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Coverage Examples Cost Sharing Calculator
Information Packet
December 13, 2019
Revision: 3.01
Prepared for:
Centers for Medicare & Medicaid Services (CMS)
Center for Consumer Information & Insurance Oversight
Prepared by:
Acumen, LLC
Coverage-Examples-Cost-Sharing-Calculator
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Revision History
Revision
Date
02.04.XX.02 2/9/2016
02.05.XX.01 2/19/2016
2.07.02
3.0
3/29/2016
2/21/2019
3.01
12/13/2019
Revisions
Changed references to “beneficiary” to “subscriber”
Changed revision number to conform to version 02.05 of the
calculator
Updated figure in §3.4 to reflect relabeling of buttons in tool
Added material to §
Added benefit categories for “Prescription Drugs: Insulin” and
“Professional Services: Inpatient”
Revised the calculation phases
Added special cost sharing options
Added guidance for rounding and the out-of-pocket limit
Updated calculation phases
Updated guidance for rounding and the out-of-pocket limit
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Table of Contents
Table of Contents ......................................................................................................................................... iii
1.0
Purpose and Construction ................................................................................................................ 1
2.0
Using the Coverage Examples Cost Sharing Calculator..................................................................... 2
3.0
Technical Overview .......................................................................................................................... 2
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4.0
The WELCOME worksheet ............................................................................................................ 3
The MANUAL_INPUT Worksheet .................................................................................................. 4
The MULTIPLE_PLAN_MODE worksheet ...................................................................................... 6
The RESULTS_SUMMARY worksheet ............................................................................................ 7
The MATERNITY_SUMMARY, DIABETES_SUMMARY and FRACTURE_SUMMARY worksheets ... 9
The TIMELINE worksheets ............................................................................................................ 9
The LINE_ITEM worksheets......................................................................................................... 18
Plan Benefit Parameters and the BENEFIT_DESIGN worksheet ..................................................... 19
4.1
4.2
4.3
4.4
4.5
Benefit Categories ....................................................................................................................... 21
Cost Sharing Options ................................................................................................................... 22
Coverage limits............................................................................................................................ 24
Out-of-pocket Limits ................................................................................................................... 24
Customizing the Benefit Categories ............................................................................................ 25
4.5.1
4.5.2
5.0
5.1
5.2
Reassigning the Benefit Category for an item or service .................................................... 25
Redefining the Benefit Categories ...................................................................................... 26
Multi-Plan Mode ............................................................................................................................. 27
Browsing and reviewing Multi-Plan Mode input data ................................................................ 29
Generating output in Multi-Plan Mode ...................................................................................... 29
Appendix A: Overview of the Coverage Examples Calculator Logic ........................................................... 30
Phase 1: Determine the covered amount ............................................................................................... 30
Phase 2: Apply the out-of-pocket limit ................................................................................................... 30
Phase 3: Apply special cost-sharing ........................................................................................................ 30
Phase 4: Apply the monthly and annual coverage limits ........................................................................ 30
Phase 5: Apply the required deductible.................................................................................................. 31
Phase 6: Apply copay and coinsurance ................................................................................................... 31
Phase 7: Calculate the total subscriber payment ................................................................................... 32
Phase 8: Summarize payments by payer and phase category ................................................................ 32
Appendix B: PLAN_INPUT_DATA external data file specifications ............................................................. 33
Appendix C: PLAN_OUTPUT_DATA external data file................................................................................. 40
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1.0
Purpose and Construction
The Coverage Examples Cost Sharing Calculator (CECSC) is a tool that can be used by health plans to
estimate the out-of-pocket expenditure under a benefit package for treatment of three stylized
examples: management of stable type 2 diabetes; an uncomplicated pregnancy with a vaginal birth; and
a simple foot fracture.
This coverage example calculator makes several assumptions which may not be valid for all plan designs.
The coverage example calculator makes the following assumptions:
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The benefit package covers maternity care, diabetes care, and simple fracture care. If the plan does
not cover these conditions, the coverage example calculator cannot be used for the non-covered
condition;
Consumer out-of-pocket costs do not include premiums.
The condition was not excluded as a pre-existing condition.
The only medical expense incurred by the subscriber was for treatment of the specified condition.
There are no medical expenses for any member covered under the plan or policy other than those
listed.
The calculator treats each condition independently of the others. (For example, the calculator does
not calculate the subscriber’s out-of-pocket cost if she is both diabetic and experiences an
uncomplicated fracture.)
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.
All services occur in same policy period.
All prior authorizations are obtained.
All services are deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the
nearest hundred dollars.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the
nearest ten dollars.
If applying the rounding rules causes the cost sharing amount displayed to exceed the actual out-ofpocket limit (for self-only coverage), then the cost sharing amount must be capped and the amount
of the actual out-of-pocket limit must be used. For example, if the out-of-pocket limit is $5,000 but
applying the rounding rules makes the sum of the deductible, copayment and coinsurance equal to
$5,100, the plan or issuer must use the out-of-pocket limit of “$5,000” and not “$5,100.” This
amount (the $5,000 out-of-pocket limit) must then be added to the monetary amount in the
exclusions and limits to determine the total Patient pays amount.
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 benefit design that is applied
reflects the cost-sharing required assuming that the patient does NOT participate in the wellness
program.
If your plan design differs significantly from these assumptions, the estimated consumer out-of-pocket
cost may be inaccurate. In such a case, the user can alter the coverage calculator to make it more
accurate. For example, if your plan covers diabetes supplies under the prescription drug benefit, a user
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2
can modify the calculator to apply prescription drug cost sharing to those items. Alternatively, the plan
can use a coverage calculator that it develops using as inputs the schedules of services provided and the
schedule of allowed amounts that are included in the cost sharing calculator.
The CECSC is a macro-enabled Excel™ workbook. The user must enable macros.
2.0
Using the Coverage Examples Cost Sharing Calculator
The CECSC can be used in two different modes. When the workbook is first opened, the WELCOME
worksheet is displayed and Mode is selected.
In the Single Plan Mode a user enters the characteristics of a single plan, and then runs the results of
the calculator. In Single Plan Mode a user can also add plans one at a time and then export an output file
for all of the plans that the user has entered.
In the Multi-Plan Mode a user imports (or copies) data from an external file for a set of plans and then
runs the calculator to produce an output file. In Multi-Plan Mode a user can also browse and review the
results for each plan before creating the output file.
3.0
Technical Overview
The CECSC has 4 core worksheets that the user interacts with:
•
•
•
•
The WELCOME worksheet in which the user chooses either the Single Plan or Multi-Plan mode.
The MULTIPLE_PLAN_MODE worksheet in which the user chooses the method that will be used to
enter data for multiple plans.
The BENEFIT_DESIGN worksheet in which the user enters the benefit design parameters (i.e., type of
cost sharing, deductible amounts, coinsurance rates, copayment amounts, coverage limits, etc.)
The RESULTS_SUMMARY worksheet which displays the estimated cost-sharing under the specified
benefit design for each of the standardized coverage examples.
From the RESULTS_SUMMARY worksheet, the user can navigate to a set of three worksheets for each of
the coverage examples. Specifically, from the Maternity Example section of the RESULTS_SUMMARY
worksheet the user can navigate to:
•
•
•
The MATERNITY_SUMMARY worksheet which shows the allowed amount, the amount of the plan
payment, and the amount of the subscriber payment for the maternity coverage example.
The MATERNITY_TIMELINE worksheet which shows the claim-by-claim development of the
consumer cost sharing amount.
The MATERNITY_LINE_ITEM worksheet which shows the allowed amount for each of the items and
services that are included in the coverage example.
From the Diabetes Type 2 section of the RESULTS_SUMMARY worksheet the user can navigate to:
•
The DIABETES_SUMMARY worksheet which shows the allowed amount, the amount of the plan
payment, and the amount of the subscriber payment for the Type 2 Diabetes coverage example.
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The DIABETES_TIMELINE worksheet which shows the claim-by-claim development of the consumer
cost sharing amount.
The DIABETES_LINE_ITEM worksheet which shows the allowed amount for each of the items and
services that are included in the coverage example.
From the Foot Fracture Example section of the RESULTS_SUMMARY worksheet the user can navigate to:
•
•
•
The FRACTURE_SUMMARY worksheet shows the allowed amount, the amount of the plan payment,
and the amount of the subscriber payment for the foot fracture coverage example.
The FRACTURE_TIMELINE worksheet which shows the claim-by-claim development of the consumer
cost sharing amount.
The FRACTURE_LINE_ITEM worksheet which shows the allowed amount for each of the items and
services that are included in the coverage example.
In addition to these worksheets, the CECSC has two worksheets that are used to store the input and
output data when the tool is being used in multi-plan mode.
•
•
The PLAN_INPUT_DATA worksheet which holds the benefit design parameters for each of the plans
that have been entered.
The PLAN_OUTPUT_DATA worksheet which holds the output data for each of the plans that have
been entered.
Each of these worksheets is described in the following sections.
3.1
The WELCOME worksheet
Welcome to the Coverage Examples Cost Sharing Calculator
All insurer data entry fields are highlighted in orange.
The Cost Sharing Calculator operates in two modes.
Click the button that corresponds to the mode you want to use.
Single Plan Mode
The user enters data for an individual plan and views the results.
Multi-Plan Mode
The user loads data for multiple plans and runs the calculator.
The user can then browse the results for the individual plans, save
the results to an external file, or copy and paste the results for
the individual plans to a separate worksheet.
On the WELCOME worksheet, which displays when the tool is opened, the user will select either the
Single Plan Mode or the Multi-Plan Mode.
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To select the Single Plan Mode, click the Single Plan Mode button. The BENEFIT_DESIGN worksheet will
then be displayed, allowing the user to enter the parameters for a single plan or multiple plans one at a
time.
To select the Multi-Plan Mode, click the Multi-Plan Mode button. The MULTIPLE_PLAN_MODE
worksheet will then be displayed, allowing the user to select the method that will be used to load data
for multiple plans.
3.2
The MANUAL_INPUT Worksheet
The BENEFIT_DESIGN worksheet is used to enter the benefit design parameters for a plan.
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At the top of the worksheet are several navigation buttons that allow a user to navigate between plans
(if more than one plan has been created and saved), to clear or reset the benefit parameters for the
displayed plan, to update the benefit parameters for the displayed plan, or to save the displayed plan as
a new plan.
The Prev Plan and Next Plan buttons allow a user to navigate between plans (if more than one plan has
been created and saved). If any changes were made to the parameters of the plan after it was loaded
into the BENEFIT_DESIGN worksheet, a dialog box will prompt the user to save the changed parameters:
Clicking the Yes button will save the updated parameters for the plan. Clicking the No button will discard
the changes to the parameters to the current plan and load the parameters for the next plan into the
BENEFIT_DESIGN worksheet. Clicking the Cancel button will allow the user to continue reviewing or
editing the updated parameters for the current plan before deciding to load a different plan.
Clicking the Clear button will reset the parameters for the plan that is currently loaded into the
BENEFIT_DESIGN worksheet to the default parameters.
Clicking the Update button will save the parameters for the plan that is currently loaded into the
BENEFIT_DESIGN worksheet.
Clicking the Save As button will save the parameters for the plan that is currently loaded into the
BENEFIT_DESIGN worksheet as a new plan, increment the number of plans that are available, and load
the parameters for the newly created plan.
Clicking the Run Calculator button will display the RESULTS_SUMMARY worksheet.
The Multi-Plan Mode button in the upper right corner of the worksheet allows a user to switch to MultiPlan Mode.
Section 4.0 discusses the entry of plan parameter data into the BENEFIT_DESIGN worksheet.
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3.3
The MULTIPLE_PLAN_MODE worksheet
6
Multiple Plan Mode
In multiple plan mode you load data for multiple plans into the calculator.
The calculator will check your plan benefit design data for errors and calculate
subscriber cost sharing for each plan.
After loading plan data you can browse the output and review the benefit design
parameters for each plan. You can also correct any errors that were identfied
and update your input data by switching to Single Plan Mode.
You have three options for loading plan-level data.
Select the option you want to use by clicking the appropriate button.
Option 1
Import data from external file.
Option
Option2:
2
Copy and paste data from an external file into the plan input data worksheet.
Option
Option3:
3
Enter data for each plan in Single Plan Mode and save the data to the input data worksheet.
Single Plan Mode
Click the button to the left to switch to Single Plan Mode
Multi-Plan Mode allows a user to load data for multiple plans into the calculator, run the calculator for
all loaded plans, and generate an output file that contains the calculated cost sharing for each of the
scenarios for each of the plans.
The MULTIPLE_PLAN_MODE worksheet allows the user to select the method that will be used to load
data for multiple plans. The three options are:
1. To import data from an external file to be used in the calculator. This data must be of a form
readable to the program. Text files (.txt) should be delimited by tabs in order to be read into the
program.
2. To copy and paste data from an external data file (such as an Excel worksheet) into the
PLAN_INPUT_DATA worksheet.
3. To enter data for each plan, one at a time, in Single Plan Mode and save the data to the input
data worksheet.
The Single Plan Mode button in the lower left corner of the worksheet allows a user to switch to Single
Plan Mode. (This will also occur if the user clicks the Option 3 button.)
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3.4
The RESULTS_SUMMARY worksheet
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The RESULTS_SUMMARY worksheet displays the estimated cost sharing for a plan that is calculated by
the CECSC.
Several navigation buttons are provided at the top of the worksheet. The View Input Data button will
display the PLAN_INPUT_DATA worksheet, which lists the benefit parameters for each of the plans that
has been loaded into to CECSC. The View Output Data button will display the PLAN_OUTPUT_DATA
worksheet.
The Plan Parameters button will navigate to the BENEFIT_DESIGN worksheet which will display the
benefit design parameters for the plan shown on the RESULTS_SUMMARY worksheet.
The Prev Plan and Next Plan buttons allow a user to navigate between plans (if more than one plan has
been created and saved).
The Export Data button will run the calculator and export the output data for all loaded plans to an
external file.
Within the section of the RESULTS_SUMMARY worksheet for each of the coverage examples, there are
three buttons.
The Detail button will display more detailed data on the calculated cost sharing amounts. For example,
in the Maternity Example:
•
•
•
Clicking the Detail button will display the MATERNITY_SUMMARY worksheet.
Clicking the Time Line button will display the MATERNITY_TIMELINE worksheet which shows the
claim-by-claim development of the consumer cost sharing amount.
Clicking the Line Item button will display the MATERNITY_LINE_ITEM worksheet which shows the
allowed amount for each of the items and services that are included in the coverage example.
Each of the buttons in the other examples works in a similar way.
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If the RESULTS_SUMMARY worksheet displays “ERROR” in the calculated cost sharing amounts, it means
that there is an uncorrected error in the BENEFIT_DESIGN. To identify the error click the Plan
Parameters button, which will navigate to the BENEFIT_DESIGN worksheet. The benefit category or
other parameter containing the error will be identified on that worksheet.
3.5
The MATERNITY_SUMMARY, DIABETES_SUMMARY and FRACTURE_SUMMARY worksheets
The summary worksheets for each of the coverage examples (MATERNITY_SUMMARY worksheet,
DIABETES_SUMMARY worksheet and FRACTURE_SUMMARY worksheet) display a summary of the
calculated payment amounts including the allowed amounts. These data are informational.
The payment data are organized by the benefit category to which claims are assigned. (See Section 4 for
additional information on benefit categories.)
3.6
The TIMELINE worksheets
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The MATERNITY_TIMELINE worksheet, DIABETES_TIMELINE worksheet and FRACTURE_TIMELINE
worksheet are where the cost sharing amounts are calculated. The cost sharing amount is calculated in
an 8-stage process that is described in Appendix A. Row 1 of this worksheet identifies the stage
(described as a “phase”) that is implemented by the column.
Columns A through G display the scenario’s data on the items and services that were provided to the
hypothetical subscriber. The remaining columns correspond to the 8 phases of the process that calculate
the consumer cost sharing.
Table 3.6. Descriptive information for the line-item claim
Column Column Heading
Description
A
Claim number
The claim number in chronological sequence of processing.
B
Date
The date the item or service was rendered.
C
Calendar Month
The calendar month in which the item or service was rendered
(Used to apply monthly limits).
D
Item or Service Code
The code for the item or service. Corresponds to the codes for
the item or service in column A of the corresponding
LINE_ITEM worksheet.
E
Description
The description for the item or service from column F of the
corresponding LINE_ITEM worksheet.
F
Benefit Category
The benefit category to which the item or service is assigned.
This is given in column E of the corresponding LINE_ITEM
worksheet where it can also be changed by the user by making
use of the drop-down menu in the relevant cell.
G
Cost-sharing type
The cost sharing type that is assigned to the item or service
based on its benefit category (column F) and the benefit
parameters for that benefit category that are given in the
BENEFIT_DESIGN worksheet.
Table 3.6.1. Phase 1. Determine Covered Amount
Column Column Heading
Description
H
Allowed amount
The allowed amount for the item or service as given in column
G of the corresponding LINE_ITEM worksheet. The allowed
amounts cannot be modified by the user.
I
Service Not Covered
The amount of the consumer’s liability (the allowed amount) if
the item or service is not covered.
J
Remaining Covered
The allowed amount, before application of coverage
Amount
limitations, cost sharing requirements, or out-of-pocket limits if
the item or service is covered. This is the starting point for the
calculation of the plan liability and the consumer’s out-ofpocket cost for a covered service.
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Table 3.6.2. Phase 2. Apply Out-of-Pocket Limit
Column Column Heading
Description
K
OPL Valid?
An indicator of whether the out-of-pocket limit applies to the
benefit category to which the item or service is assigned
(column F).
L
OPL Applies?
An indicator of whether the out-of-pocket limit applies to this
benefit category based on the benefit category to which the
item or service is assigned (column F) and the benefit
parameters specified for that benefit category in the
BENEFIT_DESIGN worksheet.
M
OPL
The out-of-pocket limit that applies to the benefit category to
which the item or service is assigned (column F).
N
Remaining OPL after
The difference between the out-of-pocket limit and the amount
previous subscriber
paid out-of-pocket by the subscriber for items and services that
payments
are subject to the out-of-pocket limit.
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Table 3.6.3. Phase 3a. Begin Primary Care Cost-Sharing After a Set Number of Visits?
Column Column Heading
Description
O
Primary Care Visit?
An indicator of whether the item or service code has been
assigned to the “Professional Services: Primary Care” benefit
category (Column F).
P
Begin Primary Care CostSharing After a Set
Number of Visits?
An indicator of whether the benefit design specifies to begin
primary care cost-sharing after a set number of visits in the
BENEFIT_DESIGN worksheet (row 38).
Q
# Visits
The total number of services that have been assigned to the
“Professional Services: Primary Care” benefit category up to the
current service date.
R
Primary Care Prior Use
The number of services that were classified as Professional
Services: Primary Care (column F) up until the current primary
care service.
S
Visit Covered at 100% by
plan
An indicator of whether the plan covers 100% of the cost of the
service.
T
Remaining Covered
Amount
The remaining covered amount of the service.
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Table 3.6.4. Phase 3b. Begin Primary Care Cost-Sharing After a Set Number of Copays?
Column Column Heading
Description
U
Primary Care Visit?
An indicator of whether the item or service code has been
assigned to the “Professional Services: Primary Care” benefit
category (Column F).
V
Begin Primary Care CostSharing After a Set
Number of Copays?
An indicator of whether the benefit design specifies to begin
primary care cost-sharing after a set number of copays in the
BENEFIT_DESIGN worksheet (row 39).
W
# Visits
The total number of services that have been assigned to the
“Professional Services: Primary Care” benefit category up to the
current service date.
X
Primary Care Prior Copay
Paid
The number of primary care copays that were paid up until the
current primary care service.
Y
Copay Value
The copayment amount that applies to the item or service
based on the benefit category to which the item or service is
assigned (column F) and the parameters for that benefit
category specified in the BENEFIT_DESIGN worksheet.
Z
Copay Applied
An indicator of whether the copay value (column Y) was
applied.
AA
Plan Paid
If the copay has been applied (column Z), it is the difference
between the remaining amount covered (column T) and the
copay value (column Y). Otherwise, the value is equal to 0.
AB
Remaining OPL
The difference between the out-of-pocket limit and the total
amount paid out-of-pocket by the subscriber for items and
services that are subject to the out-of-pocket limit.
AC
Remaining Covered
Amount
The remaining covered amount for the service.
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Table 3.6.5. Phase 4. Apply the monthly and annual coverage limits
Column Column Heading
Description
AD
An indicator of whether the benefit design specifies a monthly
Monthly Limit Valid?
limit for the benefit category to which the item or service has
been assigned in the BENEFIT_DESIGN worksheet.
AE
Monthly limit
The limit on the number of claims for the specified item or
service that the plan will cover if received in a single calendar
month. “None” if the plan does not have monthly coverage
limits that apply to the item or service.¹ The monthly limit is
determined by the benefit category to which the item or
service is assigned (column F) and the parameters for that
benefit category specified in the BENEFIT_DESIGN worksheet.
AF
Prior use (month)
The number of claims for the specified item or service that have
already been submitted and covered by the plan for the month
in which the line-item was received.
AG
Not covered because
An indicator of whether the item or service is not covered
monthly limit exceeded
because the number of claims has exceed the monthly limit.
AH
Annual limit Valid?
AI
Annual Limit
AJ
Prior use (annual)
AK
Not covered because use
limit exceeded
AL
Total not covered
because use limit
exceeded
Covered amount
AM
¹
An indicator of whether the benefit design specifies a monthly
limit for the benefit category to which the item or service has
been assigned in the BENEFIT_DESIGN worksheet (column H).
The limit on the number of claims for the specified item or
service that the plan will cover if received in a calendar year.
“None” if the plan does not have annual coverage limits that
apply to the item or service. The annual limit is determined by
the benefit category to which the item or service is assigned
(column F) and the parameters for that benefit category
specified in the BENEFIT_DESIGN worksheet.
The number of claims for the specified item or service that
have already been submitted and covered by the plan for the
year which the line-item was received.¹
An indicator of whether the item or service is not covered
because the number of claims has exceed the annual limit.
The value of the amount for the item or service that is not
covered because the number of claims has exceed the use limit.
The difference between the covered amount (column AC) and
not covered amount for the item or service (column AL).
Note that coverage limits are applied as if the only services that a consumer has received are the services listed in each coverage example.
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Table 3.6.6. Phase 5. Apply the required deductible
Column Column Heading
Description
AN
Uses plan deductible?
Indicator of whether the plan-level deductible applies to the
item or service based on its benefit category (column F) and the
cost sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
AO
Plan deductible
The value of the plan deductible that applies to the item or
service based on its benefit category (column F) and the cost
sharing parameters for that benefit category from the BENEFIT
_DESIGN worksheet.
AP
Remaining plan
The amount of the plan deductible that remains after all
deductible after previous previous charges against the plan deductible have been taken.
subscriber payments
AQ
Subscriber pays toward
If the plan deductible applies to the service, it is the lesser of 2
plan deductible
values: the remaining plan deductible (column AP) and the
covered amount (column AM).
AR
Uses Rx deductible?
Indicator of whether the Rx deductible applies to the item or
service based on its benefit category (column F) and the cost
sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
AS
Rx deductible?
The value of the Rx deductible that applies to the item or
service based on its benefit category (column F) and the cost
sharing parameters for that benefit category from the BENEFIT
_DESIGN worksheet.
AT
Remaining Rx deductible The amount of the Rx deductible that remains after all previous
after previous subscriber charges against the plan deductible have been taken.
payments?
AU
Subscriber pays toward
If the Rx deductible applies to the service, it is the lesser of 2
Rx deductible
values: the remaining Rx deductible (column AM) and the
covered amount (column AT).
AV
Uses deductible C?
Indicator of whether Deductible C applies to the item or service
based on its benefit category (column F) and the cost sharing
parameters for that benefit category from the BENEFIT_DESIGN
worksheet.
AW
Deductible C
The value of deductible C that applies to the item or service
based on its benefit category (column F) and the cost sharing
parameters for that benefit category from the BENEFIT
_DESIGN worksheet.
The amount of Deductible C that remains after all previous
AX
Remaining deductible C
after previous subscriber charges against the plan deductible have been taken.
payments
AY
Subscriber pays toward
If deductible C applies to the item or service, it is the lesser of 2
deductible C
values: the remaining Deductible C (column AX) and the
covered amount (column AM).
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Column Column Heading
AZ
Uses deductible D?
BA
Deductible D
BB
BD
Remaining Deductible D
after previous subscriber
payments
Subscriber pays toward
deductible D
Uses benefit deductible?
BE
Benefit deductible
BF
Remaining benefit
deductible after previous
subscriber payments
Subscriber pays toward
benefit deductible
Subscriber pays toward
any deductible
BC
BG
BH
BI
Subscriber-paid
deductible after applying
OPL
16
Description
Indicator of whether Deductible D applies to the item or service
based on its benefit category (column F) and the cost sharing
parameters for that benefit category from the BENEFIT_DESIGN
worksheet.
The value of deductible D that applies to the item or service
based on its benefit category (column F) and the cost sharing
parameters for that benefit category from the BENEFIT
_DESIGN worksheet.
The amount of Deductible D that remains after all previous
charges against the plan deductible have been taken.
The value the subscriber pays towards deductible D for an item
or service.
Indicator of whether a benefit-category deductible applies to
the item or service based on its benefit category (column F) and
the cost sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
The amount of the benefit deductible that applies to the item
or service based on its benefit category (Column F) in the cost
sharing parameters for that benefit category from the
BENEFIT_DESIGN worksheet.
The amount of any benefit-category deductible that remains
after all previous charges against the plan deductible have been
taken.
The value the subscriber pays towards the deductible for an
item or service.
The amount of the consumer liability under any deductible.
Equal to the sum of the amount paid toward the plan
deductible, the Rx deductible, deductible C, deductible D, or
specific benefit-category deductibles.
The amount of the consumer liability under any deductible.
Equal to the sum of the amount paid toward the plan
deductible, the Rx deductible, deductible C, deductible D, or
specific benefit-category deductibles and is capped at the outof-pocket limit.
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Table 3.6.7. Phase 6. Apply the Copay and Coinsurance
Column Column Heading
Description
BJ
Remaining OPL
The amount of OPL that remains after all previous charges
against the OPL have been taken.
BK
The amount that remains after the deductibles.
BL
Covered Amount
remaining after
deductibles
Uses Copay?
BM
Copay Value
BN
Copay paid
BO
Uses coinsurance?
Indicator of whether the plan design entered uses a copay for
the benefit category to which the service is part of.
BP
Coinsurance value
BQ
Coinsurance paid
The value of the coinsurance for the benefit category to which
the item or service is assigned in the BENEFIT_DESIGN
worksheet.
The amount of coinsurance paid by the subscriber.
BR
Subscriber-paid cost
sharing after OPL
The value the subscriber pays after applying the out-of-pocket
limit.
An indicator of whether a copay applies to this benefit
category based on the benefit category to which the item or
service is assigned (column F) and the benefit parameters
specified for that benefit category in the BENEFIT_DESIGN
worksheet
The copayment amount that applies to the item or service
based on the benefit category to which the item or service is
assigned (column F) and the parameters for that benefit
category specified in the BENEFIT_DESIGN worksheet.
The amount of copay paid by the subscriber.
Table 3.6.8. Phase 7. Calculate the subscriber and the plan payment
Column Column Heading
Description
BS
Remaining OPL
If the out-of-pocket limit applies to the item or service the
lesser of the amount subject to OPL and the subscriber
payment before application of the OPL.
BT
BU
Allowed amount after
copayment or
coinsurance
Total subscriber payment
after OPL
Total remaining allowed amount after application of
copayment or coinsurance, after applying deductible.
If the out-of-pocket limit applies to the item or service the
lesser of the amount subject to OPL and the subscriber
payment before application of the OPL.
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Table 3.6.9. Phase 8. Summarize Payments by Payer and Phase Category
Column Column Heading
Description
BV
Plan payment
The difference between the covered amount and the subscriber
payment after application of the out-of-pocket limit.
BW
Service not covered
The amount of the allowed charge if the item or service is not
covered.
BX
Exclusions
The amount of the allowed charge if the item or service was
subject to coverage limitations.
BY
Subscriber-paid
The subscriber-paid deductible after applying the out-of-pocket
deductible
limit (column BI).
BZ
Subscriber-paid
copayment
The sum of the copays paid by the subscriber (column Z and
column BN).
CA
Subscriber-paid
coinsurance
The subscriber-paid coinsurance (column BQ).
CB
Allowable charge
chkSum
Checks that the sum of the plan and subscriber payments for
each item or service is equal to the allowed amount for the
service.
3.7
Item or
Service
Code
The LINE_ITEM worksheets
1
Diagnosis Code
(ICD-9)
2
3
650, V27.0
4 650, V27.0, Proc: 73.59
5 650, V27.0, Proc: 73.59
6 650, V27.0, Proc: 73.59
7
8
CPT©, HCPCS, or
Other Billing Code
378710401
Provider
Type
Pharmacy Retail
591346601
Pharmacy Retail
S9443
795
1967
59400
OTC
OTC
Inpatient Facility
Inpatient Facility
Anesthesiology
OBGYN
Pharmacy Retail
Pharmacy Retail
Allowed
Description
Amount
Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H
6.45
PRN; 15 pills]
Prescription Drugs: Generic
Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60
11.69
pills]
Preventive Services & Vaccines
Lactation class
0.00
Inpatient Hospital Care (Facility)
Normal newborn
1,756.00
Professional Services: Procedures & Other
Anesth/analg vag delivery
1,008.00
Professional Services: Obstetric Care (BundledObstetrical Care
2,394.18
Over-the-counter Drugs
Docusate sodium (OTC) [1 pill QD]
11.20
Over-the-counter Drugs
Prenatal Vitamins (OTC - Bottle of 100) [1 pill
12.21
daily; 30 pills/month]
Category
Prescription Drugs: Generic
The MATERNITY_LINE_ITEM worksheet, DIABETES_LINE_ITEM worksheet and FRACTURE_LINE_ITEM
worksheet contain the list of items and services that appear in the TIMELINE worksheets for each
coverage example. The LINE_ITEM worksheets describe each item and service, identify the benefit
category (which can be modified by the user by making use of the drop-down menus in column E), and
the allowed amount. Table 3.7 describes the columns in these worksheets.
Table 3.7. LINE_ITEM worksheet columns
Column Column Heading
Description
A
Item or Service Code
The code for the item or service. Corresponds to the codes for
the item or service in column D of the corresponding TIMELINE
worksheet.
B
Diagnosis Code
When applicable an ICD-10 diagnosis code related to the item
(ICD-10)
or service. This is informational.
C
CPT©, HCPCS, or
The “standard” procedure code for the item or service. This is
Other Billing Code
informational.
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Column Column Heading
D
Provider
Type
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19
Description
The type of provider that typically provides the service. This is
informational.
E
Benefit Category
The benefit category to which the item or service is assigned by
default. The user can change the benefit category for individual
items or services using the drop down menu that is provided in
the cells in column E. Note that the user must select one of the
22 benefit categories used in the CECSC.
A brief description of the item or service.
F
Description
G
Allowed
Amount
The allowed amount for the item or service.
H
Notes
Brief comments provided for information only.
I
Valid Benefit Category
J
Timeline Count
An indicator that shows whether the benefit category assigned
to the item or service in column E is one of the 22 allowed
benefit categories. Provided as a check if the user changes the
default benefit category assigned to an item or service.
A count of the number of times the item or service (identified
by Item or service code (column A) appears in the related
TIMELINE worksheet.
Plan Benefit Parameters and the BENEFIT_DESIGN worksheet
In the BENEFIT_DESIGN worksheet, the coverage parameters for each coverage category are specified.
The coverage parameters include:
1. The type of cost sharing (cost sharing option) that applies to each benefit category. The CECSC
defines 19 standard cost sharing options (see §4.2).
2. The benefit-level deductible when a coverage option requiring a benefit-deductible is selected.
3. The co-payment amount when a coverage option requiring a co-payment is selected.
4. The co-payment amount when a coverage option requiring a co-payment is selected.
5. The monthly and annual coverage limits that apply to the benefit category.
6. Whether the benefit category falls under the plan’s out-of-pocket limit.
7. The plan-level deductibles that apply to the plan. Up to four plan-level deductibles may be
specified.
To select a cost sharing option for a benefit category, a user should make use of the drop-down menus
that are available when the cell specifying the type of cost sharing that applies is selected for that
benefit category. In Single Plan Mode only the allowed cost sharing options can be selected. (See Figure
4.1.)
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Figure 4.1. Use of drop-down menu to select cost sharing option
Trying to enter a cost sharing option that is not one of the 19 allowed options will trigger an error dialog
shown in Figure 4.2.
Figure 4.2. Error dialog for selection of invalid cost sharing option
Clicking the Retry button will let the user modify the data that have been entered. Clicking cancel will
restore the value that existed before the user tried to enter new data.
Depending on the cost sharing option that is selected, certain parameters either must or must not be
specified. Initially these parameters will not have been specified and the BENEFIT_DESIGN worksheet
will identify the “warnings” that result. These warnings may include parameters that must be but have
not been specified or parameters that have been but must not be specified. For example, Figure 4.3
shows the warnings that would appear if the cost sharing option for inpatient hospital care had been
changed from Plan Deductible Only to Deductible C plus Co-payment.
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Figure 4.3. Warnings associated with “incomplete” entry of benefit parameters
In this example, the user must specify a copayment amount for Inpatient Hospital Care and must specify
an amount for Deductible C.
Depending on the cost sharing option that is selected, the other parameters that are required will be
dark yellow. Parameters that are not permitted will be black and any data that has been entered will be
in red type. When the required data are entered or the prohibited data are deleted the warnings will
disappear.
4.1
Benefit Categories
The CECSC assigns claims to one of 22 benefit categories:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Inpatient Hospital Care (Facility)
Other Facility Services
Emergency Department (Facility)
Ambulance
Professional Services: Primary Care
Professional Services: Emergency Department
Professional Services: Inpatient
Professional Services: Specialist
Professional Services: Obstetric Care (Bundled)
Professional Services: Procedures & Other
Professional Services: Physical Therapy
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Prescription Drugs: Branded
Prescription Drugs: Insulin
Over-the-counter Drugs
Preventive Services & Vaccines
Durable Medical Equipment
Medical Supplies
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21. Over-the-counter Medical Supplies
22. Other Items & Services
Each line item or service code on the LINE_ITEM worksheets is assigned to one of these benefit
categories (in column E). The benefit category determines whether a plan covers the item or service, the
cost sharing requirements for the item or service under the plan, and what limits the plan applies to
coverage for that item or service. A user can customize the benefit categories to which each item or
service is assigned and can redefine the benefit categories that are used by the calculator as described in
Section 4.5.
4.2
Cost Sharing Options
The CECSC uses 19 standard coverage options as described in Table 4.2.
Table 4.2. Standard coverage options
Cost sharing option
Description
Not Covered
The benefit category is not covered by the plan.
No Cost Sharing
The benefit category identifies items and services that are
covered but that have no required cost sharing. An
example would be preventive services.
Plan Deductible Only
The benefit category identifies items and services that are
covered and that are subject to the plan-level deductible
but no coinsurance or copayment.
Rx Deductible Only
The benefit category identifies items and services that are
covered and that are subject to the prescription drug (Rx)
deductible but no coinsurance or copayment.
Deductible C Only
The benefit category identifies items and services that are
covered and that are subject to a third plan-level
deductible that applies to multiple benefit categories but
no coinsurance or copayment.
Deductible D Only
The benefit category identifies items and services that are
covered and that are subject to a fourth plan-level
deductible that applies to multiple benefit categories but
no coinsurance or copayment.
Benefit Deductible Only
The benefit category identifies items and services that are
covered and that are subject to a deductible that applies
only to the benefit category with no coinsurance or
copayment.
Copayment Only
The benefit category does not fall under any deductible
but does have a copayment.
Coinsurance Only
The benefit category does not fall under any deductible
but does require a coinsurance payment.
Plan Deductible+Co-pay
The benefit category identifies items and services that are
covered and that are subject to the plan-level deductible
and to a copayment.
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Cost sharing option
Rx Deductible+Co-pay
Deductible C+Co-pay
Deductible D+Co-pay
Benefit Deductible+Co-pay
Plan Deductible+Co-ins
Rx Deductible+Co-ins
Deductible C+Co-ins
Deductible D+Co-ins
Benefit Deductible+Co-ins
23
Description
The benefit category identifies items and services that are
covered and that are subject to the prescription drug (Rx)
deductible and to a copayment.
The benefit category identifies items and services that are
covered and that are subject to a third plan-level
deductible that applies to multiple benefit categories and
to a copayment.
The benefit category identifies items and services that are
covered and that are subject to a fourth plan-level
deductible that applies to multiple benefit categories and
to a copayment.
The benefit category identifies items and services that are
covered and that are subject to a deductible that applies
only to the benefit category and to a copayment.
The benefit category identifies items and services that are
covered and that are subject to the plan-level deductible
and to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to the prescription drug (Rx)
deductible and to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to a third plan-level
deductible that applies to multiple benefit categories and
to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to a fourth plan-level
deductible that applies to multiple benefit categories and
to a coinsurance payment.
The benefit category identifies items and services that are
covered and that are subject to a deductible that applies
only to the benefit category and to a coinsurance
payment.
Deductible amounts (of any type) must be entered as dollars and cents. Copayment amounts must be
entered as dollars and cents. Coinsurance amounts must be entered as values greater than zero and less
than or equal to 1.00, i.e. 30% must be entered as 0.30 or 30%.
4.3 Additional Cost Sharing Options
In addition to the standard cost sharing options, the CECSC allows the user to input special cost sharing
for the Professional services: Primary Care benefit category.
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Figure 4.4 Special Cost-Sharing Options
Table 4.3 Special Cost-Sharing Options
Cost Sharing Option
Begin Primary Care Cost-Sharing After A Set
Number of Visits?
Begin Primary Care Cost-Sharing Deductible or
Coinsurance After a Set Number of Copays?
4.3
Description
Cost sharing specified for the primary care
benefit category is applied only after a certain
number of primary care visits. Primary care visits
prior to the number of visits indicated are 100%
covered by the plan.
Cost-sharing specified for the primary care
benefit category is applied only after a certain
number of copays.
Coverage limits
Data for coverage limits must be entered for all services that are covered. (Coverage limits cannot be
entered for services that are not covered. Doing so will create a warning.)
If no coverage limit applies, “None” must be entered as the monthly and annual coverage limit.
If a monthly but not an annual coverage limit applies, an integer of 1 or greater must be entered in the
“per month” coverage limit column and “None” must be entered in the “per year” coverage limit
column.
If an annual but not a monthly coverage limit applies, an integer of 1 or greater must be entered in the
“per year” coverage limit column and “None” must be entered in the “per month” coverage limit
column.
If both monthly and annual coverage limits applies, an integer of 1 or greater must be entered in both
the “per month” coverage limit column and the “per year” coverage limit column.
4.4
Out-of-pocket Limits
If a benefit category contributes to the out-of-pocket limit, then “Yes” must be entered in the column
headed “OOP Limit applies?” If the benefit category does not contribute to the out-of-pocket limit, then
“No” must be entered in that column.
If the benefit category is not covered, the out-of-pocket limit column must be left blank.
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4.5
Customizing the Benefit Categories
25
A user may customize the cost calculator to better reflect the way a specific plan covers the items and
services specified on the LINE_ITEM worksheets for the three coverage examples. A user can customize
the benefit categories to which each item or service is assigned, and can redefine the benefit categories
the calculator uses.
4.5.1
Reassigning the Benefit Category for an item or service
The calculator allows each item or service listed in the LINE_ITEM worksheets for the three coverage
examples to be assigned to one of 22 benefit categories. A user can change the benefit category to which
an item or service is assigned on the LINE_ITEM worksheet.
For example, by default the coverage calculate assigns diabetic test strips to the Medical Supplies benefit
category. However, a user may change that category so that test trips are covered under the Over-thecounter Medical Supplies benefit category or under the Other Items & Services benefit category using
the drop-down list of benefit categories:
Note, a user must select one of the 22 listed benefit categories. These are the benefit categories that are
listed on the BENEFIT_DESIGN worksheet.
Note that the reassignment of an item or service to a benefit category using the LINE_ITEM worksheet
will apply only to the item or service in the coverage example. For example, influenza vaccination is a
line item in both the diabetes and maternity coverage examples. Changing the benefit category to which
influenza vaccination is assigned in the DIABETES_TIME_LINE will not change the benefit category to
which influenza vaccination is assigned in the MATERNITY_TIME_LINE.
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4.5.2
Redefining the Benefit Categories
26
Any of the 22 benefit categories can be redefined in the calculator. The only limitation imposed by the
calculator is that the number of benefit categories cannot exceed 22. However, if a plan needs to define
a specific benefit category for Diabetic Supplies it can do so by following a two-step procedure.
Step one is to change the labels that are used to identify the benefit categories on the BENEFIT_DESIGN
worksheet. For example, a user might want to use the Other Items & Services benefit category:
to identify Diabetes Supplies:
This changes makes the benefit category Diabetes Supplies available for use in the calculator. However,
it also means that the benefit category Other Items & Services is no longer available and any item or
service that is assigned to the Other Items & Services benefit category in a LINE_ITEM worksheet must
be re-assigned either to Diabetes Supplies or to another of the benefit categories listed on the
BENEFIT_DESIGN worksheet.
Step 2 is to change the benefit category for the items and services that are to be paid under the new
Diabetes Supplies benefit category. In this example, the user will modify the benefit categories to which
the items on the DIABETES_LINE_ITEM worksheet are assigned. These items and services may include
lancing devices, test strips, lancets, control solutions, and syringes. The user must change the benefit
category for each of those items to Diabetes Supplies using the drop-down menu.
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The re-designated benefit category Diabetes Supplies will now be an available option in the drop-down
list.
A user can, in fact, redefine all 22 of the benefit categories to better match the categories that the plan
uses. However, in this case the user will need to make extensive revisions to the TIME_LINE worksheets
so that every item or service is correctly mapped to one of the newly defined benefit categories.
CAUTION: If a user changes the designation for a benefit category that is used by multiple coverage
examples (for example, both the FRACTURE example and the DIABETES example), any item or service
in any of the LINE_ITEM schedules that was assigned to the benefit category as it was originally
designated will need to be reassigned either to the new category or to another available category.
5.0
Multi-Plan Mode
When used in Multi-Plan Mode, the CECSC allows a user to populate the PLAN_INPUT_DATA worksheet
with benefit parameters for multiple plans.
This worksheet may be populated by importing a tab-separated text file containing the benefit
parameter data (see Appendix B) or by directly entering data on the PLAN_INPUT_DATA worksheet.
(Directly entering data into the PLAN_INPUT_DATA worksheet is not recommended as 146 variables or
columns must be completed for each plan.)
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Figure 5.0. PLAN_INPUT_DATA worksheet
Run Calculator
PLAN_ID
Plan 1
Plan 2
Plan 3
This worksheet contains the benefit parameters for multiple plans.
You can copy and paste data for individual plans from an external source starting on ro
Plan deductible Rx deductible
$1,000.00
$1,000.00
$100.00
Deductible C
$500.00
Deductible D
OOP Limit
$5,000.00
$5,000.00
The first 7 rows of the PLAN_INPUT_DATA worksheet contain a button that will run the calculator and
generate output for the plans whose parameters are listed starting on row 8. Rows 6 and 7 are the
“header” for the plan parameter data.
WARNING: Do NOT separate groups of plans by using a blank row. A blank row is interpreted by the
CECSC as signaling the end of the entered data. Any data below a blank row will be ignored by the
CECSC.
The plan parameter data are divided into 23 groups.
1. Plan-level parameters (Columns A through F): the plan identifier, the plan deductible, the Rx
deductible, Deductible C, Deductible D, and the out-of-pocket limit (if any) that applies to the
plan.
2. Inpatient hospital care coverage parameters (columns G through M):
a. The cost sharing option or type (column G)
b. Benefit deductible (if required by the cost sharing option) (column H)
c. Copayment amount (if required by the cost sharing option) (column I)
d. Coinsurance rate (if required by the cost sharing option) (column J)
e. The monthly coverage limit (if required by the cost sharing option) (column K)
f. The annual coverage limit (if required by the cost sharing option) (column L)
g. Whether the out-of-pocket limit applies(column M)
3. Other Facility Services coverage parameters (columns N through T)
4. Emergency Department (Facility) (columns U through AA)
5. Ambulance (columns AB through AH)
6. Professional Services: Primary Care (columns AI through AO)
7. Professional Services: Emergency Department (columns AP through AV)
8. Professional Services: Inpatient
9. Professional Services: Specialist (columns AW through BC)
10. Professional Services: Obstetric Care (Bundled) (columns BD through BJ)
11. Professional Services: Procedures & Other (columns BK through BQ)
12. Professional Services: Physical Therapy (columns BR through BX)
13. Diagnostic Services: Radiology (columns BY through CE)
14. Diagnostic Services: Laboratory (columns CF through CL)
15. Prescription Drugs: Generic (columns CM through CS)
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16.
17.
18.
19.
20.
21.
22.
23.
29
Prescription Drugs: Branded (columns CT through CZ)
Prescription Drugs: Insulin (columns (DA through DG)
Over-the-counter Drugs (columns DA through DG)
Preventive Services & Vaccines (columns GH through DN)
Durable Medical Equipment (columns DO through DU)
Medical Supplies (columns DV through EB)
Over-the-counter Medical Supplies (columns EC through EI)
Other Items & Services (columns EJ through EP)
An external data file that will be imported using Multi-Plan Mode Option 1 must be a tab-separated
value file consisting of 146 “fields” or “variables” corresponding to the above.
5.1
Browsing and reviewing Multi-Plan Mode input data
Once the plan parameter data for multiple plans have been loaded into the PLAN_INPUT_DATA
worksheet, the BENEFIT_DESIGN worksheet can be used to browse and review the plan input data. As
each plan is loaded, error checking will be performed and any errors will be identified by “warning”
notices in the BENEFIT_DESIGN worksheet.
If errors exist in the input data for a plan, the output data will simply indicate ERROR.
5.2
Generating output in Multi-Plan Mode
To generate output in Multi-Plan Mode the user will click the Run Calculator button that is found on the
PLAN_INPUT_DATA worksheet or the PLAN_OUTPUT_DATA worksheet, or the user can click the View
Output Data button or the Export Data button on the RESULTS_SUMMARY worksheet.
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30
Appendix A: Overview of the Coverage Examples Calculator Logic
The Coverage Examples Cost Sharing Calculator (the Calculator) calculates the subscriber and plan
payment for a claim (i.e., the claim for a service provided on a specified date) for a subscriber with selfonly coverage in eight phases:
1. Determine the covered amount.
2. Apply the out-of-pocket limit.
3. Apply special cost-sharing
a. Begin primary cost-sharing after a set number of visits?
b. Begin primary cost-sharing after a set number of copays?
4. Apply the monthly and annual coverage limits.
5. Apply the required deductible.
6. Apply the required co-payment or co-insurance.
7. Calculate the subscriber and the plan payment.
8. Summarize payments by payer and phase category.
The following sections describe the Calculator logic for each phase.
Phase 1: Determine the covered amount
For the line item, the Calculator looks up the benefit category (broadly speaking, the benefit that the
line item falls under) that applies to the Item or Service Code in the associated “line item” charge
schedule. It then looks up the coverage that applies to the benefit category. The calculator determines
the amount that is covered for each item or service.
Phase 2: Apply the out-of-pocket limit
The Calculator determines, based on the benefit category that applies to the line item, whether the
claim is subject to the out-of-pocket limit. For each line item the out-of-pocket limit applies to, the
calculator determines the remaining out-of-pocket limit by deducting the allowed amount from the
previous line item.
Phase 3: Apply special cost-sharing
The plan determines whether the claim is subject to special cost sharing. The calculator determines
whether special cost sharing has been specified. If special cost sharing has been specified by the benefit
design, the calculator counts the number of visits or copays specified in the BENEFIT_DESIGN worksheet
for each line item that has been classified as Professional Services: Primary Care and applies primary
care cost-sharing once the number of visits or copays has been reached.
Phase 4: Apply the monthly and annual coverage limits
Based on the coverage that applies to the benefit category, the Calculator looks up the monthly limit
that applies to the line item. It calculates the total number of claims for the same service that have been
provided during the same month as the current claim. If the total number of claims is less than the
monthly limit or if the plan does not apply a monthly limit, the claim is covered by the plan and nothing
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix A: Overview of the Coverage Examples Calculator Logic
31
accrues to the subscriber. If the total number of claims equals or exceeds the monthly limit, the
allowable charge accrues to the subscriber.
Based on the coverage that applies to the benefit category, the Calculator looks up the annual limit that
applies to the line item. It calculates the total number of claims for the same service that have been
provided during the same year as the current claim. If the total number of claims is less than the annual
limit or if the plan does not apply an annual limit, the claim is covered by the plan and nothing accrues
to the subscriber. If the total number of claims equals or exceeds the annual limit, the allowable charge
accrues to the subscriber.
Phase 5: Apply the required deductible
The amount of the allowed amount that is subject to the deductible is equal to the allowed amount less
any copayment or coinsurance that has accrued to the subscriber.
The application of the appropriate deductible proceeds in five stages corresponding to each of the five
deductibles that may apply to a line item. The benefit design may subject each line item to one of five
deductibles or to no deductible. These five deductibles are:
1.
2.
3.
4.
5.
The overall plan deductible;
The prescription drug deductible;
An optional deductible (e.g., that applies to Emergency Services) referred to as deductible C;
An optional deductible (e.g., that applies to Physician Services) referred to as deductible D;
A deductible that applies only to the benefit category.
The calculator determines whether the overall plan deductible applies to the line item based on the
benefit category for the line item. If the overall plan deductible applies, the calculator obtains the plan
deductible and deducts any payments that counted toward the plan deductible for items and services
that were received prior to the line-item being adjudicated. If the remaining plan deductible is greater
than the allowed amount that is subject to the deductible, the amount subject to the deductible accrues
to the subscriber. If the remaining plan deductible is less than the allowed amount that is subject to the
deductible, the amount of the remaining plan deductible accrues to the subscriber.
This same procedure is repeated for each of the remaining deductibles.
Phase 6: Apply copay and coinsurance
If the line-item is covered by the plan and is not subject to the monthly or annual limit, the Calculator
looks up the co-payment that applies to the line item based on the coverage that applies to the benefit
category. If the copayment amount is greater than zero, the amount of the copayment accrues to the
subscriber.
If the line item is covered by the plan and is not subject to the monthly or annual limit, the Calculator
looks up the co-insurance rate that applies to the line item based on the coverage that applies to the
benefit category. If the insurance rate is greater than zero, the amount of the coinsurance that accrues
to the subscriber is calculated by multiplying the coinsurance rate by the allowable amount.
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix A: Overview of the Coverage Examples Calculator Logic
32
Phase 7: Calculate the total subscriber payment
Calculates the remaining covered allowed amount and subscriber-paid amounts after applying
subscriber cost-sharing from previous steps.
Phase 8: Summarize payments by payer and phase category
The amount of any subscriber liability is allocated to the reporting categories (i.e., not covered or
exclusions, coinsurance, copayment, or deductibles) by comparing the amount of the subscriber’s
liability that is determined at each step to the amount of the subscriber’s liability after application of the
out-of-pocket limit.
If the subscriber is liable for the claim because the monthly or annual limits have been exceeded, the
amount of the allowed amount up to the amount of the total subscriber liability after application of the
out-of-pocket limit is allocated to “exclusions”.
If the subscriber was not liable for the claim because the monthly or annual limits have been exceeded,
and the amount of copayment is less than or equal to the amount of the total subscriber liability after
application of the out-of-pocket limit, the amount of the copayment up to the total subscriber liability
after application of the out-of-pocket limit is allocated to “co-payments”.
If the subscriber was not liable for the claim because the monthly or annual limits have been exceeded,
and the amount of coinsurance is less than or equal to the amount of the total subscriber liability after
application of the out-of-pocket limit, the amount of the coinsurance up to the total subscriber liability
after application of the out-of-pocket limit is allocated to “co-insurance”.
If the subscriber was not liable for the claim because the monthly or annual limits have been exceeded,
and the amount of the allowed amount that was charged against deductibles is less than or equal to the
amount of the total subscriber liability after application of the out-of-pocket limit less the amount of any
coinsurance or deductible, the amount of the allowed amount that was charged against deductibles up
to the total subscriber liability after application of the out-of-pocket limit is allocated to “deductibles”.
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
33
Appendix B: PLAN_INPUT_DATA external data file specifications
Table B-1 specifies the required data elements and formats for an external data file of plan parameters.
This file must have no header and no trailer. It should contain only plan parameter data.
Table B-1. Layout of PLAN_INPUT_DATA external data file
Column Data category
Variable
1
Plan-level
PLAN_ID
parameters
2
Plan-level
Plan deductible
parameters
3
Plan-level
Rx deductible
parameters
4
Plan-level
Deductible C
parameters
5
Plan-level
Deductible D
parameters
6
Plan-level
OOP Limit
parameters
7
Inpatient Hospital
Cost sharing Type
Care (Facility)
8
Inpatient Hospital
Benefit Deductible
Care (Facility)
9
Inpatient Hospital
Co-payment
Care (Facility)
10
Inpatient Hospital
Co-insurance
Care (Facility)
11
Inpatient Hospital
Monthly Limits
Care (Facility)
12
Inpatient Hospital
Annual Limits
Care (Facility)
13
Inpatient Hospital
OOP Limit Applies
Care (Facility)
14
Other Facility
Cost sharing Type
Services
15
Other Facility
Benefit Deductible
Services
16
Other Facility
Co-payment
Services
17
Other Facility
Co-insurance
Services
18
Other Facility
Monthly Limits
Services
19
Other Facility
Annual Limits
Services
20
Other Facility
OOP Limit Applies
Services
Coverage-Examples-Cost-Sharing-Calculator
Allowable values
Alphanumeric
Blank or numeric
Blank or numeric
Blank or numeric
Blank or numeric
Blank or numeric
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
Column
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Data category
Emergency
Department
(Facility)
Emergency
Department
(Facility)
Emergency
Department
(Facility)
Emergency
Department
(Facility)
Emergency
Department
(Facility)
Emergency
Department
(Facility)
Emergency
Department
(Facility)
Ambulance
Ambulance
Ambulance
Ambulance
Ambulance
Ambulance
Ambulance
Professional
Services: Primary
Care
Professional
Services: Primary
Care
Professional
Services: Primary
Care
Professional
Services: Primary
Care
Professional
Services: Primary
Care
34
Variable
Cost sharing Type
Allowable values
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
Benefit Deductible
Co-payment
Co-insurance
Monthly Limits
Annual Limits
OOP Limit Applies
Cost sharing Type
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
Column
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
Data category
Professional
Services: Primary
Care
Professional
Services: Primary
Care
Professional
Services: Emergency
Department
Professional
Services: Emergency
Department
Professional
Services: Emergency
Department
Professional
Services: Emergency
Department
Professional
Services: Emergency
Department
Professional
Services: Emergency
Department
Professional
Services: Emergency
Department
Professional
Services: Inpatient
Professional
Services: Inpatient
Professional
Services: Inpatient
Professional
Services: Inpatient
Professional
Services: Inpatient
Professional
Services: inpatient
Professional
Services: Inpatient
Professional
Services: Specialist
Professional
Services: Specialist
35
Variable
Annual Limits
Allowable values
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, “None” or numeric
Annual Limits
Blank, “None” or numeric
OOP Limit Applies
Blank, “Yes” or “No”
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
Column
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
Data category
Professional
Services: Specialist
Professional
Services: Specialist
Professional
Services: Specialist
Professional
Services: Specialist
Professional
Services: Specialist
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Obstetric
Care (Bundled)
Professional
Services: Procedures
& Other
Professional
Services: Procedures
& Other
Professional
Services: Procedures
& Other
Professional
Services: Procedures
& Other
Professional
Services: Procedures
& Other
36
Variable
Co-payment
Allowable values
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
Column
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
Data category
Professional
Services: Procedures
& Other
Professional
Services: Procedures
& Other
Professional
Services: Physical
Therapy
Professional
Services: Physical
Therapy
Professional
Services: Physical
Therapy
Professional
Services: Physical
Therapy
Professional
Services: Physical
Therapy
Professional
Services: Physical
Therapy
Professional
Services: Physical
Therapy
Diagnostic Services:
Radiology
Diagnostic Services:
Radiology
Diagnostic Services:
Radiology
Diagnostic Services:
Radiology
Diagnostic Services:
Radiology
Diagnostic Services:
Radiology
Diagnostic Services:
Radiology
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
37
Variable
Annual Limits
Allowable values
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
Column
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
Data category
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Prescription Drugs:
Generic
Prescription Drugs:
Generic
Prescription Drugs:
Generic
Prescription Drugs:
Generic
Prescription Drugs:
Generic
Prescription Drugs:
Generic
Prescription Drugs:
Generic
Prescription Drugs:
Branded
Prescription Drugs:
Branded
Prescription Drugs:
Branded
Prescription Drugs:
Branded
Prescription Drugs:
Branded
Prescription Drugs:
Branded
Prescription Drugs:
Branded
Prescription Drugs:
Insulin
Prescription Drugs:
Insulin
Prescription Drugs:
Insulin
Prescription Drugs:
Insulin
38
Variable
Co-payment
Allowable values
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix B: PLAN_INPUT_DATA external data file specifications
Column
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
Data category
Prescription Drugs:
Insulin
Prescription Drugs:
Insulin
Prescription Drugs:
Insulin
Over-the-counter
Drugs
Over-the-counter
Drugs
Over-the-counter
Drugs
Over-the-counter
Drugs
Over-the-counter
Drugs
Over-the-counter
Drugs
Over-the-counter
Drugs
Preventive Services
& Vaccines
Preventive Services
& Vaccines
Preventive Services
& Vaccines
Preventive Services
& Vaccines
Preventive Services
& Vaccines
Preventive Services
& Vaccines
Preventive Services
& Vaccines
Durable Medical
Equipment
Durable Medical
Equipment
Durable Medical
Equipment
Durable Medical
Equipment
Durable Medical
Equipment
Durable Medical
Equipment
39
Variable
Monthly Limits
Allowable values
Blank, “None” or numeric
Annual Limits
Blank, “None” or numeric
OOP Limit Applies
Blank, “Yes” or “No”
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix C: PLAN_OUTPUT_DATA external data file
Column
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
Data category
Durable Medical
Equipment
Medical Supplies
Medical Supplies
Medical Supplies
Medical Supplies
Medical Supplies
Medical Supplies
Medical Supplies
Over-the-counter
Medical Supplies
Over-the-counter
Medical Supplies
Over-the-counter
Medical Supplies
Over-the-counter
Medical Supplies
Over-the-counter
Medical Supplies
Over-the-counter
Medical Supplies
Over-the-counter
Medical Supplies
Other Items &
Services
Other Items &
Services
Other Items &
Services
Other Items &
Services
Other Items &
Services
Other Items &
Services
Other Items &
Services
40
Variable
OOP Limit Applies
Allowable values
Blank, "Yes" or "No"
Cost sharing Type
Benefit Deductible
Co-payment
Co-insurance
Monthly Limits
Annual Limits
OOP Limit Applies
Cost sharing Type
See note 1
Blank or numeric
Blank or numeric
Blank or numeric
Blank, "None" or numeric
Blank, "None" or numeric
Blank, "Yes" or "No"
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Cost sharing Type
See note 1
Benefit Deductible
Blank or numeric
Co-payment
Blank or numeric
Co-insurance
Blank or numeric
Monthly Limits
Blank, "None" or numeric
Annual Limits
Blank, "None" or numeric
OOP Limit Applies
Blank, "Yes" or "No"
Note 1: One of the 19 cost sharing options listed in §4.2, Table 4.2. Must match the spelling of one of the 19 options.
Appendix C: PLAN_OUTPUT_DATA external data file
The CECSC generates an external data file containing the output data for the plans listed in the
PLAN_INPUT_DATA worksheet. (NOTE: when the CECSC generates output data it also generates a
corresponding PLAN_INPUT_DATA file. Therefore be careful not to overwrite an input data file.)
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
Appendix C: PLAN_OUTPUT_DATA external data file
41
The CECSC output data file consists of a tab-separated text file containing 19 variables. These
correspond to the data that are generated and stored on the PLAN_OUTPUT_DATA worksheet. The
outputs from the CECSC can be used to populate the Deductibles, Copayments, Coinsurance, Limits or
Exclusions, and Total [patient] would pay is sections of the coverage example in the SBC.
1. The plan identifier (PLAN_ID)
2. Six output variables for the Maternity example:
a. The amount of the plan payment
b. The amount of the subscriber payment
c. The amount of the subscriber payment attributable to deductibles
d. The amount of the subscriber payment attributable to co-payment
e. The amount of the subscriber payment attributable to co-insurance
f. The amount of the subscriber payment attributable to exclusions and non-covered
items and services
3. Six output variables for the Diabetes example:
a. The amount of the plan payment
b. The amount of the subscriber payment
c. The amount of the subscriber payment attributable to deductibles
d. The amount of the subscriber payment attributable to co-payment
e. The amount of the subscriber payment attributable to co-insurance
f. The amount of the subscriber payment attributable to exclusions and non-covered
items and services
4. Six output variables for the Foot Fracture example:
a. The amount of the plan payment
b. The amount of the subscriber payment
c. The amount of the subscriber payment attributable to deductibles
d. The amount of the subscriber payment attributable to co-payment
e. The amount of the subscriber payment attributable to co-insurance
f. The amount of the subscriber payment attributable to exclusions and non-covered
items and services
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 [0.02] 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.
Coverage-Examples-Cost-Sharing-Calculator
Rev. 3.01
| File Type | application/pdf |
| File Title | Coverage Examples Cost Sharing Calculator Information Packet |
| Subject | SBC, Calculator, Cost Sharing, Examples |
| Author | CMS |
| File Modified | 2022-05-13 |
| File Created | 2020-01-28 |