Summary of Benefits and Coverage

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

Having-a-Baby-Guide-11-2019.xlsx

Summary of Benefits and Coverage

OMB: 1210-0147

Document [xlsx]
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Overview

Label and Assumptions
Scenario
Provider Types
Categories


Sheet 1: Label and Assumptions

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022)
(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)
Having a baby Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab.
Sample Care Costs no data
Inpatient Hospital Care (Facility) $8,460
Professional Services: Obstetric Care (Bundled) $2,610
Diagnostic Services: Radiology $343
Diagnostic Services: Laboratory $1,153
Prescription Drugs: Generic $11
Over-the-counter Drugs $61
Preventive Services & Vaccines $49
Total (unrounded) $12,687
No data
Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
These assumptions are standard across all scenarios.
Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks.
No out-of-network charges or any other variation in Sample Care Costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
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 amount must be capped and 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 services listed in a treatment scenario, the plan or issuer must complete the calculations for that treatment scenario assuming that the patient is NOT participating in the wellness program.
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 (Expires 10/31/2022). The time required to complete this information collection is estimated to average [0.08] hours 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.
End of worksheet

Sheet 2: Scenario

Medical Condition: Having a baby
Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into that category in the "Sample care costs" section so that those costs are uniform across all group health plans and health insurance issuers. However, some plans or issuers may classify an item or service under another category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs" section. Examples of cost sharing and benefit features include, but are not limited to:

• Payment of services based on the location such as inpatient, outpatient, or office; and
• Payment of items as prescription drugs vs. medical equipment.

Explanation of Scenario:
Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded.
Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered.
ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service.
ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service.
CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC.
Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider.
Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab.
Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code.
Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing.

CPT copyright 2010 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
Totals: $12,686.85
Date of Service ICD-10 Diagnosis Code CPT©, HCPCS, or Other Billing Code Provider Type Category Description Allowed Amount
This is a filter cell This is a filter cell This is a filter cell This is a filter cell This is a filter cell This is a filter cell This is a filter cell
7-Jan No data OTC Pharmacy Retail Over-the-counter 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
1-Apr Z3400 87591 OBGYN Diagnostic Services: Laboratory N.gonorrhoeae dna amp prob $43.82
7-Apr Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
7-Apr No data OTC Pharmacy Retail Over-the-counter 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 $595.43
24-Jun Z3400 36415 OBGYN Diagnostic Services: Laboratory Routine Venipuncture $5.30
24-Jun Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
6-Jul No data OTC Pharmacy Retail Over-the-counter 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 $8.21
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 Ultrasound of pregnant uterus, 1 or more fetus(es) 133.68
30-Sep Z3400 59400 OBGYN Professional Services: Obstetric Care (Bundled) Office/Outpatient Visit Est -
4-Oct No data OTC Pharmacy Retail Over-the-counter 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 -
9-Dec O80, Z370 1967 Anesthesiology Professional Services: Inpatient Anesth/analg vag delivery $1,399.34
no data 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 51991045757 Pharmacy Retail Over-the-counter Drugs Polyethylene Glycol 3350 [1 dose / 17 GM daily] $15.10
11-Dec No data 53746046605 Pharmacy Retail Prescription Drugs: Generic Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 30 pills] $3.77
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 -
** 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.)
End of worksheet

Sheet 3: Provider Types

The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids group health plans and health insurance issuers in applying benefits to each item and service.
Provider Type What providers are covered under this Provider Type and other notes:
Pharmacy Retail no data
OBGYN no data
Radiology no data
Alternative Provider no data
Inpatient Facility no data
Inpatient Professional no data
Anesthesiology no data
End of worksheet

Sheet 4: Categories

The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to the same category in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" tab and Coverage Example label.
Category What services are covered under this Category and other notes:
Over-the-counter Drugs No data
Diagnostic Services: Laboratory No data
Professional Services: Obstetric Care (Bundled) No data
Diagnostic Services: Radiology No data
Preventive Services & Vaccines No data
Inpatient Hospital Care (Facility) No data
Professional Services: Inpatient No data
Prescription Drugs: Generic No data
End of worksheet
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