SBC Disclosure

Simple Fracture 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. Simple Fracture Sample Care Costs
Simple Fracture
Other Facility Services
Ambulance
Emergency Department: Facility
Professional Services: Emergency Department
Professional Services: Specialist
Professional Services: Physical Therapy
Diagnostic Services: Radiology
Durable Medical Equipment
Prescription Drugs: Generic
Total

Sample Care Costs

$43
$944
$357
$385
$341
$364
$113
$248
$5
$2,800

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

Scenario
Medical Condition: Simple Fracture
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 (Expiration Date: XX/XX/XXXX)

Table 2. Simple Fracture Scenario Timeline
Date of
Service

ICD-10
Diagnosis
Code

Totals:

CPT©,
HCPCS,
or
Other
Billing
Code

Provider
Type

Category

Description

Allowed
Amount

$2,800.17

2-Jun

S99929A

A0425

Ambulance
(land)
Ambulance
(land)

Ambulance

2-Jun

S99929A

A0429

2-Jun

S92355A

99283

Outpatient
Hospital

Emergency
Department:
Facility

2-Jun

S92355A

73630

Outpatient
Hospital

Professional
Services:
Emergency
Department

2-Jun

S92355A

28470

Outpatient
Hospital

Professional
Services:
Emergency
Department

Closed treatment of
metatarsal fracture;
without manipulation,
each

$335.16

2-Jun

S92355A

L4361

Outpatient
Hospital

Durable
Medical
Equipment

$211.56

2-Jun

No data

E0114

Pharmacy
Retail

Durable
Medical
Equipment

2-Jun

No data

0009301
5010

Pharmacy
Retail

Prescription
Drugs: Generic

Walking boot, nonpneumatic, with or
without joints, with or
without interface material,
prefabricated, off-the-shelf
Crutches, underarm, other
than wood, adjustable or
fixed, pair, with pads, tips,
and handgrips
Week supply of
Acetaminophen 300 MG /
Codeine Phosphate 30 MG
Oral Tablet

Ambulance

Ground mileage, per
statute mile
Ambulance service, basic
life support, emergency
transport (bls-emergency)
Emergency department
visit for evaluation and
management of patient,
which req 3 key
components. Usually,
presenting problem(s) are
high severity, & require
urgent physician
evaluation but do not pose
Radiologic examination,
foot; complete, minimum
of 3 views

$161.71
$782.16
$357.31

$49.72

$35.97

$5.24

Date of
Service

ICD-10
Diagnosis
Code

9-Jun

S92355A

9-Jun

CPT©,
HCPCS,
or
Other
Billing
Code

Provider
Type

Category

99203

Outpatient
Hospital

Professional
Services:
Specialist

S92355A

73630

Outpatient
Hospital

Diagnostic
Services:
Radiology

9-Jun

S92355A

29405

Outpatient
Hospital

9-Jun

S92355A

Q4038

14-Jul

S92355A

14-Jul

Description

Allowed
Amount

Office or other outpatient
visit for the evaluation and
management of a new
patient, which requires at
least 3 key components.
Physicians typically spend
30 minutes face-to-face
with the patient.
Radiologic examination,
foot; complete, minimum
of 3 views

$127.51

Professional
Services:
Specialist

Application of short leg
cast (below knee to toes);

$132.03

Outpatient
Hospital

Other Facility
Services

$43.22

73610

Primary

Diagnostic
Services:
Radiology

Cast supplies, short leg
cast, adult (11 years +),
fiberglass
X-ray of ankle, minimum of
3 views

S92355A

99213

Primary

Professional
Services:
Specialist

$81.66

4-Aug

S92355A

97001

Physical
Therapy

11-Aug

S92355A

97110

Physical
Therapy

Professional
Services:
Physical
Therapy
Professional
Services:
Physical
Therapy

Office or other outpatient
visit for the evaluation and
management of an
established patient, which
requires at least 2 of 3 key
components. Physicians
typically spend 15 minutes
face-to-face with the
Physical therapy
evaluation
Therapeutic procedure, 1
or more areas, each 15
minutes; therapeutic
exercises to develop
strength and endurance,
range of motion and
flexibility

$49.72

$63.18

$116.43

$82.53

Date of
Service

ICD-10
Diagnosis
Code

11-Aug

S92355A

CPT©,
HCPCS,
or
Other
Billing
Code

97110

Provider
Type

Physical
Therapy

Category

Description

Allowed
Amount

Professional
Services:
Physical
Therapy

Therapeutic procedure, 1
$82.53
or more areas, each 15
minutes; therapeutic
exercises to develop
strength and endurance,
range of motion and
flexibility
18-Aug
S92355A
97110
Physical
Professional
Therapeutic procedure, 1
$82.53
Therapy
Services:
or more areas, each 15
Physical
minutes; therapeutic
Therapy
exercises to develop
strength and endurance,
range of motion and
flexibility
** 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. Simple Fracture Provider Types
Provider Type
Ambulance (Land)
Outpatient Hospital
Pharmacy Retail
Primary
Physical Therapy

What providers are covered under this Provider
Type and other notes:
No data
No data
No data
Primary Care Physician or non-Specialist
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. Simple Fracture Categories
Category
Ambulance
Emergency Department: Facility
Professional Services: Emergency Department
Other Facility Services
Durable Medical Equipment
Professional Services: Specialist
Professional Services: Radiology
Professional Services: Physical Therapy
Prescription Drugs: Generic

What providers are covered under this Category
and other notes:
No data
No data
No data
No data
No data
No data
No data
No data
No data

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146