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

Simple Fracture		Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab.
Sample Care Costs
Other Facility Services	$37
Ambulance	$593
Professional Services: Emergency Department	$557
Professional Services: Specialist	$293
Professional Services: Physical Therapy	$216
Diagnostic Services: Radiology	$30
Durable Medical Equipment	$199
Total (unrounded)	$1,925
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

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Sheet 2: Scenario

Medical Condition:			Simple Fracture
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
Totals:							$1,925.04
Date of Service	ICD-9 Diagnosis Code	ICD-10 Diagnosis Code	CPT©, HCPCS, or Other Billing Code	Provider Type	Category	Description	Allowed Amount
2-Jun	959.7	S99929A	A0425	Ambulance (land)	Ambulance	Ground mileage, per statute mile	$75.95
2-Jun	959.7	S99929A	A0429	Ambulance (land)	Ambulance	Ambulance service, basic life support, emergency transport (bls-emergency)	$516.60
2-Jun	825.25	S92353A	99284	Outpatient Hospital	Professional Services: Emergency Department	Emergency department visit for evaluation and management of patient, which req 3 key components. Usually, presenting problem(s) are high severity, & require urgent physician evaluation but do not pose	$271.37
2-Jun	825.25	S92353A	73630	Outpatient Hospital	Professional Services: Emergency Department	Radiologic examination, foot; complete, minimum of 3 views	$33.92
2-Jun	825.25	S92353A	28470	Outpatient Hospital	Professional Services: Emergency Department	Closed treatment of metatarsal fracture; without manipulation, each	$252.12
2-Jun	825.25	S92353A	L4387	Outpatient Hospital	Durable Medical Equipment	Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf	$162.00
2-Jun	V54.16		E0114	Pharmacy Retail	Durable Medical Equipment	Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips, and handgrips	$36.61
16-Jun	825.25	S92353A	99203	Outpatient Hospital	Professional Services: Specialist	Office or other outpatient visit for the evaluation and management of a new patient, which requires at least 3 key components. Physicians typically spend 30 minutes face-to-face with the patient.	$109.78
16-Jun	825.25	S92353A	29405	Outpatient Hospital	Professional Services: Specialist	Application of short leg cast (below knee to toes);	$110.59
16-Jun	825.25	S92353A	Q4038	Outpatient Hospital	Other Facility Services	Cast supplies, short leg cast, adult (11 years +), fiberglass	$37.14
28-Jul	825.25	S92353A	73600	Primary	Diagnostic Services: Radiology	Radiologic examination, foot; 2 views	$30.20
28-Jul	825.25	S92353A	99213	Primary	Professional Services: Specialist	Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of 3 key components. Physicians typically spend 15 minutes face-to-face with the	$73.00
4-Aug	825.25	S92353A	97001	Physical Therapy	Professional Services: Physical Therapy	Physical therapy evaluation	$75.00
4-Aug	825.25	S92353A	97110	Physical Therapy	Professional Services: Physical Therapy	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility	$46.92
11-Aug	825.25	S92353A	97110	Physical Therapy	Professional Services: Physical Therapy	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility	$46.92
18-Aug	825.25	S92353A	97110	Physical Therapy	Professional Services: Physical Therapy	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility	$46.92
** 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:
Ambulance (land)
Outpatient Hospital
Pharmacy Retail
Primary
Physical Therapy
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:
Ambulance
Professional Services: Emergency Department
Other Facility Services
Durable Medical Equipment
Professional Services: Specialist
Diagnostic Services: Radiology
Professional Services: Physical Therapy
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146