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

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022) (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)
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	no data
Inpatient Hospital Care (Facility)	$8,460
Professional Services: Obstetric Care (Bundled)	$2,610
Diagnostic Services: Radiology	$343
Diagnostic Services: Laboratory	$1,153
Prescription Drugs: Generic	$11
Over-the-counter Drugs	$61
Preventive Services & Vaccines	$49
Total (unrounded)	$12,687
No data
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.
If applying the rounding rules causes the out-of-pocket amount displayed to exceed the actual out-of-pocket limit (for self-only coverage), then the out-of-pocket amount must be capped and shown as the amount of the actual out-of-pocket limit.
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.
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 (Expires 10/31/2022). The time required to complete this information collection is estimated to average [0.08] 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.
End of worksheet

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Sheet 2: Scenario

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.
Totals:						$12,686.85
Date of Service	ICD-10 Diagnosis Code	CPT©, HCPCS, or Other Billing Code	Provider Type	Category	Description	Allowed Amount
This is a filter cell	This is a filter cell	This is a filter cell	This is a filter cell	This is a filter cell	This is a filter cell	This is a filter cell
7-Jan	No data	OTC	Pharmacy Retail	Over-the-counter 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	88164	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
1-Apr	Z3400	87591	OBGYN	Diagnostic Services: Laboratory	N.gonorrhoeae dna amp prob	$43.82
7-Apr	Z3400	59400	OBGYN	Professional Services: Obstetric Care (Bundled)	Office/Outpatient Visit Est	-
7-Apr	No data	OTC	Pharmacy Retail	Over-the-counter 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	$595.43
24-Jun	Z3400	36415	OBGYN	Diagnostic Services: Laboratory	Routine Venipuncture	$5.30
24-Jun	Z3400	59400	OBGYN	Professional Services: Obstetric Care (Bundled)	Office/Outpatient Visit Est	-
6-Jul	No data	OTC	Pharmacy Retail	Over-the-counter 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	$8.21
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	Ultrasound of pregnant uterus, 1 or more fetus(es)	133.68
30-Sep	Z3400	59400	OBGYN	Professional Services: Obstetric Care (Bundled)	Office/Outpatient Visit Est	-
4-Oct	No data	OTC	Pharmacy Retail	Over-the-counter 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	0
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	-
9-Dec	O80, Z370	1967	Anesthesiology	Professional Services: Inpatient	Anesth/analg vag delivery	$1,399.34
no data	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-the-counter Drugs	Polyethylene Glycol 3350 [1 dose / 17 GM daily]	$15.10
11-Dec	No data	53746046605	Pharmacy Retail	Prescription Drugs: Generic	Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 30 pills]	$3.77
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	-
** 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:
Pharmacy Retail	no data
OBGYN	no data
Radiology	no data
Alternative Provider	no data
Inpatient Facility	no data
Inpatient Professional	no data
Anesthesiology	no data
End of worksheet

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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:
Over-the-counter Drugs	No data
Diagnostic Services: Laboratory	No data
Professional Services: Obstetric Care (Bundled)	No data
Diagnostic Services: Radiology	No data
Preventive Services & Vaccines	No data
Inpatient Hospital Care (Facility)	No data
Professional Services: Inpatient	No data
Prescription Drugs: Generic	No data
End of worksheet