{"text_format":"1","workbook":"xlsx","n_sheets":6,"sheets":["EnableMacros","Benefits Package 1","Cost Share Variances 1","DefaultBP","DefaultCSV","Names"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":43,"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":"EnableMacros","index":0,"n_rows":17,"n_cols":2,"rows_kept":17,"cut":false,"hidden":true,"merged":[[0,0,0,15],[1,0,1,15],[2,0,2,15]]}
["Plans & Benefits Template"]
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[null,"If you are seeing this sheet, macros are not enabled, please follow the following steps: "]
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[null,"If using Excel 2007 and 2010:"]
[null,"1. Set the macro security setting to Disable macros with notifications (Recommended) or Enable all macros. To change"]
[null,"    the macro security setting, click the Office Button and select Excel Option -> Trust Center -> Trust Center Settings -> "]
[null,"    Macro Settings."]
[null,"2. If the macro security setting is set to Disable macros with notifications, click the Option button and select Enable this "]
[null,"    content."]
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[null,"Note: This screen will flash momentarily when you save or finalize this workbook."]

{"sheet":"Benefits Package 1","index":1,"n_rows":127,"n_cols":30,"rows_kept":127,"cut":false,"hidden":true,"merged":[[126,0,126,1],[5,25,5,29],[68,0,68,1],[5,0,5,5],[5,6,5,20],[5,21,5,22],[5,23,5,24],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[58,0,58,1],[59,0,59,1],[60,0,60,1],[61,0,61,1],[62,0,62,1],[57,0,57,2],[57,3,57,9],[57,10,57,11],[81,0,81,1],[70,0,70,1],[71,0,71,1],[72,0,72,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[69,0,69,1],[93,0,93,1],[82,0,82,1],[83,0,83,1],[84,0,84,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[105,0,105,1],[94,0,94,1],[95,0,95,1],[96,0,96,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[117,0,117,1],[106,0,106,1],[107,0,107,1],[108,0,108,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[124,0,124,1],[125,0,125,1],[118,0,118,1],[119,0,119,1],[120,0,120,1],[121,0,121,1],[122,0,122,1],[123,0,123,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",99999,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*","NM",null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*","Individual",null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*","No",null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
["99999NM0010001","SOPA Sample Gold","99999NM001 ","NMN001","NMS001","NMF001","Existing","HMO","Gold","Not Applicable","Yes","On the Exchange","No",null,null,"No","Allows Adult and Child-Only",null,"Yes",null,1,null,null,"2024-01-01","2024-12-31","No",null,"Yes","All","No"]
["99999NM0010002","SOPA Sample Silver","99999NM001 ","NMN001","NMS001","NMF001","Existing","HMO","Silver","Not Applicable","Yes","On the Exchange","No",null,null,"No","Allows Adult and Child-Only",null,"Yes",null,1,null,null,"2024-01-01","2024-12-31","No",null,"Yes","All","No"]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["Primary Care Visit to Treat an Injury or Illness",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialist Visit",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Other Practitioner Office Visit (Nurse, Physician Assistant)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Surgery Physician/Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hospice Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Routine Dental Services (Adult)"]
["Infertility Treatment",null,"Yes","Covered",null,null,null,null,"Diagnosis and medically indicated treatments for physical conditions causing infertility",null,"No","No"]
["Long-Term/Custodial Nursing Home Care"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)"]
["Urgent Care Centers or Facilities",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Home Health Care Services",null,"Yes","Covered","Yes",100,"Days per Year",null,null,null,"No","No"]
["Emergency Room Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Emergency Transportation/Ambulance",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Hospital Services (e.g., Hospital Stay)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Inpatient Physician and Surgical Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Bariatric Surgery",null,"Yes","Covered",null,null,null,null,"Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related comorbid medical conditions.",null,"No","No"]
["Cosmetic Surgery"]
["Skilled Nursing Facility",null,"Yes","Covered","Yes",60,"Days per Year",null,null,null,"No","No"]
["Prenatal and Postnatal Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Delivery and All Inpatient Services for Maternity Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Mental/Behavioral Health Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Outpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Substance Abuse Disorder Inpatient Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Generic Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Non-Preferred Brand Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Specialty Drugs",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Outpatient Rehabilitation Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Habilitation Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chiropractic Care",null,"Yes","Covered","Yes",20,"Visit(s) per Year",null,"Unless for Habilitative and Rehabilitative Services",null,"No","No"]
["Durable Medical Equipment",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Hearing Aids",null,"Yes","Covered","Yes",1,"Item(s) per 3 Years",null,"Per ear",null,"No","No"]
["Imaging (CT/PET Scans, MRIs)",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Preventive Care/Screening/Immunization",null,"Yes","Covered",null,null,null,null,"Shall include artery calcification testing for the diagnosis of heart disease",null,"No","No"]
["Routine Foot Care"]
["Acupuncture",null,"Yes","Covered","Yes",20,"Visit(s) per Year",null,"Unless for Habilitative and Rehabilitative Services",null,"No","No"]
["Weight Loss Programs",null,"Yes","Covered",null,null,null,null,"Includes coverage for drugs and programs if medically necessary for morbid obesity and obesity.",null,"No","No"]
["Routine Eye Exam for Children",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Eye Glasses for Children",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Dental Check-Up for Children",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Speech Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Rehabilitative Occupational and Rehabilitative Physical Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Well Baby Visits and Care",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Laboratory Outpatient and Professional Services",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["X-rays and Diagnostic Imaging",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Child",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Orthodontia – Child",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Major Dental Care – Child",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Basic Dental Care – Adult"]
["Orthodontia – Adult"]
["Major Dental Care – Adult"]
["Abortion for Which Public Funding is Prohibited"]
["Transplant",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Accidental Dental",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Dialysis",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Allergy Testing",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Chemotherapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Radiation",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Diabetes Education",null,"Yes","Covered",null,null,null,null,"Benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education.",null,"No","No"]
["Prosthetic Devices",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Infusion Therapy",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Treatment for Temporomandibular Joint Disorders",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Nutritional Counseling",null,"Yes","Covered",null,null,null,null,"Covered: The following are covered benefits: Nutritional supplements for prenatal care when prescribed by a practitioner/provider are covered for pregnant women.; Nutritional counseling as medically necessary; Nutritional supplements that require a prescription to be dispensed are covered when prescribed by a Practitioner/Provider and when medically necessary to replace a specific documented deficiency.; Nutritional supplements administered by injection at the practitioner's/provider's office are covered when medically necessary.; Enteral formulas or products, as nutritional support, are covered only when prescribed by a practitioner/provider and administered by enteral tube feedings.; Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is covered when ordered by a practitioner/provider.; Special medical foods as listed as covered benefits in the Genetic Inborn Errors of Metabolism (IEM) benefit or as medically necessary.; Not Covered: The following are not covered: Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings.; Nutritional supplements prescribed by an attending practitioner/provider not due to a deficiency or as the sole source of nutrition.",null,"No","No"]
["Reconstructive Surgery",null,"Yes","Covered",null,null,null,null,null,null,"No","No"]
["Gender Affirming Care"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3",null,null,null,null,null,null,null,"Primary Care Visit to Treat an Injury or Illness",null,null,null,null,null,"Specialist Visit",null,null,null,null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)",null,null,null,null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",null,null,null,null,null,"Outpatient Surgery Physician/Surgical Services",null,null,null,null,null,"Hospice Services",null,null,null,null,null,"Infertility Treatment",null,null,null,null,null,"Urgent Care Centers or Facilities",null,null,null,null,null,"Home Health Care Services",null,null,null,null,null,"Emergency Room Services",null,null,null,null,null,"Emergency Transportation/Ambulance",null,null,null,null,null,"Inpatient Hospital Services (e.g., Hospital Stay)",null,null,null,null,null,"Inpatient Physician and Surgical Services",null,null,null,null,null,"Bariatric Surgery",null,null,null,null,null,"Skilled Nursing Facility",null,null,null,null,null,"Prenatal and Postnatal Care",null,null,null,null,null,"Delivery and All Inpatient Services for Maternity Care",null,null,null,null,null,"Mental/Behavioral Health Outpatient Services",null,null,null,null,null,"Mental/Behavioral Health Inpatient Services",null,null,null,null,null,"Substance Abuse Disorder Outpatient Services",null,null,null,null,null,"Substance Abuse Disorder Inpatient Services",null,null,null,null,null,"Generic Drugs",null,null,null,null,null,"Preferred Brand Drugs",null,null,null,null,null,"Non-Preferred Brand Drugs",null,null,null,null,null,"Specialty Drugs",null,null,null,null,null,"Outpatient Rehabilitation Services",null,null,null,null,null,"Habilitation Services",null,null,null,null,null,"Chiropractic Care",null,null,null,null,null,"Durable Medical Equipment",null,null,null,null,null,"Hearing Aids",null,null,null,null,null,"Imaging (CT/PET Scans, MRIs)",null,null,null,null,null,"Preventive Care/Screening/Immunization",null,null,null,null,null,"Acupuncture",null,null,null,null,null,"Weight Loss Programs",null,null,null,null,null,"Routine Eye Exam for Children",null,null,null,null,null,"Eye Glasses for Children",null,null,null,null,null,"Dental Check-Up for Children",null,null,null,null,null,"Rehabilitative Speech Therapy",null,null,null,null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy",null,null,null,null,null,"Well Baby Visits and Care",null,null,null,null,null,"Laboratory Outpatient and Professional Services",null,null,null,null,null,"X-rays and Diagnostic Imaging",null,null,null,null,null,"Basic Dental Care – Child",null,null,null,null,null,"Orthodontia – Child",null,null,null,null,null,"Major Dental Care – Child",null,null,null,null,null,"Transplant",null,null,null,null,null,"Accidental Dental",null,null,null,null,null,"Dialysis",null,null,null,null,null,"Allergy Testing",null,null,null,null,null,"Chemotherapy",null,null,null,null,null,"Radiation",null,null,null,null,null,"Diabetes Education",null,null,null,null,null,"Prosthetic Devices",null,null,null,null,null,"Infusion Therapy",null,null,null,null,null,"Treatment for Temporomandibular Joint Disorders",null,null,null,null,null,"Nutritional Counseling",null,null,null,null,null,"Reconstructive Surgery"]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID \n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","SOPA Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default Coinsurance","Individual","Family","Individual","Family","HSA Eligible*","HSA/HRA Employer Contribution","HSA/HRA Employer Contribution Amount","Maximum Coinsurance for Specialty Drugs","Maximum Number of Days for Charging an Inpatient Copay?","Begin Primary Care Cost-Sharing After a Set Number of Visits?","Begin Primary Care Deductible/ Coinsurance After a Set Number of Copays?","Blank","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network","In Network (Tier 1)","In Network (Tier 2)","Out of Network"]
["99999NM0010001-90","SOPA Sample - 90% AV Turquoise","Gold","90% AV Turquoise",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,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,"No",null,null,null,null,null,null,null,null,null,0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group",0,"$0 per person | $0 per group"]
["99999NM0010002-95","SOPA Sample - 95% AV Turquoise","Silver","95% AV Turquoise",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,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,"No"]
["99999NM0010002-99","SOPA Sample - 99% AV Turquoise","Silver","99% AV Turquoise"]

{"sheet":"DefaultBP","index":3,"n_rows":127,"n_cols":30,"rows_kept":127,"cut":false,"hidden":true,"merged":[[126,0,126,1],[5,23,5,24],[5,25,5,29],[57,10,57,11],[58,0,58,1],[59,0,59,1],[5,0,5,5],[60,0,60,1],[5,6,5,20],[5,21,5,22],[57,0,57,2],[57,3,57,9],[72,0,72,1],[61,0,61,1],[62,0,62,1],[63,0,63,1],[64,0,64,1],[65,0,65,1],[66,0,66,1],[67,0,67,1],[68,0,68,1],[69,0,69,1],[70,0,70,1],[71,0,71,1],[84,0,84,1],[73,0,73,1],[74,0,74,1],[75,0,75,1],[76,0,76,1],[77,0,77,1],[78,0,78,1],[79,0,79,1],[80,0,80,1],[81,0,81,1],[82,0,82,1],[83,0,83,1],[96,0,96,1],[85,0,85,1],[86,0,86,1],[87,0,87,1],[88,0,88,1],[89,0,89,1],[90,0,90,1],[91,0,91,1],[92,0,92,1],[93,0,93,1],[94,0,94,1],[95,0,95,1],[108,0,108,1],[97,0,97,1],[98,0,98,1],[99,0,99,1],[100,0,100,1],[101,0,101,1],[102,0,102,1],[103,0,103,1],[104,0,104,1],[105,0,105,1],[106,0,106,1],[107,0,107,1],[120,0,120,1],[109,0,109,1],[110,0,110,1],[111,0,111,1],[112,0,112,1],[113,0,113,1],[114,0,114,1],[115,0,115,1],[116,0,116,1],[117,0,117,1],[118,0,118,1],[119,0,119,1],[121,0,121,1],[122,0,122,1],[123,0,123,1],[124,0,124,1],[125,0,125,1]]}
["2024 Plans & Benefits Template v13.0 [assistive technology users, please reference cell C1 for instructions]",null,"Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N keys. After that, select the Enable All Content option by pressing enter. Note that you can press the C key to select \"Enable All Content\". Template instructions can be found in cells D1 through D5.","To use this template, please review the user guide and instructions. All fields with an asterisk (*) are required"]
["HIOS Issuer ID*",null,null,"You will need to save the latest version of the add-in file (PlansBenefitsAddInPY24.xlam) on your machine."]
["Issuer State*",null,null,"To create the cost share variance worksheet and enter the cost sharing amounts for both individual and SHOP (small group) markets, use the Create Cost Share Variances macro."]
["Market Coverage*",null,null,"To create additional Benefits Package worksheets, use the Create New Benefits Package macro."]
["Dental Only Plan*",null,null,"To populate the benefits on the Benefits Package worksheet with your State EHB Standards, use the Refresh EHB macro."]
["Plan Identifiers",null,null,null,null,null,"Plan Attributes",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Stand Alone Dental Only",null,"Plan Dates",null,"Geographic Coverage"]
["HIOS Plan ID*\n(Standard Component)","Plan Marketing Name*","HIOS Product ID*","Network ID*","Service Area ID*","Formulary ID*","New/Existing Plan?*","Plan Type*","Level of Coverage*","Design Type*","Unique Plan Design?*","QHP/Non-QHP*","Notice Required for Pregnancy*","Plan Level Exclusions","Limited Cost Sharing Plan Variation - Est Advanced Payment","Does this plan offer Composite Rating?*","Child-Only Offering*","Child Only Plan ID","Tobacco Wellness Program Offered*","Disease Management Programs Offered","EHB Percent of Total Premium*","EHB Apportionment for Pediatric Dental ","Guaranteed Rate ","Plan Effective Date*","Plan Expiration Date","Out of Country Coverage*","Out of Country Coverage Description","Out of Service Area Coverage*","Out of Service Area Coverage Description","National Network*"]
[]
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[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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["Benefit Information",null,null,"General Information",null,null,null,null,null,null,"Out of Pocket Exceptions"]
["Benefits",null,"EHB","Is this Benefit Covered?","Quantitative Limit on Service","Limit Quantity","Limit Unit","Exclusions","Benefit Explanation","EHB Variance Reason","Excluded from In Network MOOP","Excluded from Out of Network MOOP"]
["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"]
["Private-Duty Nursing"]
["Routine Eye Exam (Adult)"]
["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"]
["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"]
["Reconstructive Surgery"]
["Gender Affirming Care"]

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["All fields with an asterisk (*) are required",null,null,null,null,null,null,null,null,null,null,null,null,"SBC Scenario",null,null,null,null,null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Drug EHB Benefits",null,null,null,null,null,null,null,"Maximum Out of Pocket for Medical and Drug EHB Benefits (Total)",null,null,null,null,null,null,null,"Medical EHB Deductible",null,null,null,null,null,null,null,null,null,"Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"Combined Medical and Drug EHB Deductible",null,null,null,null,null,null,null,null,null,"HSA/HRA Detail",null,null,"AV Calculator Additional Benefit Design",null,null,null,null,null,null,"custom 1",null,null,null,null,null,null,null,"custom 2",null,null,null,null,null,null,null,"custom 3"]
["Plan Cost Sharing Attributes",null,null,null,null,null,null,null,null,null,null,null,null,"Having a Baby",null,null,null,"Having Diabetes",null,null,null,"Treatment of a Simple Fracture",null,null,null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,null,"In Network (Tier 2)",null,null,"Out of Network",null,"Combined In/Out Network",null,null,null,null,null,null,null,null,null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"In Network",null,"In Network (Tier 2)",null,"Out of Network",null,"Combined In/Out Network",null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance",null,null,"Copay",null,null,"Coinsurance"]
["HIOS Plan ID\n(Standard Component + Variant)","Plan Variant Marketing Name*","Level of Coverage\n(Metal Level)","CSR Variation Type","Issuer Actuarial Value","AV Calculator Output Number*","Medical & Drug Deductibles Integrated?*","Medical & Drug Maximum Out of Pocket Integrated?*","Is a Referral Required for Specialist?*","Specialist(s) Requiring a Referral","Multiple In Network Tiers?*","1st Tier Utilization*","2nd Tier Utilization","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Deductible*","Copayment*","Coinsurance*","Limit*","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Individual","Family","Default Coinsurance","Individual","Family","Default 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{"sheet":"Names","index":5,"n_rows":141,"n_cols":9,"rows_kept":141,"cut":false,"hidden":true,"merged":[]}
["Individual","AK","Yes","Accidental Ingestion of a Controlled Drug",null,"CSV Code Name","Already Ran AVC","Data Modified After Running AVC","Modified Fields"]
["SHOP (Small Group)","AL",null,"Anesthetics",null,"Sheet3",false,false]
[null,"AR",null,"Applied Behavior Analysis Based Therapies"]
["Bronze","AZ",null,"Attention Deficit Disorder"]
["Expanded Bronze","CA",null,"Autism Spectrum Disorders"]
["Silver","CO",null,"Blood and Blood Services"]
["Gold","CT",null,"Bone Marrow Testing"]
["Platinum","DC",null,"Bone Marrow Transplant"]
["Catastrophic","DE",null,"Bone Marrow Transplants for Treatment of Breast Cancer"]
[null,"FL",null,"Bones/Joints"]
["Yes","GA",null,"Brain Injury"]
["No","HI",null,"Breast Implant Removal"]
[null,"IA",null,"Breast Reconstructive Surgery"]
["Indemnity","ID",null,"Cancer Treatments"]
["PPO","IL",null,"Cardiac Rehabilitation"]
["HMO","IN",null,"Clinical Trials"]
["POS","KS",null,"Cochlear Implants"]
["EPO","KY",null,"Congenital Anomaly, including Cleft Lip/Palate"]
[null,"LA",null,"Contraceptive Services"]
["Allows Adult and Child-Only","MA",null,"Coverage for Effects of Diethylstilbestrol"]
["Allows Adult-Only","MD",null,"Dental Anesthesia"]
["Allows Child-Only","ME",null,"Developmental Needs of Children & Youth with Cancer"]
[null,"MI",null,"Diabetes Care Management"]
["New","MN",null,"Domestic Violence Treatment"]
["Existing","MO",null,"Drug Infusion Administration"]
[null,"MS",null,"Early Intervention Services"]
["Yes","MT",null,"Eating Disorder Treatment"]
["No","NC",null,"Emegency Transportation/Ambulance"]
["Not Applicable","ND",null,"Experimental or Investigational Services"]
[null,"NE",null,"Family Therapy"]
[null,"NH",null,"Gastric Electrical Stimulation"]
["$X","NJ",null,"Heart Transplant"]
["Not Applicable","NM",null,"Hormone Replacement Therapy (HRT)"]
[null,"NV",null,"Human Leukocyte Antigen Testing"]
["On the Exchange","NY",null,"Hypodermic Syringes or Needles "]
["Off the Exchange","OH",null,"Infant Formulas"]
["Both","OK",null,"Inherited Metabolic Disorder - PKU"]
[null,"OR",null,"Mental Health Other"]
["Covered","PA",null,"Mental Health Parity"]
["Not Covered","RI",null,"Morbid Obesity Treatment"]
[null,"SC",null,"Multiple Sclerosis "]
["Standard Plan","SD",null,"Network Retail Pharmacy (60-90 Day Supply) Covered"]
["73% AV CSR Silver Plan Variation","TN",null,"Newborn Hearing Screening"]
["87% AV CSR Silver Plan Variation","TX",null,"Newborn Services Other"]
["94% AV CSR Silver Plan Variation","UT",null,"Nutrition/Formulas"]
["Zero Cost Sharing Plan Variation","VA",null,"Off Label Prescription Drugs"]
["Limited Cost Sharing Plan Variation","VT",null,"Oral Surgery"]
[null,"WA",null,"Organ Transplants"]
["Click here to select","WI",null,"Osteoporosis"]
[null,"WV",null,"Outpatient Contraceptive Services Including Sterilizations"]
["Not EHB","WY",null,"Oxygen"]
["Substituted",null,null,"Pediatric Services Other"]
["Substantially Equal",null,null,"Port-Wine Stain Removal"]
["Using Alternate Benchmark",null,null,"Post-Mastectomy Care"]
["Other Law/Regulation",null,null,"Prescription Drugs Other"]
["Additional EHB Benefit",null,null,"Prescription Drugs Other "]
["Dental Only Plan Available",null,null,"Rape and Incest Coverage"]
[null,null,null,"Rehabilitative Occupational Therapy"]
["No Charge",null,null,"Rehabilitative Physical Therapy"]
["No Charge after deductible",null,null,"Residential Treatment for Children with Emotional Disabilities"]
["$X",null,null,"Second Opinion"]
["$X Copay after deductible",null,null,"Second Opinions Related to Chemical Dependency and Mental Health"]
["$X Copay with deductible",null,null,"Second Surgical Opinion"]
["Not Applicable",null,null,"Services to Ventilator-Dependent Persons"]
[null,null,null,"Sickle Cell Anemia"]
["$X Copay per Stay",null,null,"Third Opinion"]
["$X Copay per Stay with deductible",null,null,"Transplant Donor Coverage"]
["$X Copay per Stay after deductible",null,null,"Transplant Surgery—Donor Charges"]
["$X Copay per Day",null,null,"Treatment of hemophilia"]
["$X Copay per Day with deductible",null,null,"Treatment of Lyme Disease"]
["$X Copay per Day after deductible",null,null,"Treatment of Medical Complications of Alcoholism"]
["No Charge",null,null,"Well Child Care"]
["No Charge after deductible",null,null,"Wigs"]
["Not Applicable",null,null,"Wilm's Tumor"]
[null,null,null,"Wound Care for Individuals with Epidermolysis Bullosa"]
["No Charge"]
["No Charge after deductible",null,null,"Abortion for Which Public Funding is Prohibited"]
["X%",null,null,"Acupuncture"]
["X% Coinsurance after deductible",null,null,"Allergy Testing"]
["Not Applicable",null,null,"Bariatric Surgery"]
[null,null,null,"Chemotherapy"]
["Asthma",null,null,"Chiropractic Care"]
["Heart Disease",null,null,"Cosmetic Surgery"]
["Depression",null,null,"Delivery and All Inpatient Services for Maternity Care"]
["Diabetes",null,null,"Diabetes Education"]
["High Blood Pressure & High Cholesterol",null,null,"Dialysis"]
["Low Back Pain",null,null,"Durable Medical Equipment"]
["Pain Management",null,null,"Emergency Room Services"]
["Pregnancy",null,null,"Emergency Transportation/Ambulance"]
["Weight Loss Programs",null,null,"Eye Glasses for Children"]
[null,null,null,"Habilitation Services"]
["Visit(s)",null,null,"Hearing Aids"]
["Dollars",null,null,"Home Health Care Services"]
["Exam(s)",null,null,"Hospice Services"]
["Days",null,null,"Imaging (CT/PET Scans, MRIs)"]
["Item(s)",null,null,"Infertility Treatment"]
["Months",null,null,"Infusion Therapy"]
["Treatment(s)",null,null,"Inpatient Hospital Services (e.g., Hospital Stay)"]
["Procedure(s)",null,null,"Inpatient Physician and Surgical Services"]
["Hours",null,null,"Laboratory Outpatient and Professional Services"]
["Admission(s)",null,null,"Long-Term/Custodial Nursing Home Care"]
[null,null,null,"Mental/Behavioral Health Inpatient Services"]
["Year",null,null,"Mental/Behavioral Health Outpatient Services"]
["Benefit Period",null,null,"Non-Emergency Care When Traveling Outside the U.S."]
["Lifetime",null,null,"Nutritional Counseling"]
["Month",null,null,"Other Practitioner Office Visit (Nurse, Physician Assistant)"]
["Episode",null,null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"]
["Stay",null,null,"Outpatient Rehabilitation Services"]
["Transplant",null,null,"Outpatient Surgery Physician/Surgical Services"]
["6 Months",null,null,"Prenatal and Postnatal Care"]
["2 Years",null,null,"Preventive Care/Screening/Immunization"]
["3 Years",null,null,"Primary Care Visit to Treat an Injury or Illness"]
["Procedure",null,null,"Private-Duty Nursing"]
["Week",null,null,"Prosthetic Devices"]
["Admission",null,null,"Radiation"]
[null,null,null,"Reconstructive Surgery"]
["Guaranteed Rate ",null,null,"Rehabilitative Occupational and Rehabilitative Physical Therapy"]
[null,null,null,"Rehabilitative Speech Therapy"]
[null,null,null,"Routine Eye Exam (Adult)"]
["High",null,null,"Routine Eye Exam for Children"]
["Low",null,null,"Routine Foot Care"]
[null,null,null,"Skilled Nursing Facility"]
["$X Copay per Stay",null,null,"Specialist Visit"]
["$X Copay per Stay with deductible",null,null,"Substance Abuse Disorder Inpatient Services"]
["$X Copay per Stay after deductible",null,null,"Substance Abuse Disorder Outpatient Services"]
["$X Copay per Day",null,null,"Transplant"]
["$X Copay per Day with deductible",null,null,"Treatment for Temporomandibular Joint Disorders"]
["$X Copay per Day after deductible",null,null,"Urgent Care Centers or Facilities"]
["$X",null,null,"Weight Loss Programs"]
["$X Copay with deductible",null,null,"Well Baby Visits and Care"]
["$X Copay after deductible",null,null,"X-rays and Diagnostic Imaging"]
["No Charge"]
["No Charge after deductible",null,null,"Click to enter Family MOOP"]
["Not Applicable"]
[null,null,null,"Click to enter Family Deductible"]
["Not Applicable"]
["Design 1"]
["Design 2"]
["Design 3"]
["Design 4"]
["Design 5"]