Coverage Example Calculator Instructions
The Departments developed this calculator for plans and issuers to use as a safe harbor for
the first year of applicability to complete the coverage examples in a streamlined fashion;
because this approach will be less accurate, it is being allowed as a transitional tool for the
first year of applicability. This tool is intended to provide plans and issuers with time to
develop accurate methods to populate the coverage examples treatment tables in the
summary of benefits and coverage (SBC) template. Plans and issuers will be required to
provide comprehensive coverage examples that are based on the coverage information
specific to the benefit package no later than January 1, 2014. The calculator allows plans
and issuers to input a discrete number of elements about the benefit package. Calculator
inputs generally are expected to coincide with the data fields used to populate the front
portion of the SBC template. These instructions accompany the coverage example calculator,
available at http://cciio.cms.gov/resources/other/index.html#sbcug.
To use the coverage calculator, you will need information on the plan's cost sharing, deductibles,
and coverage limits for several benefit categories. See
http://cciio.cms.gov/resources/other/index.html#sbcug for an overview of the inputs required.
The coverage example calculator does not require information at the billing code level.
Follow the instructions below to run the coverage example calculator. Data entry fields requiring
input are highlighted in orange in the coverage example calculator. The outputs from the
calculator can be used to populate the "Plan pays" and the "Patient pays" section of the coverage
example in the SBC.
To enable the functions of this calculator, you may need to manually enable the Macros function
when you first use this tool.
This coverage example calculator makes several important assumptions which will not be
accurate for all plan designs. If your plan design differs significantly from these assumptions,
the results may be inaccurate. In that case, we make two suggestions. You can alter the coverage
calculator to make it more accurate (for example, if your plan covers diabetes supplies under the
prescription drug benefit, you can modify the calculator to apply prescription drug cost sharing
to those items); or you can design your own coverage calculator.
The coverage example calculator makes the following assumptions:
? The benefit package covers maternity care and diabetes care. If the plan does not cover
one or both of these benefits categories, the coverage example calculator cannot be used
for the non-covered benefit;
? All items and services in the maternity and type 2 diabetes scenarios1 are covered by the
benefit package, unless otherwise indicated by the plan or issuer with the exception of the
? Over-the-counter drugs and alcohol swabs are not covered; and
? Birthing education classes are not covered;
? All items and services are subject to the overall deductible, unless they are subject to a
? All items and services count toward the overall plan deductible, except those subject to
? Any applicable deductibles must be met before the patient is charged copayments or
? All cost sharing (all deductibles, copayments and coinsurance amounts) counts toward
the out-of-pocket limit, except for the services that are not covered by the benefit package
or assumed not to be covered by the calculator (see above);
? Diabetes education (codes 98960 and 97803) is treated as Visits and Procedures, meaning
that it is subject to the overall deductible and is subject to the physician cost sharing;
? If a copayment is greater than the allowed amount, the patient is charged the allowed
amount. For example, if the lab copayment is $15 but the lab allowed amount is $7.00
then the patient pays $7.00;
? Items and services in the diabetes scenario labeled "Medical equipment and supplies" are
considered durable medical equipment (DME) and treated under the DME benefit; and
? All covered prescription medications are subject to the generic medication cost sharing
? For the maternity scenario inpatient stay, the copayment or coinsurance amount is applied
one time for all three inpatient services in the scenario. If the plan design would apply
multiple cost sharing amounts (e.g. a copayment for each inpatient service listed in the
scenario), enter the total applicable amount (not the per service amount) in the input field.
II. Starting Screen
From the "Starting Screen," select whether you would like to import data from a Comma
Separated Value (.csv) file or enter benefit package data manually. Click "Let's Get Started."
You will need to enable macros to continue.
If you select manual entry of benefit package data, you will enter the information described
below for each benefit category listed. The outputs will be specific to that benefit package. If
1 The complete lists of items and services for each scenario - and that the coverage calculator assumes are covered -
are available at http://cciio.cms.gov/resources/other/index.html#sbcug.
2 Note that the coverage example calculator does allow plans and issuers to indicate that specific categories of care
are not covered.
you choose the automatic entry option, you will input a .csv file with the values in a specified
order. That order is described below.
III. Entry Screens
For each of the coverage categories, select whether a copayment or coinsurance applies from the
drop-down menu in column J and enter the corresponding value in column L. For example, if the
copayment amount is $10, you would select "Copayment" and enter "10." If the coinsurance rate
is 30%, you would select "Coinsurance" and enter "30." Do not enter a dollar symbol or a
percentage symbol into column L. If a coverage category is subject to the deductible, but no
other cost sharing, select "Coinsurance" and enter "0"3.
If a copayment or coinsurance does not apply, select "No cost sharing" from the drop-down
menu. If a category is not covered, select "Not covered." Selecting "No cost sharing" means that
the plan will be charged the entire allowed amount for a service; selecting "Not covered" means
that the patient will be charged the entire amount for a service and that the service will be treated
as excluded (will not count toward deductible or out-of-pocket limit). If you select either "No
cost sharing" or "not covered" leave column L blank.
For Routine obstetric care, in the drop down menu you must select whether "Copayment,"
"Coinsurance," "Deductible," "No cost sharing," or "Not covered" applies. Unlike the other
benefit categories, you can only select one cost sharing option for this benefit to incorporate the
assumption that only one form of cost sharing can apply to this bundled service. If your
coverage has a benefit specific deductible applicable to routine obstetric care, select
"Deductible" in column J then enter the deductible amount in column L. This dollar amount will
also appear in column L, line 20.
The coverage categories include the following:
? Durable medical equipment and supplies (DME)
? Prescription drugs (generic)
? Hospital inpatient and anesthesia
? Laboratory tests
? Radiology (ultrasounds)
? Routine obstetric care (prenatal and postnatal care)
? Visits and procedures (physician services)
3 This would apply if a plan covers a category of care with no cost sharing after the patient has met a deductible.
For example, if a patient must pay 100% of the cost for DME prior to meeting a $500 deductible, and after the
deductible has been met, the plan will pay 100% of the cost for DME.
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Title: Coverage Examples Calculator Instructions
Keywords: Coverage Examples, Summary of Benefits and Coverage
Author: Center for Consumer Informaiton and Insurance Oversight
Creator: Acrobat PDFMaker 10.1 for Word
Producer: Adobe PDF Library 10.0
CreationDate: Mon Jun 4 16:16:40 2012
ModDate: Mon Jun 4 16:45:35 2012
Page size: 612 x 792 pts (letter) (rotated 0 degrees)
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PDF version: 1.6