CMS-10448 Summary of Benefits Template

The State's EHB-Benchmark Plan's Benefits and Limits

OMB Control Number: 0938-1174
Expiration Date: XX/XX/20XX

Instructions: All fields in columns B, C, and D are required to be completed. To ensure that this Benefits and Limits Summary Template corresponds with the EHB-benchmark plan document, please indicate the page number in which the benefit is
covered under Column H if answering "Covered" under Column C (for example, "Covered" in Column C, "pg. 12" in Column H). If there is a quantitative limit on a benefit, then complete the Limit Quantity and Limit Unit fields. If there are no
exclusions for a benefit, then leave the Exclusions field blank. Add an explanation in Column H to provide more details on a benefit.
A
Benefit

B
EHB

C
Is the Benefit
Covered?

D
Quantitative Limit
on Service?

E
Limit Quantity

F
Limit Unit

G
Exclusions

H
Explanations

Primary Care Visit to Treat an Injury or Illness
Specialist Visit
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
No
Private-Duty Nursing
Routine Eye Exam (Adult)
No
Urgent Care Centers or Facilities
Home Health Care Services
Emergency Room Services
Emergency Transportation/Ambulance
Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Physician and Surgical Services
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Prenatal and Postnatal Care
Delivery and All Inpatient Services for Maternity Care
Mental/Behavioral Health Outpatient Services
Mental/Behavioral Health Inpatient Services
Substance Abuse Disorder Outpatient Services
Substance Abuse Disorder Inpatient Services
Generic Drugs
Preferred Brand Drugs
Non-Preferred Brand Drugs
Specialty Drugs
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Eye Glasses for Children
Dental Check-Up for Children
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Laboratory Outpatient and Professional Services
X-rays and Diagnostic Imaging
Basic Dental Care - Child
Orthodontia - Child
Major Dental Care - Child
Basic Dental Care - Adult
Orthodontia - Adult
No
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
No
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
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 0938-1174. The
information collection included in this package reflects the time and effort for states to select a new EHB-benchmark plan. The time required to complete this information collection is estimated to average less than 205 hours per response,
including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection, pursuant to 45 C.F.R. 156.111, requires states who wish to modify
their benchmark plans to respond to this ICR. All information collected will be kept private in accordance with regulations at 45 C.F.R. 155.260, Privacy and Security of Personally Identifiable Information. 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, Mail Stop c4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer, or email Ken
Buerger at Ken.Buerger@cms.hhs.gov.