Having-a-Baby-Guide-051222 508

OMB control number: 0938-1146
Expiration date: XX/XX/20XX

Having a Baby Guide
Label and Assumptions
Instructions to Plans and Issuers: Do not modify this table. The numbers shown here come from the
Scenario table.
Table 1. Having a Baby Sample Care Costs
Having a Baby
Inpatient Hospital Care (Facility)
Professional Services: Inpatient
Professional Services: Obstetric Care (Bundled)
Diagnostic Services: Radiology
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Over-the-counter Drugs
Preventive Services & Vaccines
Total

Sample Care Costs

$7,061
$1,399
$2,610
$343
$1,153
$11
$61
$49
$12,687

Assumptions
The following are assumptions that all group health plans and insurance issuers must use for this
scenario. These assumptions are standard across all scenarios.
•
•
•
•
•
•
•
•
•
•
•

•

Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
All care is in-network and considered first tier (or the tier associated with the lowest level of cost
sharing), for those products that incorporate tiered provider networks.
No out-of-network charges or any other variation in sample care costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to
the nearest hundred.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the
nearest ten.
If applying the rounding rules causes the cost sharing amount displayed to exceed the actual
out-of-pocket 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 plan or issuer must complete
the calculations for that treatment scenario assuming that the patient is NOT participating in the
wellness program.

OMB Control Numbers 1545-0047, 1210-0147, and 0938-1146

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

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

Explanation of Scenario
• Total – the sum of allowed amounts for the listed items and services, which is cross-referenced
in the "Label and Assumptions" tab, where it is rounded.
• Date of Service – includes the day and month of service so plans and issuers understand the
order in which items or services are rendered.
• ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service.
• CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-thecounter medications are listed as OTC.
• Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item
or service by provider.
• Category – includes one of the categories listed on the "Categories" tab to classify each item or
service so it rolls up into the same category in the "Label and Assumptions" tab.
• Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for
a non-CPT billing code.
• Allowed Amount – includes an estimated national average allowed amount for each item or
service, which plans or issuers must use to calculate cost sharing.
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of
the American Medical Association.OMB Control Numbers 1545-0047, 1210-0147, and 0938-1146

Table 2. Having a Baby Scenario Timeline
Date of
Service

ICD-10
Diagnosis
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider
Type

Category

Description

Totals:

Allowed
Amount

$12,686.85

7-Jan

No data

OTC

Pharmacy
Retail

Over-thecounter Drugs

Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]

$11.48

1-Apr

Z3400

80055

OBGYN

Diagnostic
Services:
Laboratory

Obstetric Panel

$56.04

1-Apr

Z3400

87801

OBGYN

Diagnostic
Services:
Laboratory

Detect agnt mult
dna ampli

$119.67

1-Apr

Z3400

88175

OBGYN

Diagnostic
Services:
Laboratory

Cytopath c/v auto
fluid redo

$36.94

1-Apr

Z3400

86701

OBGYN

Diagnostic
Services:
Laboratory

HIV-1

$17.37

1-Apr

Z3400

36415

OBGYN

Diagnostic
Services:
Laboratory

Routine
Venipuncture

$5.30

1-Apr

Z3201

81025

OBGYN

Diagnostic
Services:
Laboratory

Urine Pregnancy
Test

$9.86

1-Apr

O80, Z370

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Obstetrical Care

$2,609.93

1-Apr

Z3400

87086

OBGYN

Diagnostic
Services:
Laboratory

Urin
culture/colony
count

$13.12

1-Apr

Z3400

81001

OBGYN

Diagnostic
Services:
Laboratory

Urinalysis auto
w/scope

$8.67

1-Apr

Z3400

87491

OBGYN

Diagnostic
Services:
Laboratory

Chlmd trach dna
amp probe

$44.48

Date of
Service

ICD-10
Diagnosis
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider
Type

Category

Description

Allowed
Amount

1-Apr

Z3400

87591

OBGYN

Diagnostic
Services:
Laboratory

N.gonorrhoeae
dna amp prob

7-Apr

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

7-Apr

No data

OTC

Pharmacy
Retail

Over-thecounter Drugs

Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]

$11.48

27-May

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

24-Jun

Z3400

82105

OBGYN

Diagnostic
Services:
Laboratory

Alpha-fetoprotein
serum

$23.21

24-Jun

Z3400

82677

OBGYN

Diagnostic
Services:
Laboratory

Assay of estriol

$28.67

24-Jun

Z3400

84702

OBGYN

Diagnostic
Services:
Laboratory

Chorionic
gonadotropin test

$24.94

24-Jun

Z3400

86336

OBGYN

Diagnostic
Services:
Laboratory

Inhibin A

$21.67

24-Jun

Z3400

81220

OBGYN

Diagnostic
Services:
Laboratory

CFTR gene
analysis, common
variants

24-Jun

Z3400

36415

OBGYN

Diagnostic
Services:
Laboratory

Routine
Venipuncture

24-Jun

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

$43.82

$595.43

$5.30

-

Date of
Service

ICD-10
Diagnosis
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider
Type

Category

Description

Allowed
Amount

6-Jul

No data

OTC

Pharmacy
Retail

Over-thecounter Drugs

Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]

$11.48

22-Jul

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

22-Jul

Z3400

76805

Radiology

Diagnostic
Services:
Radiology

OB US >/= 14
WKS SNGL FETUS

$209.73

19-Aug

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

16-Sep

Z3400

82947

OBGYN

Diagnostic
Services:
Laboratory

Assay Glucose
Blood Quant

16-Sep

Z3400

85025

OBGYN

Diagnostic
Services:
Laboratory

Complete cbc
w/auto diff wbc

$13.99

16-Sep

Z3400

82950

OBGYN

Diagnostic
Services:
Laboratory

Glucose Test

$10.03

16-Sep

Z3400

36415

OBGYN

Diagnostic
Services:
Laboratory

Routine
Venipuncture

$5.30

16-Sep

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

16-Sep

Z3400

76815

Radiology

Diagnostic
Services:
Radiology

133.68

30-Sep

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Ultrasound of
pregnant uterus,
1 or more
fetus(es)
Office/Outpatient
Visit Est

$8.21

-

Date of
Service

ICD-10
Diagnosis
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider
Type

Category

Description

Allowed
Amount

4-Oct

No data

OTC

Pharmacy
Retail

Over-thecounter Drugs

Prenatal Vitamins
(OTC - Bottle of
100) [1 pill daily;
30 pills/month]

$11.48

14-Oct

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

28-Oct

Z3400

87653

OBGYN

Diagnostic
Services:
Laboratory

Strep B DNA Amp
Probe

$61.22

28-Oct

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

28-Oct

Z23

90471

OBGYN

Preventive
Services &
Vaccines

Immunization
Admin

$28.56

28-Oct

Z23

90656

OBGYN

Preventive
Services &
Vaccines

Flu Vaccine N0
Preserv 3 & >

$20.20

11-Nov

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

18-Nov

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

25-Nov

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

2-Dec

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

Date of
Service

ICD-10
Diagnosis
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider
Type

Category

Description

Allowed
Amount

9-Dec

O80, Z370

1967

Anesthesiolo
gy

Professional
Services:
Inpatient

Anesth/analg vag
delivery

$1,399.34

9-Dec

Z3800

775

Inpatient
Facility

Inpatient
Hospital Care
(Facility)

Vaginal delivery
w/o complicating
diagnoses

$7,060.58

9-Dec

Z3400

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

11-Dec

No data

51991045757

Pharmacy
Retail

Over-thecounter Drugs

$15.10

11-Dec

No data

53746046605

Pharmacy
Retail

Prescription
Drugs: Generic

Polyethylene
Glycol 3350 [1
dose / 17 GM
daily]
Ibuprofen 800mg
(Rx) [1 pill Q8H
PRN; 30 pills]

11-Dec

No data

228298150

Pharmacy
Retail

Prescription
Drugs: Generic

Oxycodone/APAP
5mg/325mg (Rx)
[1 pill Q6H PRN;
15 pills]

$6.80

23-Dec

Z392

59400

OBGYN

Professional
Services:
Obstetric Care
(Bundled)

Office/Outpatient
Visit Est

-

$3.77

** Inpatient costs were calculated based on national averages using the indicated DRG codes. Additional variances
may occur based on how health plan hospital contracts are structured (e.g., case rate, per diems, percentage of
billed charges, etc.)

Provider Types
The following are the provider types to use in the “Scenario” table ~ "Provider Type" column to classify
each service by provider type. This aids group health plans and health insurance issuers in applying
benefits to each item and service.
Table 3. Having a Baby Provider Types
Provider Type
Pharmacy Retail
OBGYN
Radiology
Inpatient Facility
Anesthesiology

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

OMB Control Numbers 1545-0047, 1210-0147, and 0938-1146

Categories
The following are the categories to use in the “Scenario” table ~ "Category" column to classify each item
and service so it rolls up to the same category in the Coverage Example label in the "Label and
Assumptions" table. This facilitates consistency between the "Scenario" table and Coverage Example
label.
Table 4. Having a Baby Categories
Category
Over-the-counter Drugs
Diagnostic Services: Laboratory
Professional Services: Obstetric Care (Bundled)
Preventive Services & Vaccines
Professional Services: Inpatient
Prescription Drugs: Generic

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

OMB Control Numbers 1545-0047, 1210-0147, and 0938-1146

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