-insurance
Services
18
Other Facility
Monthly Limits
Services
19
Other Facility
Annual Limits
Services
20
Other Facility
OOP Limit Applies
Services
Coverage Examples Cost Sharing Calculator
Allowable values
Alphanumeric
Blank or numeric
Blank or numeric
Blank or numeric
Blank or numeric
Blank or numeric
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
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Appendix B: PLAN_INPUT_DATA external data file specifications
Column Data category
21
Emergency
Department (Facility)
22
Emergency
Department (Facility)
23
Emergency
Department (Facility)
24
Emergency
Department (Facility)
25
Emergency
Department (Facility)
26
Emergency
Department (Facility)
27
Emergency
Department (Facility)
28
Ambulance
29
Ambulance
30
Ambulance
31
Ambulance
32
Ambulance
33
Ambulance
34
Ambulance
35
Professional Services:
Primary Care
36
Professional Services:
Primary Care
37
Professional Services:
Primary Care
38
Professional Services:
Primary Care
39
Professional Services:
Primary Care
40
Professional Services:
Primary Care
41
Professional Services:
Primary Care
42
Professional Services:
Emergency
Department
43
Professional Services:
Emergency
Department
44
Professional Services:
Emergency
Department
30
Variable
Cost sharing Type
Allowable values
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
Benefit Deductible
Co-payment
Co-insurance
Monthly Limits
Annual Limits
OOP Limit Applies
Cost sharing Type
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix B: PLAN_INPUT_DATA external data file specifications
Column Data category
45
Professional Services:
Emergency
Department
46
Professional Services:
Emergency
Department
47
Professional Services:
Emergency
Department
48
Professional Services:
Emergency
Department
49
Professional Services:
Specialist
50
Professional Services:
Specialist
51
Professional Services:
Specialist
52
Professional Services:
Specialist
53
Professional Services:
Specialist
54
Professional Services:
Specialist
55
Professional Services:
Specialist
56
Professional Services:
Obstetric Care
(Bundled)
57
Professional Services:
Obstetric Care
(Bundled)
58
Professional Services:
Obstetric Care
(Bundled)
59
Professional Services:
Obstetric Care
(Bundled)
60
Professional Services:
Obstetric Care
(Bundled)
61
Professional Services:
Obstetric Care
(Bundled)
31
Variable
Co-insurance
Allowable values
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix B: PLAN_INPUT_DATA external data file specifications
Column Data category
62
Professional Services:
Obstetric Care
(Bundled)
63
Professional Services:
Procedures & Other
64
Professional Services:
Procedures & Other
65
Professional Services:
Procedures & Other
66
Professional Services:
Procedures & Other
67
Professional Services:
Procedures & Other
68
Professional Services:
Procedures & Other
69
Professional Services:
Procedures & Other
70
Professional Services:
Physical Therapy
71
Professional Services:
Physical Therapy
72
Professional Services:
Physical Therapy
73
Professional Services:
Physical Therapy
74
Professional Services:
Physical Therapy
75
Professional Services:
Physical Therapy
76
Professional Services:
Physical Therapy
77
Diagnostic Services:
Radiology
78
Diagnostic Services:
Radiology
79
Diagnostic Services:
Radiology
80
Diagnostic Services:
Radiology
81
Diagnostic Services:
Radiology
82
Diagnostic Services:
Radiology
83
Diagnostic Services:
Radiology
32
Variable
OOP Limit Applies
Allowable values
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix B: PLAN_INPUT_DATA external data file specifications
Column Data category
84
Diagnostic Services:
Laboratory
85
Diagnostic Services:
Laboratory
86
Diagnostic Services:
Laboratory
87
Diagnostic Services:
Laboratory
88
Diagnostic Services:
Laboratory
89
Diagnostic Services:
Laboratory
90
Diagnostic Services:
Laboratory
91
Prescription Drugs:
Generic
92
Prescription Drugs:
Generic
93
Prescription Drugs:
Generic
94
Prescription Drugs:
Generic
95
Prescription Drugs:
Generic
96
Prescription Drugs:
Generic
97
Prescription Drugs:
Generic
98
Prescription Drugs:
Branded
99
Prescription Drugs:
Branded
100
Prescription Drugs:
Branded
101
Prescription Drugs:
Branded
102
Prescription Drugs:
Branded
103
Prescription Drugs:
Branded
104
Prescription Drugs:
Branded
105
Over-the-counter
Drugs
106
Over-the-counter
Drugs
33
Variable
Cost sharing Type
Allowable values
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix B: PLAN_INPUT_DATA external data file specifications
Column Data category
107
Over-the-counter
Drugs
108
Over-the-counter
Drugs
109
Over-the-counter
Drugs
110
Over-the-counter
Drugs
111
Over-the-counter
Drugs
112
Preventive Services
& Vaccines
113
Preventive Services
& Vaccines
114
Preventive Services
& Vaccines
115
Preventive Services
& Vaccines
116
Preventive Services
& Vaccines
117
Preventive Services
& Vaccines
118
Preventive Services
& Vaccines
119
Durable Medical
Equipment
120
Durable Medical
Equipment
121
Durable Medical
Equipment
122
Durable Medical
Equipment
123
Durable Medical
Equipment
124
Durable Medical
Equipment
125
Durable Medical
Equipment
126
Medical Supplies
127
Medical Supplies
128
Medical Supplies
129
Medical Supplies
130
Medical Supplies
131
Medical Supplies
132
Medical Supplies
34
Variable
Co-payment
Allowable values
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
Benefit Deductible
Co-payment
Co-insurance
Monthly Limits
Annual Limits
OOP Limit Applies
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix C: PLAN_OUTPUT_DATA external data file
Column Data category
133
Over-the-counter
Medical Supplies
134
Over-the-counter
Medical Supplies
135
Over-the-counter
Medical Supplies
136
Over-the-counter
Medical Supplies
137
Over-the-counter
Medical Supplies
138
Over-the-counter
Medical Supplies
139
Over-the-counter
Medical Supplies
140
Other Items &
Services
141
Other Items &
Services
142
Other Items &
Services
143
Other Items &
Services
144
Other Items &
Services
145
Other Items &
Services
146
Other Items &
Services
35
Variable
Cost sharing Type
Allowable values
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Note 1: One of the 19 cost sharing options listed in §4.2, Table 4.2. Must match the spelling of one of the 19 options.
Appendix C: PLAN_OUTPUT_DATA external data file
The CECSC generates an external data file containing the output data for the plans listed in the
PLAN_INPUT_DATA worksheet. (NOTE: when the CECSC generates output data it also generates a
corresponding PLAN_INPUT_DATA file. Therefore be careful not to overwrite an input data file.)
The CECSC output data file consists of a tab-separated text file containing 19 variables. These
correspond to the data that are generated and stored on the PLAN_OUTPUT_DATA worksheet. The
outputs from the CECSC can be used to populate the Deductibles, Copayments, Coinsurance, Limits or
Exclusions, and Total [patient] would pay is sections of the coverage example in the SBC.
1. The plan identifier (PLAN_ID)
2. Six output variables for the Maternity example:
a. The amount of the plan payment
b. The amount of the subscriber payment
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
Appendix C: PLAN_OUTPUT_DATA external data file
36
c.
d.
e.
f.
The amount of the subscriber payment attributable to deductibles
The amount of the subscriber payment attributable to co-payment
The amount of the subscriber payment attributable to co-insurance
The amount of the subscriber payment attributable to exclusions and non-covered
items and services
3. Six output variables for the Diabetes example:
a. The amount of the plan payment
b. The amount of the subscriber payment
c. The amount of the subscriber payment attributable to deductibles
d. The amount of the subscriber payment attributable to co-payment
e. The amount of the subscriber payment attributable to co-insurance
f. The amount of the subscriber payment attributable to exclusions and non-covered
items and services
4. Six output variables for the Foot Fracture example:
a. The amount of the plan payment
b. The amount of the subscriber payment
c. The amount of the subscriber payment attributable to deductibles
d. The amount of the subscriber payment attributable to co-payment
e. The amount of the subscriber payment attributable to co-insurance
f. The amount of the subscriber payment attributable to exclusions and non-covered
items and services
Coverage Examples Cost Sharing Calculator
Rev. 02.07.02
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |