{"text_format":"1","workbook":"xlsx","n_sheets":2,"sheets":["Summary of Benefits ","Limit Units"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":1,"defined_names":9,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Summary of Benefits ","index":0,"n_rows":75,"n_cols":8,"rows_kept":75,"cut":false,"hidden":false,"merged":[]}
["The State's EHB-benchmark Plan's Benefits and Limits ",null,null,null,null,null,null,"OMB Control Number: 0938-1174\nExpiration Date: 02/28/2024"]
["Instructions: All fields on this template that are marked red 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.  "]
["\nA\nBenefit","\nB\nEHB","\nC\nIs the Benefit Covered?","\nD\nQuantitative Limit \non Service? ","\nE\nLimit Quantity ","\nF\nLimit Unit","\nG\nExclusions","\nH\nExplanations"]
["Primary Care Visit to Treat an Injury or Illness","Yes","Covered","No","",""]
["Specialist Visit","Yes","Covered","No","",""]
["Other Practitioner Office Visit (Nurse, Physician Assistant)","Yes","Covered","No","",""]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Yes","Covered","No","",""]
["Outpatient Surgery Physician/Surgical Services","Yes","Covered","No","",""]
["Hospice Services","Yes","Covered","Yes",14," Day(s) per Lifetime"]
["Routine Dental Services (Adult)","No","Not Covered","No","",""]
["Infertility Treatment","Yes","Covered","No","","","Only artificial insemination is covered. ","Artificial Insemination must be covered as it is covered by the state base benchmark plan."]
["Long-Term/Custodial Nursing Home Care","No","Not Covered","No","",""]
["Private-Duty Nursing","No","Not Covered","No","",""]
["Routine Eye Exam (Adult)","No","Not Covered","No","",""]
["Urgent Care Centers or Facilities","Yes","Covered","No","",""]
["Home Health Care Services","Yes","Covered","Yes",130,"Visit(s) per Year"]
["Emergency Room Services","Yes","Covered","No","",""]
["Emergency Transportation/Ambulance","Yes","Covered","No","",""]
["Inpatient Hospital Services (e.g., Hospital Stay)","Yes","Covered","No","",""]
["Inpatient Physician and Surgical Services","Yes","Covered","No","",""]
["Bariatric Surgery","No","Not Covered","No","",""]
["Cosmetic Surgery","No","Not Covered","No","","",null,"Covers cosmetic surgery when medically necessary."]
["Skilled Nursing Facility","Yes","Covered","Yes",60,"Day(s) per Year",null,"Coverage is limited to 60-inpatient days/year."]
["Prenatal and Postnatal Care","Yes","Covered","No","",""]
["Delivery and All Inpatient Services for Maternity Care","Yes","Covered","No","",""]
["Mental/Behavioral Health Outpatient Services","Yes","Covered","No","",""]
["Mental/Behavioral Health Inpatient Services","Yes","Covered","No","",""]
["Substance Abuse Disorder Outpatient Services","Yes","Covered","No","",""]
["Substance Abuse Disorder Inpatient Services","Yes","Covered","No","",""]
["Generic Drugs","Yes","Covered","Yes",30," Day(s) per Year",null,"Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill."]
["Preferred Brand Drugs","Yes","Covered","Yes",30," Day(s) per Year",null,"Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill."]
["Non-Preferred Brand Drugs","Yes","Covered","Yes",30," Day(s) per Year",null,"Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill."]
["Specialty Drugs","Yes","Covered","Yes",30," Day(s) per Year",null,"First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self- administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill."]
["Outpatient Rehabilitation Services","Yes","Covered","Yes",25,"Visit(s) per Year"]
["Habilitation Services","Yes","Covered","Yes",30,"Visit(s) per Year",null,"Coverage for habilitative services is limited to 30- inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year."]
["Chiropractic Care","Yes","Covered","Yes",10,"Visits(s) per Year"]
["Durable Medical Equipment","Yes","Covered","No","",""]
["Hearing Aids","Yes","Covered","No",1,"Item(s) per 3 Years","An annual hearing exam and one hearing aid per ear each 3 years is covered. Cochlear Implants for children are also covered.","Coverage is limited to an annual hearing exam and one hearing aid per ear every 3 years. Cochlear Implants for children are also covered."]
["Imaging (CT/PET Scans, MRIs)","Yes","Covered","No","",""]
["Preventive Care/Screening/Immunization","Yes","Covered","No","",""]
["Routine Foot Care","Yes","Covered","No","",""]
["Acupuncture","Yes","Covered","No"]
["Weight Loss Programs","No","Not Covered","No","",""]
["Routine Eye Exam for Children","Yes","Covered","Yes",1,"Exam(s) per Year"]
["Eye Glasses for Children","Yes","Covered","Yes",1,"Item(s) per Year",null,"Coverage is limited to one frame and one pair (two lenses) / calendar year or contacts (in lieu of glasses)."]
["Dental Check-Up for Children","Yes","Covered","Yes",2,"Visit(s) per Year"]
["Rehabilitative Speech Therapy","Yes","Covered","Yes",30,"Visit(s) per Year",null,"Coverage is limited to 30-inpatient days/year and 25- outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services."]
["Rehabilitative Occupational and Rehabilitative Physical Therapy","Yes","Covered","Yes",30,"Visit(s) per Year",null,"Coverage is limited to 30-inpatient days/year and 25- outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services."]
["Well Baby Visits and Care","Yes","Covered","No","","","Human donor milk is covered in an inpatient setting when applicable criteria is met as outlined in RCW 48.43.815. See EHB base benchmark plan for details.","Human donor milk must be covered as it is covered by the state base benchmark plan."]
["Laboratory Outpatient and Professional Services","Yes","Covered","No","",""]
["X-rays and Diagnostic Imaging","Yes","Covered","No","",""]
["Basic Dental Care - Child","Yes","Covered","Yes",1,"Exam(s) per Year"]
["Orthodontia - Child","Yes","Covered","No","","","Orthodontia that is not medically necessary.","Medically necessary orthodontia must be covered."]
["Major Dental Care - Child","Yes","Covered","No","","","Exclusions apply - see EHB base benchmark plan.","Quantitative limits apply; see EHB base benchmark plan."]
["Basic Dental Care - Adult","No","Not Covered","No","",""]
["Orthodontia - Adult","No","Not Covered","No","",""]
["Major Dental Care – Adult","No","Not Covered","No","",""]
["Abortion for Which Public Funding is Prohibited","No","Covered","No","","",null,"Coverage includes termination of pregnancy for all female members."]
["Transplant","Yes","Covered","No","",""]
["Accidental Dental","No","Not Covered","No","",""]
["Dialysis","Yes","Covered","No","",""]
["Allergy Testing","No","Not Covered","No","",""]
["Chemotherapy","Yes","Covered","No","","","Coverage of oral anti-cancer drugs is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy; other chemotherapy is covered under the applicable service (such as office visit).","Covered under the base benchmark plan."]
["Radiation","Yes","Covered","No","","",null,"Covered under the base benchmark plan; covered under applicable benefit (such as office visit)."]
["Diabetes Education","Yes","Covered","No","",""]
["Prosthetic Devices","Yes","Covered","No","",""]
["Infusion Therapy","Yes","Covered","No","","",null,"Covered under applicable benefit (such as office visit)."]
["Treatment for Temporomandibular Joint Disorders","Yes","Covered","No","",""]
["Nutritional Counseling","Yes","Covered","No","",""]
["Reconstructive Surgery","Yes","Covered","No","","",null,"Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state-based benchmark plan."]
["Gender Affirming Care","Yes","Covered","No",null,null,null,"Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services."]
["Diabetes Care Management","Yes","Covered","No"]
["Inherited Metabolic Disorder - PKU","Yes","Covered","No"]
["Dental Anesthesia","Yes","Covered","No"]
["PRA Disclosure Statement\nAccording 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 (Expires 02/28/2024). The time required to complete this information collection is estimated to average 47 hours or 2,820 minutes per response for States. For Form 1, the estimate is 4 hours. For Form 2, the estimate is 19 hours. For Form 3, the estimate is 12 hours. For Form 4, the estimate is 12 hours. 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. \n\n****CMS Disclosure****\nPlease do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Ken Buerger at Ken.Buerger@cms.hhs.gov. "]

{"sheet":"Limit Units","index":1,"n_rows":5,"n_cols":131,"rows_kept":5,"cut":false,"hidden":true,"merged":[]}
[" "," Visit(s) per Year"," Visit(s) per Benefit Period"," Visit(s) per Lifetime"," Visit(s) per Month"," Visit(s) per Episode"," Visit(s) per Stay"," Visit(s) per Transplant"," Visit(s) per 6 Months"," Visit(s) per 2 Years"," Visit(s) per 3 Years"," Visit(s) per Procedure"," Visit(s) per Week"," Visit(s) per Admission"," Dollar(s) per Year"," Dollar(s) per Benefit Period"," Dollar(s) per Lifetime"," Dollar(s) per Month"," Dollar(s) per Episode"," Dollar(s) per Stay"," Dollar(s) per Transplant"," Dollar(s) per 6 Months"," Dollar(s) per 2 Years"," Dollar(s) per 3 Years"," Dollar(s) per Procedure"," Dollar(s) per Week"," Dollar(s) per Admission"," Exam(s) per Year"," Exam(s) per Benefit Period"," Exam(s) per Lifetime"," Exam(s) per Month"," Exam(s) per Episode"," Exam(s) per Stay"," Exam(s) per Transplant"," Exam(s) per 6 Months"," Exam(s) per 2 Years"," Exam(s) per 3 Years"," Exam(s) per Procedure"," Exam(s) per Week"," Exam(s) per Admission"," Day(s) per Year"," Day(s) per Benefit Period"," Day(s) per Lifetime"," Day(s) per Month"," Day(s) per Episode"," Day(s) per Stay"," Day(s) per Transplant"," Day(s) per 6 Months"," Day(s) per 2 Years"," Day(s) per 3 Years"," Day(s) per Procedure"," Day(s) per Week"," Day(s) per Admission"," Item(s) per Year"," Item(s) per Benefit Period"," Item(s) per Lifetime"," Item(s) per Month"," Item(s) per Episode"," Item(s) per Stay"," Item(s) per Transplant"," Item(s) per 6 Months"," Item(s) per 2 Years"," Item(s) per 3 Years"," Item(s) per Procedure"," Item(s) per Week"," Item(s) per Admission"," Month(s) per Year"," Month(s) per Benefit Period"," Month(s) per Lifetime"," Month(s) per Month"," Month(s) per Episode"," Month(s) per Stay"," Month(s) per Transplant"," Month(s) per 6 Months"," Month(s) per 2 Years"," Month(s) per 3 Years"," Month(s) per Procedure"," Month(s) per Week"," Month(s) per Admission"," Treatment(s) per Year"," Treatment(s) per Benefit Period"," Treatment(s) per Lifetime"," Treatment(s) per Month"," Treatment(s) per Episode"," Treatment(s) per Stay"," Treatment(s) per Transplant"," Treatment(s) per 6 Months"," Treatment(s) per 2 Years"," Treatment(s) per 3 Years"," Treatment(s) per Procedure"," Treatment(s) per Week"," Treatment(s) per Admission"," Procedure(s) per Year"," Procedure(s) per Benefit Period"," Procedure(s) per Lifetime"," Procedure(s) per Month"," Procedure(s) per Episode"," Procedure(s) per Stay"," Procedure(s) per Transplant"," Procedure(s) per 6 Months"," Procedure(s) per 2 Years"," Procedure(s) per 3 Years"," Procedure(s) per Procedure"," Procedure(s) per Week"," Procedure(s) per Admission"," Hour(s) per Year"," Hour(s) per Benefit Period"," Hour(s) per Lifetime"," Hour(s) per Month"," Hour(s) per Episode"," Hour(s) per Stay"," Hour(s) per Transplant"," Hour(s) per 6 Months"," Hour(s) per 2 Years"," Hour(s) per 3 Years"," Hour(s) per Procedure"," Hour(s) per Week"," Hour(s) per Admission"," Admission(s) per Year"," Admission(s) per Benefit Period"," Admission(s) per Lifetime"," Admission(s) per Month"," Admission(s) per Episode"," Admission(s) per Stay"," Admission(s) per Transplant"," Admission(s) per 6 Months"," Admission(s) per 2 Years"," Admission(s) per 3 Years"," Admission(s) per Procedure"," Admission(s) per Week"," Admission(s) per Admission"]
["§ 156.111(a)(1) – Select the EHB-benchmark plan from another State","§ 156.111(a)(2) - Replace one or more categories of EHBs from another State’s EHB-benchmark plan","§ 156.111(a)(3) - Select a set of benefits that would become the State’s EHB-benchmark plan"]
["Not Applicable to State's Selection Option","Alabama","Alaska","Arizona","Arkansas","California","Colorado","Connecticut","Delaware","District of Columbia","Florida","Georgia","Hawaii","Idaho","Illinois","Indiana","Iowa","Kansas","Kentucky","Louisiana","Maine","Maryland","Massachusetts","Michigan","Minnesota","Mississippi","Missouri","Montana","Nebraska","Nevada","New Hampshire","New Jersey","New Mexico","New York","North Carolina","North Dakota","Ohio","Oklahoma","Oregon","Pennsylvania","Rhode Island","South Carolina","South Dakota","Tennessee","Texas","Utah","Vermont","Virginia","Washington","West Virginia","Wisconsin","Wyoming"]
["Plan Year 2019","Plan Year 2020","Plan Year 2021","Plan Year 2022"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Not Applicable to State's Selection Option","Yes"]