Revised Benchmark Benefits Instructions
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- Theresa Owen
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1 Title: Subtitle: Purpose: Revised Benchmark Instructions Instructions for using state-specific information to accurately reflect Individual Market and Small Group Market and state-required benefits on the Plans and Template. This document provides issuers with instructions for correcting the Package Worksheet of the Plans and Template using the included state-specific worksheets (e.g., AK, HI, PA). Version: 1 Date: Thursday, May 15, 2014
2 Background To help issuers, this document lists important state- and CMS-identified corrections to the benefit data auto-populated by the 2015 Add-In file on the Package Worksheet of the Plans and Template. that have incorrectly auto-populated benefit data for the Small Group Market are indicated in the "Small Group Market Add-In Changes" columns of the state-specific spreadsheets (e.g., AK, AL, etc.) in this document. Issuers should use the step-by-step instructions below when entering the benefit coverage information for each set of plans offered in the Small Group Market in the Package Worksheet of the Plan and Template. These instructions explain how an issuer should complete the benefit coverage information for the benefits that auto-populated inaccurately. 1 Identify the benefits that have incorrectly auto-populated data in the Package Worksheet Select the appropriate state-specific spreadsheet. Review the "Small Group Market Add-In Changes" columns of the spreadsheet to identify the benefits indicated to have corrections in how the benefit data autopopulated. These benefits are also highlighted in yellow to facilitate identification. Review the " Information" or "General Information" fields that have changed for these benefits, which are indicated in the "" column (e.g.,, ), and compare them to the auto-populated data in the Package Worksheet of the Plans and Template.
3 2 Select the appropriate scenario based on the corrections identified in the state-specific spreadsheet Select the appropriate scenario below (A, B, or C) for each benefit indicated to have a correction to the Add-In File in the state-specific spreadsheet. The state-specific worksheet DOES identify a given benefit as an and/or State and the benefit DOES NOT appear on the Plans and Template ("" = "Added "): Scenario A Do t If you intend to cover the benefit, add the benefit using the "Add " button on the menu bar under the Plans and ribbon, select overed in the "Is this " field, and select!dditional EH as the " Variance Reason." If you do not intend to cover the benefit and instead want to substitute with actuarially equivalent coverage of another benefit in the same category, add the benefit using the "Add " button on the menu bar under the Plans & ribbon, select "t " in the "Is this " field, and select Substituted as the " Variance Reason." [ For the "new" benefit that is taking the place of this one, select "Additional " as the " Variance Reason."] If you do not intend to cover a pediatric dental benefit and there is a stand-alone dental plan available, add the pediatric dental benefit using the "!dd enefit" button on the menu bar, select "t overed," and select Dental Only Plan!vailable as the " Variance Reason." The state-specific spreadsheet DOES identify a given benefit as an and/or State and the benefit DOES appear on the Plans & Template, but the "Is this " field is BLANK: Scenario B Do t If you intend to cover the benefit, add overed in the "Is this " field and select!dditional EH enefit as the " Variance Reason." If you do not intend to cover the benefit and instead intend to substitute with actuarially equivalent coverage of another benefit in the same category, select t overed in the "Is this " field and select Substituted as the Variance Reason. [For the "new" benefit that is taking the place of this one, select "Additional " as the " Variance Reason."] If you do not intend to cover a pediatric dental benefit and there is a stand-alone dental plan available, select "t " and select Dental Only Plan!vailable as the " Variance Reason." The state-specific worksheet DOES NOT identify a given benefit as an and/or State and the Plans & Template DOES populate the benefit as in the Is this field: Scenario C Do t If you intend to cover the benefit, leave overed in the "Is this " field and select!bove EH as the " Variance Reason." If you do not intend to cover the benefit, change overed to t overed in the "Is this " field and select!bove " as the " Variance Reason."
4 3 Populate the "General Information" fields when completing the Plans and Template Provide benefit coverage information for each set of plans in the Package Worksheet of the Plan and Template. For benefits indicated to have corrections in how the benefit data auto-populated: Complete the "Is this " and the " Variance Reason" fields according to the scenario selected in Step 2. For benefits NOT indicated to have any corrections: Complete the "General Information" fields according to Chapter 10: Instructions for the Plans and Application Section in the QHP Template Instructions, Sections 4.10 and 4.11.
5 AZ - Individual Market Individual Market Add-In Changes Information General Information Is this 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 n-emergency Care When Traveling Outside the U.S. Routine Dental Services (Adult) Limit Quantity Limit Unit Minimum Stay Exclusions Explanation Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing, Limit Quantity, Limit Unit Routine Eye Exam (Adult) Urgent Care Centers or Facilities Home Health Care Services 42 Visit(s) per Year 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 90 Days per Year 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 apply, see Preferred Brand Drugs n-preferred Brand Drugs Specialty Drugs Outpatient Rehabilitation Services 60 Visit(s) per Year Habilitation Services Chiropractic Care 20 Visit(s) per Year Page 1
6 AZ - Individual Market Individual Market Add-In Changes Information General Information Is this Limit Quantity Limit Unit Minimum Stay Exclusions Explanation Durable Medical Equipment Hearing Aids Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Routine Foot Care apply, see apply, see Acupuncture Weight Loss Programs Routine Eye Exam for Children 1 Visit(s) per Year Eye Glasses for Children 1 Item(s) per Year Dental Check-Up for Children Visit(s) per 6 1 Months, 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 Major Dental Care Adult Abortion for Which Public Funding is Prohibited Transplant Accidental Dental, Dialysis Allergy Testing, Chemotherapy Radiation Diabetes Education Prosthetic Devices, Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling Page 2
7 AZ - Individual Market Individual Market Add-In Changes Information General Information Is this Reconstructive Surgery Clinical Trials Diabetes Care Management Inherited Metabolic Disorder - PKU Off Label Prescription Drugs Prescription Drugs Other Limit Quantity Limit Unit Minimum Stay Exclusions Explanation Page 3
8 AZ - SHOP Market Small Group Market Add-In Changes Information General Information Is this 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 n-emergency Care When Traveling Outside the U.S. Routine Dental Services (Adult) Limit Quantity Limit Unit Minimum Stay Exclusions Explanation Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing, Limit Quantity, Limit Unit Routine Eye Exam (Adult) Urgent Care Centers or Facilities Home Health Care Services 42 Visit(s) per Year 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 90 Days per Year 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 apply, see Preferred Brand Drugs n-preferred Brand Drugs Specialty Drugs Outpatient Rehabilitation Services 60 Visit(s) per Year Habilitation Services Chiropractic Care 20 Visit(s) per Year Page 1
9 AZ - SHOP Market Small Group Market Add-In Changes Information General Information Is this Limit Quantity Limit Unit Minimum Stay Exclusions Explanation Durable Medical Equipment Hearing Aids Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Routine Foot Care apply, see apply, see Acupuncture Weight Loss Programs Routine Eye Exam for Children 1 Visit(s) per Year Eye Glasses for Children 1 Item(s) per Year Dental Check-Up for Children Visit(s) per 6 1 Months, 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 Major Dental Care Adult Abortion for Which Public Funding is Prohibited Transplant Accidental Dental, Dialysis Allergy Testing, Chemotherapy Radiation Diabetes Education Prosthetic Devices, Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling Page 2
10 AZ - SHOP Market Small Group Market Add-In Changes Information General Information Is this Reconstructive Surgery Clinical Trials Diabetes Care Management Inherited Metabolic Disorder - PKU Off Label Prescription Drugs Prescription Drugs Other Limit Quantity Limit Unit Minimum Stay Exclusions Explanation Page 3
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://www.aetnastudenthealth.com/uva or by calling 1-800-466-3027.
Health Care Plans - Which is the Most Deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
$0 See the chart starting on page 2 for your costs for services this plan covers.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthfirstny.org or by calling 1-888-250-2220. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthfirstny.org or by calling 1-888-250-2220. Important
How Much Does Your Health Care Plan Cover?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.arml.org\benefit_programs.html or by calling 1-501-978-6137.
Important Questions Answers Why this Matters: What is the overall deductible?
Molina Healthcare of Ohio, Inc.: Molina Gold Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family ǀ Plan
Coverage for: Individual, Family Plan Type: PPO. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bbsionline.com or by calling 1-866-927-2200. Important
Silver Basic Plus: QCA Health Plan, Inc. Coverage Period: Beginning on or after 01/01/2014
Silver Basic Plus: QCA Health Plan, Inc. Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan
Important Questions Answers Why this Matters: What is the overall deductible?
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
Coverage for: Individual Plan Type: PPO. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important
How Much Does My In-Network Provider Cover?
OMB Control Numbers 1545-2229, Affinity Health Plan: Affinity Essential Silver Plan Coverage Period: 01/01/2014 12/31/2014 This is only a summary. If you want more detail about your coverage and costs,
$6,600 /person $13,200 /family Does not apply to preventive care. Yes. $6,600 /person. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthrepublicinsurance.org or by calling 1-888-990-6635.
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Coverage level: Employee/Retiree Only Plan Type: EPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan documents at www.dbm.maryland.gov/benefits or by calling 410-767-4775
You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-445-7490. Important Questions
You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.sas-mn.com or by calling 1-800-328-2739. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.alaskacare.gov or by calling 1-800-821-2251. Important
Not applicable because there s no out-of-pocket limit on your expenses. You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.njcf.org or by calling 1-800-624-3096. Important Questions
Important Questions Answers Why this Matters: What is the overall deductible? pocket limit.
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in
You can see the specialist you choose without permission from this plan.
Primary Select Silver I Plan: Health Republic Insurance of New York Coverage Period: 01/01/2014 12/31/2014 This is only a summary. If you want more detail about your coverage and costs, you can get the
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Contract Types Plan Type: HMO
CLSSSM BCN Classic HMO Gold $1500 Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Contract Types Plan Type: HMO This is only
$1,300 /person $2,600 /family Does not apply to preventative care. Yes. $6,350 /person $12,700 /family. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthrepublicinsurance.org or by calling 1-888-990-6635.
Important Questions Answers Why this Matters: Network: $500 Individual / $1,500 Family;
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthscopebenefits.com or by calling 1-866-208-4281.