CMS-10433 Plans and Benefits Template

OMB Control Number: 0938-1187
Expiration Date: XX/XX/20XX

To use this arrow
template,
please
review
the
user
and cell
instructions.
All
with anpress
asterisk
) arethe
required
2023 Plans & Benefits Template v12.0 [assistive
users,
reference
C1 for
instructions]
Press TABtechnology
and directional
keys
toplease
read
through
theguide
document.
If macros
arefields
disabled,
and( *hold
ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select "Enable All Content". Template instructions can be found in cells D1 through D5.
HIOS Issuer ID*
Issuer State*
Market Coverage*
Dental Only Plan*

You will need to save the latest version of the add-in file (PlansBenefitsAddIn.xlam) on your machine.
To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro.
To create additional Benefits Package worksheets, use the Create New Benefits Package macro.
To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro.

Plan Identifiers
HIOS Plan ID*
(Standard Component)

Plan Marketing Name*

Plan Attributes

HIOS Product
ID*

Network ID*

Service Area ID*

Formulary ID*

EHB

Is this Benefit
Covered?

Quantitative Limit on
Service

Limit Quantity

Benefit Information
Benefits

New/Existing Plan?*

Plan Type*

Level of Coverage*

Design Type*

Unique Plan Design?*

Exclusions

Benefit Explanation

EHB Variance Reason

Excluded from In
Network MOOP

General Information
Limit Unit

QHP/Non-QHP*

Notice Required
for Pregnancy*

Plan Level
Exclusions

Stand Alone Dental Only
Limited Cost
Sharing Plan
Variation - Est
Advanced
Payment

Does this plan offer
Composite Rating?*

Child-Only
Offering*

Child Only Plan ID

Tobacco Wellness
Program Offered*

Disease Management
Programs Offered

EHB Percent of Total
Premium*

EHB Apportionment for
Pediatric Dental

Guaranteed vs.
Estimated Rate

Plan Dates

Plan Effective Date*

Plan Expiration
Date

Geographic Coverage
Out of Country
Coverage*

Out of Country
Coverage
Description

Out of Service Area
Coverage*

Out of Service
Area Coverage
Description

National Network*

Out of Pocket Exceptions
Excluded from Out of
Network MOOP

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
Gender Affirming Care

PRA DISCLOSURE:
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
0938-1187, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 24.50 hours per issuer per year, including the time to review instructions, gather the information 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. ****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 Nicole Levesque at [email protected].