Summary of Benefits and Coverage

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Overview

Label and Assumptions
Scenario
Provider Types
Categories

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Sheet 1: Label and Assumptions

Having a baby (normal delivery)		Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab.
Sample care costs:
Hospital charges (mother)	$2,700
Routine obstetric care	$2,100
Hospital charges (baby)	$900
Anesthesia	$900
Laboratory Tests	$500
Prescriptions	$200
Radiology	$200
Vaccines, other preventive	$40
Total	$7,540
Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
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 hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
All medications are covered as generic equivalents if available.
If the plan has a wellness program that varies the deductibles, co-payments, co-insurance, or coverage for any of the services listed in a treatment scenario, the plan must complete the calculations for that treatment scenario assuming that the patient is participating in the wellness program. networks.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

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Sheet 2: Scenario

Medical Condition:			Maternity
Note: Services on this tab 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-9 Diagnosis Code – includes the ICD-9 code for each item or service. 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-the-counter 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. Notes – includes any special notes for an item or service. CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Totals:							$7,466.39
Date of Service	ICD-9 Diagnosis Code	ICD-10 Diagnosis Code	CPT©, HCPCS, or Other Billing Code	Provider Type	Category	Description	Allowed Amount	Notes
7-Jan			OTC	Pharmacy Retail	Pharmacy	Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month]	$30.00
1-Apr	V22.0	Z34.01	80055	OBGYN	Laboratory tests	Obstetric Panel	$54.24	80055 - Global OB panel code
1-Apr	V22.0	Z34.01	87801 x2	OBGYN	Laboratory tests	Detect agnt mult dna ampli	$9.45	Gonorrhea / Chlamydia screen
1-Apr	V22.0	Z34.01	88164	OBGYN	Laboratory tests	Cytopath TBS C/V Manual	$14.74	Pap smear
1-Apr	V22.0	Z34.01	86701	OBGYN	Laboratory tests	HIV-1	$12.94
1-Apr	V22.0	Z34.01	36415	OBGYN	Laboratory tests	Routine Venipuncture	$4.13
1-Apr	V72.42	Z32.01 Z34.01	81025	OBGYN	Laboratory tests	Urine Pregnancy Test	$8.87
1-Apr	V22.0	Z34.01	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
7-Apr	V22.0	Z34.01	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
7-Apr			OTC	Pharmacy Retail	Pharmacy	Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month]	$30.00
27-May	V22.0	Z34.01	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
24-Jun	V22.0	Z34.01	82105	OBGYN	Laboratory tests	Alpha-fetoprotein serum	$27.86	Maternal serum quad screen
24-Jun	V22.0	Z34.01	82677	OBGYN	Laboratory tests	Alssay of estriol	$26.63	Maternal serum quad screen
24-Jun	V22.0	Z34.01	84702	OBGYN	Laboratory tests	Chorionic gonadotropin test	$21.47	Maternal serum quad screen
24-Jun	V22.0	Z34.01	86336	OBGYN	Laboratory tests	Inhibin A	$22.50	Maternal serum quad screen
24-Jun	V22.0	Z34.01	83912	OBGYN	Laboratory tests	Genetic examination	$11.78	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	83891	OBGYN	Laboratory tests	Molecule isolate nucleic	$7.20	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	83900	OBGYN	Laboratory tests	Molecule nucleic ampli 2 seq	$31.84	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	83901 x13	OBGYN	Laboratory tests	Molecule nucleic ampli addon	$129.52	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	83914 x32	OBGYN	Laboratory tests	Mutation ident ola/sbce/aspe	$50.06	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	83909	OBGYN	Laboratory tests	Nucleic acid high resolute	$18.98	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	36415	OBGYN	Laboratory tests	Routine Venipuncture	$4.13	Cystic fibrosis screen
24-Jun	V22.0	Z34.01	Bundled in global OB package - 59400	OBGYN	Routne Obstetric Care	Office/Outpatient Visit Est	Bundled
6-Jul			OTC	Pharmacy Retail	Pharmacy	Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month]	$30.00
22-Jul	V22.0	Z34.02	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
22-Jul	V22.0	Z34.00	76805	Radiology	Radiology	OB US >/= 14 WKS SNGL FETUS	$176.11
19-Aug	V22.0	Z34.02	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
16-Sep	V22.0	Z34.02	82947	OBGYN	Laboratory tests	Assay Glucose Blood Quant	$6.43
16-Sep	V22.0	Z34.02	85025	OBGYN	Laboratory tests	Complete cbc w/auto diff wbc	$12.28
16-Sep	V22.0	Z34.02	82950	OBGYN	Laboratory tests	Glucose Test	$6.95
16-Sep	V22.0	Z34.02	36415	OBGYN	Laboratory tests	Routine Venipuncture	$4.13
16-Sep	V22.0	Z34.02	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
30-Sep	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
4-Oct			OTC	Pharmacy Retail	Pharmacy	Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month]	$30.00
14-Oct	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
20-Oct		Z32.2 Z34.03	S9442	Alternative Provider	Education	Birthing class	-
27-Oct		Z32.2 Z34.03	S9442	Alternative Provider	Education	Birthing class	-
28-Oct	V22.0	Z34.03	87653	OBGYN	Laboratory tests	Strep B DNA Amp Probe	$40.61
28-Oct	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
28-Oct	V04.81	Z23	90471	OBGYN	Vaccines, other preventive	Immunization Admin	$20.04
28-Oct	V04.81	Z23	90656	OBGYN	Vaccines, other preventive	Flu Vaccine N0 Preserv 3 & >	$15.04
1-Nov		Z32.2 Z34.03	S9442	Alternative Provider	Education	Birthing class	-
8-Nov		Z32.2 Z34.03	S9442	Alternative Provider	Education	Birthing class	-
11-Nov	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
18-Nov	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
25-Nov	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
2-Dec	V22.0	Z34.03	Bundled in global OB package - 59400	OBGYN	Routine Obstetric Care	Office/Outpatient Visit Est	Bundled
9-Dec	650 V27.0 Proc: 73.59	080 Z37.0 Proc: 10E0XZZ	01967	Anesthesiology	Anesthesia	Anesth/analg vag delivery	$905.62
9-Dec	650 V27.0 Proc: 73.59	080 Z37.0 Z39.01 Proc: 10E0XZZ	**(DRG) 795	Inpatient Facility	Hospital charges (baby)	Normal newborn	$851.56
9-Dec	V30.00	Z38.00	**(DRG) 775	Inpatient Facility	Hospital charges (mother)	Vaginal delivery w/o complicating diagnoses	$2,714.26
9-Dec	650 V27.0 Proc: 73.59	080 Z37.0 Proc: 10E0XZZ	59400	OBGYN	Routine Obstetric Care	Obstetrical Care	$2,084.28	59400 - Global OB package description/code
9-Dec	650 V27.0	Z34.03	S9443	Inpatient Facility	Education	Lactation class	-	Included in hospital rate**
11-Dec			OTC	Pharmacy Retail	Pharmacy	Docusate sodium (OTC) [1 pill QD]	$30.00
11-Dec			00591346601	Pharmacy Retail	Pharmacy	Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60 pills]	$17.52
11-Dec			00378710401	Pharmacy Retail	Pharmacy	Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H PRN; 15 pills]	$5.21
23-Dec	V24.2	Z39.2	Bundled in global OB package - 59400	OBGYN	Routine obstetric Care	Office/Outpatient Visit Est	Bundled	Post partum visit
** 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.)

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Sheet 3: Provider Types

The following are the provider types to use on the "Scenario" tab ~ "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.
Provider Type	What providers are covered under this Provider Type and other notes:
Anesthesiology
Inpatient Facility
Obstetrics/Gynecology
Pharmacy Retail
Radiology
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

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Sheet 4: Categories

The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to the same category in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" tab and Coverage Example label.
Category	What services are covered under this Category and other notes:
Hospital charges (mother)	Applies to maternity scenario only; other scenarios would use "Hospital charges"
Routine obstetric care	Applies to maternity scenario only; typically a bundled payment
Hospital charges (baby)	Applies to maternity scenario only; other scenarios would use "Hospital charges"
Anesthesia
Laboratory tests	Includes blood work
Prescriptions	Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not administered in a hospital, physician's office or other facility. Note, this category also includes over-the-counter drugs such as prenatal vitamins and other pharmacy items.
Radiology	Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays
Vaccines, other preventive
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146