CMS-10448 Summary of Benefits Template

OMB Control Number: 0938-1174
Expiration Date: 06/01/2021

The State's EHB-benchmark Plan's Benefits and Limits

Instructions: All fields on this template that are marked red are required to be completed. To ensure that this Benefits and Limits Summary Template corresponds with the EHB-benchmark plan document, please indicate the page number in which
the benefit is covered under Column H if answering "Covered" under Column C (for example, "Covered" in Column C, "pg. 12" in Column H). If there is a quantitative limit on a benefit, then complete the Limit Quantity and Limit Unit fields. If there are
no exclusions for a benefit, then leave the Exclusions field blank. Add an explanation in Column H to provide more details on a benefit.
A
Benefit
Primary Care Visit to Treat an Injury or Illness
Specialist Visit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Home Health Care Services
Emergency Room Services
Emergency Transportation/Ambulance
Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Physician and Surgical Services
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Prenatal and Postnatal Care
Delivery and All Inpatient Services for Maternity Care
Mental/Behavioral Health Outpatient Services
Mental/Behavioral Health Inpatient Services
Substance Abuse Disorder Outpatient Services
Substance Abuse Disorder Inpatient Services
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Eye Glasses for Children
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Laboratory Outpatient and Professional Services
X-rays and Diagnostic Imaging
Basic Dental Care - Child
Orthodontia - Child
Major Dental Care - Child
Basic Dental Care - Adult
Orthodontia - Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery

B
EHB

C
Is the Benefit
Covered?

D
Quantitative Limit
on Service?

E
Limit Quantity

F
Limit Unit

G
Exclusions

H
Explanations

No
No
No

No
No

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 0938-1174 (Expires
06/01/2021). The time required to complete this information collection is estimated to average 47 hours or 2,820 minutes per response for States. For Form 1, the estimate is 4 hours. For Form 2, the estimate is 19 hours. For Form 3, the estimate
is 12 hours. For Form 4, the estimate is 12 hours. 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.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Valisha Jackson at
[email protected].