Having a baby | Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab. | |
Sample Care Costs | ||
Inpatient Hospital Care (Facility) | $8,959 | |
Professional Services: Primary Care | $198 | |
Professional Services: Obstetric Care (Bundled) | $2,394 | |
Diagnostic Services: Radiology | $164 | |
Diagnostic Services: Laboratory | $882 | |
Prescription Drugs: Generic | $36 | |
Over-the-counter Drugs | $60 | |
Preventive Services & Vaccines | $37 | |
Total (unrounded) | $12,731 | |
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, 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 1545-2229, 1210-0147, and 0938-1146 |
Medical Condition: | Having a baby | ||||||
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. 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 |
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Totals: | $12,731.28 | ||||||
Date of Service | ICD-9 Diagnosis Code | ICD-10 Diagnosis Code | CPT©, HCPCS, or Other Billing Code | Provider Type | Category | Description | Allowed Amount |
7-Jan | OTC | Pharmacy Retail | Over-the-counter Drugs | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $12.21 | ||
1-Apr | V22.0 | Z3400 | 80055 | OBGYN | Diagnostic Services: Laboratory | Obstetric Panel | $42.75 |
1-Apr | V22.0 | Z3400 | 87801 | OBGYN | Diagnostic Services: Laboratory | Detect agnt mult dna ampli | $94.00 |
1-Apr | V22.0 | Z3400 | 88164 | OBGYN | Diagnostic Services: Laboratory | Cytopath TBS C/V Manual | $12.64 |
1-Apr | V22.0 | Z3400 | 86701 | OBGYN | Diagnostic Services: Laboratory | HIV-1 | $15.48 |
1-Apr | V22.0 | Z3400 | 36415 | OBGYN | Diagnostic Services: Laboratory | Routine Venipuncture | $4.17 |
1-Apr | V72.42 | Z3201 | 81025 | OBGYN | Diagnostic Services: Laboratory | Urine Pregnancy Test | $9.06 |
1-Apr | 650, V27.0, Proc: 73.59 | O80, Z370 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Obstetrical Care | $2,394.18 |
7-Apr | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
7-Apr | OTC | Pharmacy Retail | Over-the-counter Drugs | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $12.21 | ||
27-May | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
24-Jun | V22.0 | Z3400 | 82105 | OBGYN | Diagnostic Services: Laboratory | Alpha-fetoprotein serum | $17.53 |
24-Jun | V22.0 | Z3400 | 82677 | OBGYN | Diagnostic Services: Laboratory | Assay of estriol | $23.82 |
24-Jun | V22.0 | Z3400 | 84702 | OBGYN | Diagnostic Services: Laboratory | Chorionic gonadotropin test | $16.40 |
24-Jun | V22.0 | Z3400 | 86336 | OBGYN | Diagnostic Services: Laboratory | Inhibin A | $17.43 |
24-Jun | V22.0 | Z3400 | 81220 | OBGYN | Diagnostic Services: Laboratory | CFTR gene analysis, common variants | $561.73 |
24-Jun | V22.0 | Z3400 | 36415 | OBGYN | Diagnostic Services: Laboratory | Routine Venipuncture | $4.17 |
24-Jun | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
6-Jul | OTC | Pharmacy Retail | Over-the-counter Drugs | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $12.21 | ||
22-Jul | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
22-Jul | V22.0 | Z3400 | 76805 | Radiology | Diagnostic Services: Radiology | OB US >/= 14 WKS SNGL FETUS | $163.99 |
19-Aug | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
16-Sep | V22.0 | Z3400 | 82947 | OBGYN | Diagnostic Services: Laboratory | Assay Glucose Blood Quant | $5.73 |
16-Sep | V22.0 | Z3400 | 85025 | OBGYN | Diagnostic Services: Laboratory | Complete cbc w/auto diff wbc | $11.14 |
16-Sep | V22.0 | Z3400 | 82950 | OBGYN | Diagnostic Services: Laboratory | Glucose Test | $5.14 |
16-Sep | V22.0 | Z3400 | 36415 | OBGYN | Diagnostic Services: Laboratory | Routine Venipuncture | $4.17 |
16-Sep | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
30-Sep | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
4-Oct | OTC | Pharmacy Retail | Over-the-counter Drugs | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $12.21 | ||
14-Oct | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
20-Oct | S9442 | Alternative Provider | Preventive Services & Vaccines | Birthing class | - | ||
27-Oct | S9442 | Alternative Provider | Preventive Services & Vaccines | Birthing class | - | ||
28-Oct | V22.0 | Z3400 | 87653 | OBGYN | Diagnostic Services: Laboratory | Strep B DNA Amp Probe | $36.78 |
28-Oct | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
28-Oct | V04.81 | Z23 | 90471 | OBGYN | Preventive Services & Vaccines | Immunization Admin | $23.00 |
28-Oct | V04.81 | Z23 | 90656 | OBGYN | Preventive Services & Vaccines | Flu Vaccine N0 Preserv 3 & > | $14.27 |
1-Nov | S9442 | Alternative Provider | Preventive Services & Vaccines | Birthing class | - | ||
8-Nov | S9442 | Alternative Provider | Preventive Services & Vaccines | Birthing class | - | ||
11-Nov | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
18-Nov | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
25-Nov | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
2-Dec | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
9-Dec | Inpatient Facility | Inpatient Hospital Care (Facility) | Inpatient Maternity Bundle (Bundled line items 4, 5, 34) | $8,959.38 | |||
9-Dec | V22.0 | Z3400 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
9-Dec | 650, V27.0 | O80, Z370 | S9443 | Inpatient Facility | Preventive Services & Vaccines | Lactation class | - |
10-Dec | 99460 | Inpatient Professional | Professional Services: Primary Care | Initial hospital or birthing center care, per day, for E/M of normal newborn infant | $99.00 | ||
11-Dec | 99460 | Inpatient Professional | Professional Services: Primary Care | Initial hospital or birthing center care, per day, for E/M of normal newborn infant | $99.00 | ||
11-Dec | OTC | Pharmacy Retail | Over-the-counter Drugs | Docusate sodium (OTC) [1 pill QD] | $11.20 | ||
11-Dec | 591346601 | Pharmacy Retail | Prescription Drugs: Generic | Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60 pills] | $11.69 | ||
11-Dec | 378710401 | Pharmacy Retail | Prescription Drugs: Generic | Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H PRN; 15 pills] | $6.45 | ||
23-Dec | V24.2 | Z392 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
11-Dec | V24.2 | Z392 | 591346601 | Pharmacy Retail | Prescription Drugs: Generic | Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60 pills] | $11.69 |
11-Dec | V24.2 | Z392 | 378710401 | Pharmacy Retail | Prescription Drugs: Generic | Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H PRN; 15 pills] | $6.45 |
23-Dec | V24.2 | Z392 | 59400 | OBGYN | Professional Services: Obstetric Care (Bundled) | Office/Outpatient Visit Est | - |
** 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.) |
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: |
Pharmacy Retail | |
OBGYN | |
Radiology | |
Alternative Provider | |
Inpatient Facility | |
Inpatient Professional | |
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
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: |
Over-the-counter Drugs | |
Diagnostic Services: Laboratory | |
Professional Services: Obstetric Care (Bundled) | |
Diagnostic Services: Radiology | |
Preventive Services & Vaccines | |
Inpatient Hospital Care (Facility) | |
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |