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pdfHaving a Baby Guide
Label and Assumptions
Instructions to Plans and Issuers: Do not modify this table. The numbers shown here come from the
Scenario table.
Table 1. Having a Baby Sample Care Costs
Having a Baby
Inpatient Hospital Care (Facility)
Professional Services: Inpatient
Professional Services: Obstetric Care (Bundled)
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Over-the-counter Drugs
Preventive Services & Vaccines
Total
Sample Care Costs
$7,061
$1,399
$2,610
$343
$1,153
$11
$61
$49
$12,687
Assumptions
The following are assumptions that all group health plans and insurance issuers must use for this
scenario. 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 hundred.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the
nearest ten.
If applying the rounding rules causes the out-of-pocket amount displayed to exceed the actual
out-of-pocket limit (for self-only coverage), then the out-of-pocket limit amount must be shown
as the amount of the actual-out-of-pocket limit.
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 listed services 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 (Expiration Date:
XX/XX/XXXX
Scenario
Medical Condition: Having a Baby
Note: Services 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.
• 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-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-thecounter 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
Table 2. Having a Baby Scenario Timeline
Date of
Service
ICD-10
Diagnosis
Code
CPT©,
HCPCS, or
Other Billing
Code
Provider
Type
Category
Description
Totals:
Allowed
Amount
$12,686.85
7-Jan
No data
OTC
Pharmacy
Retail
Over-thecounter Drugs
Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]
$11.48
1-Apr
Z3400
80055
OBGYN
Diagnostic
Services:
Laboratory
Obstetric Panel
$56.04
1-Apr
Z3400
87801
OBGYN
Diagnostic
Services:
Laboratory
Detect agnt mult
dna ampli
$119.67
1-Apr
Z3400
88164
OBGYN
Diagnostic
Services:
Laboratory
Cytopath c/v auto
fluid redo
$36.94
1-Apr
Z3400
86701
OBGYN
Diagnostic
Services:
Laboratory
HIV-1
$17.37
1-Apr
Z3400
36415
OBGYN
Diagnostic
Services:
Laboratory
Routine
Venipuncture
$5.30
1-Apr
Z3201
81025
OBGYN
Diagnostic
Services:
Laboratory
Urine Pregnancy
Test
$9.86
1-Apr
O80, Z370
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Obstetrical Care
$2,609.93
1-Apr
Z3400
87086
OBGYN
Diagnostic
Services:
Laboratory
Urin
culture/colony
count
$13.12
1-Apr
Z3400
81001
OBGYN
Diagnostic
Services:
Laboratory
Urinalysis auto
w/scope
$8.67
1-Apr
Z3400
87491
OBGYN
Diagnostic
Services:
Laboratory
Chlmd trach dna
amp probe
$44.48
Date of
Service
ICD-10
Diagnosis
Code
CPT©,
HCPCS, or
Other Billing
Code
Provider
Type
Category
Description
Allowed
Amount
1-Apr
Z3400
87591
OBGYN
Diagnostic
Services:
Laboratory
N.gonorrhoeae
dna amp prob
7-Apr
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
7-Apr
No data
OTC
Pharmacy
Retail
Over-thecounter Drugs
Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]
$11.48
27-May
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
24-Jun
Z3400
82105
OBGYN
Diagnostic
Services:
Laboratory
Alpha-fetoprotein
serum
$23.21
24-Jun
Z3400
82677
OBGYN
Diagnostic
Services:
Laboratory
Assay of estriol
$28.67
24-Jun
Z3400
84702
OBGYN
Diagnostic
Services:
Laboratory
Chorionic
gonadotropin test
$24.94
24-Jun
Z3400
86336
OBGYN
Diagnostic
Services:
Laboratory
Inhibin A
$21.67
24-Jun
Z3400
81220
OBGYN
Diagnostic
Services:
Laboratory
CFTR gene
analysis, common
variants
24-Jun
Z3400
36415
OBGYN
Diagnostic
Services:
Laboratory
Routine
Venipuncture
24-Jun
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
$43.82
$595.43
$5.30
-
Date of
Service
ICD-10
Diagnosis
Code
CPT©,
HCPCS, or
Other Billing
Code
Provider
Type
Category
Description
Allowed
Amount
6-Jul
No data
OTC
Pharmacy
Retail
Over-thecounter Drugs
Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]
$11.48
22-Jul
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
22-Jul
Z3400
76805
Radiology
Diagnostic
Services:
Radiology
OB US >/= 14
WKS SNGL FETUS
$209.73
19-Aug
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
16-Sep
Z3400
82947
OBGYN
Diagnostic
Services:
Laboratory
Assay Glucose
Blood Quant
16-Sep
Z3400
85025
OBGYN
Diagnostic
Services:
Laboratory
Complete cbc
w/auto diff wbc
$13.99
16-Sep
Z3400
82950
OBGYN
Diagnostic
Services:
Laboratory
Glucose Test
$10.03
16-Sep
Z3400
36415
OBGYN
Diagnostic
Services:
Laboratory
Routine
Venipuncture
$5.30
16-Sep
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
16-Sep
Z3400
76815
Radiology
Diagnostic
Services:
Radiology
133.68
30-Sep
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Ultrasound of
pregnant uterus,
1 or more
fetus(es)
Office/Outpatient
Visit Est
$8.21
-
Date of
Service
ICD-10
Diagnosis
Code
CPT©,
HCPCS, or
Other Billing
Code
Provider
Type
Category
Description
Allowed
Amount
4-Oct
No data
OTC
Pharmacy
Retail
Over-thecounter Drugs
Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]
$11.48
14-Oct
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
28-Oct
Z3400
87653
OBGYN
Diagnostic
Services:
Laboratory
Strep B DNA Amp
Probe
$61.22
28-Oct
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
0
28-Oct
Z23
90471
OBGYN
Preventive
Services &
Vaccines
Immunization
Admin
$28.56
28-Oct
Z23
90656
OBGYN
Preventive
Services &
Vaccines
Flu Vaccine N0
Preserv 3 & >
$20.20
11-Nov
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
18-Nov
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
25-Nov
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
2-Dec
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
Date of
Service
ICD-10
Diagnosis
Code
CPT©,
HCPCS, or
Other Billing
Code
Provider
Type
Category
Description
Allowed
Amount
9-Dec
O80, Z370
1967
Anesthesiolo
gy
Professional
Services:
Inpatient
Anesth/analg vag
delivery
$1,399.34
9-Dec
Z3800
775
Inpatient
Facility
Inpatient
Hospital Care
(Facility)
Vaginal delivery
w/o complicating
diagnoses
$7,060.58
9-Dec
Z3400
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
11-Dec
No data
5.199E+10
Pharmacy
Retail
Over-thecounter Drugs
$15.10
11-Dec
No data
5.375E+10
Pharmacy
Retail
Prescription
Drugs: Generic
Polyethylene
Glycol 3350 [1
dose / 17 GM
daily]
Ibuprofen 800mg
(Rx) [1 pill Q8H
PRN; 30 pills]
11-Dec
No data
228298150
Pharmacy
Retail
Prescription
Drugs: Generic
Oxycodone/APAP
5mg/325mg (Rx)
[1 pill Q6H PRN;
15 pills]
$6.80
23-Dec
Z392
59400
OBGYN
Professional
Services:
Obstetric Care
(Bundled)
Office/Outpatient
Visit Est
-
$3.77
** 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.)
Provider Types
The following are the provider types to use in the “Scenario table ~ "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.
Table 3. Having a Baby Provider Types
Provider Type
Pharmacy Retail
OBGYN
Radiology
Inpatient Facility
Anesthesiology
What providers are covered under this Provider
Type and other notes:
No data
No data
No data
No data
No data
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Categories
The following are the categories to use in the “Scenario” table ~ "Category" column to classify each item
and service so it rolls up to the same category in the Coverage Example label in the "Label and
Assumptions" table. This facilitates consistency between the "Scenario" table and Coverage Example
label.
Table 4. Having a Baby Categories
Category
What providers are covered under this Category
and other notes:
Over-the-counter Drugs
No data
Diagnostic Services: Laboratory
No data
Professional Services: Obstetric Care (Bundled)
No data
Preventive Services & Vaccines
No data
Professional Services: Inpatient
No data
Prescription Drugs: Generic
No data
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 (Expiration date: XX/XX/XXXX).
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-1146 . The time required to complete this information collection is
estimated to average [1 hour] per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
File Type | application/pdf |
File Title | Having a Baby Guide |
Subject | SBC Scenario Guide |
Author | Acumen, LLC |
File Modified | 2019-08-22 |
File Created | 2019-05-03 |