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["Benefit Components Template for Individual and Small Group Medical Filings"]
["Instructions"]
["Version 3.1"]
[]
["Purpose"]
["The purpose of this document is to enable carriers to summarize the benefits of each of their plans in a consistent way while capturing all the information needed to assess the plan designs for compliance. Compared to the Plans and Benefits Template and Actuarial Value Calculator, this template allows significantly more flexibility in both the benefit categories and cost-sharing structures that can be entered. Carriers should enter their plan designs as best as the template will accommodate and make notes of plan features that do not fit into the template (see instructions below)."]
[]
["Understanding the Template"]
["You are currently on the Instructions sheet of this document. Please read this sheet fully before beginning the process of completing the templates. Once you are ready to begin, you can use the \"Add Plan Worksheet\" button (above) to add exactly one sheet for each plan (and each CSR variation) you are offering. Under the added sheets, you will see six more buttons, which allow you to add or subtract lines from the benefits table as needed to accommodate your plan design. You will need to fill out the plan information at the top of the template and then fill out the table below to display a summary of your plan's benefits and cost sharing structure. Note that the \"Update Plan Worksheet Names\" button (above) is used to update all of the plan sheet names to the HIOS Plan IDs entered under Line 1.1 in each of the corresponding sheets (which should be done before this document is submitted in the rate filing)."]
[]
["Plan Worksheet Cell Legend"]
["Cell Format","Cell Color and Further Explanation"]
["Entry Required","These cells require a user entry or selection."]
["\"Yes\" Entry","Cells with a value of \"Yes\" will take on a yellow-orange color."]
[null,"These cells are not applicable based on user entries or selections in the corresponding plan sheet. If you believe an entry should be made, consider why this cell is deemed not applicable based on your other entries in the sheet. Make a note in the sheet if necessary."]
["Delete Text","Some cells start out like this when the template is first copied. After you enter a plan design into the template, you must delete the text from any remaining cells formatted this way (grey cells with red text). As indicated above, grey cells are not applicable and therefore should have no entries."]
["Unique Plan Design","These cells indicate that the cost-sharing structure you entered in the plan sheet creates a unique plan design for the purpose of calculating the actuarial value (AV) based on the functionality of the federal AV calculator or that the entry is an error. The format of these cells changes from the \"Entry Required\" format above to the format shown to the left based on the user's entry in the cells. Please see the \"Automatic Checks\" table below for details. Note that if your plan design is unique, you must submit an exhibit in the rate filing showing and justifying your adjustment to the AV calculation."]
[]
["Instructions"]
["Sheet","Guidance"]
["Instructions","Fully read through these instructions before beginning. This will almost surely save you time in the long run. There are specific ways in which the plans must be entered, as explained below. If, as you are entering a plan, there seems to be ambiguity about how it should be entered, please recheck these instructions, contact the OIC with your question, and/or make a note (as allowed in the template)."]
["Instructions","Add one sheet with the \"Add Plan Sheet\" button (found at the top of this sheet) for each plan you are offering (and one of each CSR variation). You may not include two plans on one sheet. If you have plans that are identical (or nearly so) you may find that it is faster to fill out one sheet and then duplicate it, making any changes necessary from that starting point. To do this, right click the sheet found at the bottom of the Excel application and click \"More or Copy...\", then check \"Create a Copy\", highlight (i.e., click) the sheet you want this new sheet to come before in the \"Before Sheet\" box, then click \"OK\". If you choose to duplicate sheets to save time, be very careful not to miss plan differences when adjusting the duplicated sheets. We recommend you duplicate tabs sparingly."]
["Plan Sheets\n(Section 1)","In Section 1, enter the HIOS Plan ID, Plan Name, Metal Level, and whether this is a CSR plan variant. Ensure that the Plan Name matches the forms, binder and rate filing documents exactly."]
["Plan Sheets\n(Section 2)","In Section 2, enter the Plan Design Information. Lines 2.2-2.10 should be entered the same way as they are entered in the AV Calculator. On Line 2.11, if you enter \"Yes\" to indicate different cost-sharing between virtual care and non-virtual care, add a note (\"Note 1\") under the underlined \"Notes\" header at the bottom of the page. In this note, explain how the cost-sharing is different and how you are accounting for those differences in this template, in the Plans and Benefits template, and in the AV Calculator. Be aware that the instructions for Section 4 (below) include that you should add rows to the benefit table to reflect any differing virtual cost shares."]
["Plan Sheets\n(Section 3)","In Section 3, enter the network and tier information. Based on your selection in Line 3.3 and Line 3.7, the table below will allow up to four tiers (including one for out-of-network benefits). The tiers will be part of the table in Section 4."]
["Plan Sheets\n(Section 4)","In Section 4, enter a tier name or description in Line 4.1. Do this for all tiers. The entries should describe the tiers in enough detail so that the tiers can be understood. For example, you might write \"In-Network Tier,\" \"Without-Referral Tier,\" or \"Virtual Tier.\""]
["Plan Sheets\n(Section 4)","Customize the table to match the benefits you offer for the plan. The six buttons at the top of the sheet can be used to add or subtract rows from the table. There are 4 sections of the table:\n(1) Medical Benefits: Most of these categories are identical to those in the AV Calculator, with a few additions. Fill in all of these rows unless the benefit is not offered.\n(2) Other EHB Categories: If the plan offers EHBs not shown in the Medical Benefits section above, add a row for each such benefit. This section should also be used whenever the Medical Benefit categories above do not adequately describe the cost-sharing structure; for example, if you split the Outpatient Facility Fee benefits into multiple categories, you can add rows to display the different subcategory cost shares. Make sure to title the categories appropriately and add notes as necessary for the sake of clarity.\n(3) Non-EHB Benefits: Add rows for non-EHB benefits that the plan offers.\n(4) Drug Benefit Tiers: These drug tiers are the 4 standard tiers, as seen in the AV Calculator. If your plan design has more than 4 tiers, add more rows and title them appropriately.\n*** It is assumed that your plan designs cover virtual visits at the same cost shares as in-person visits. If this is not the case for one or more categories of services, add rows to the table as necessary to reflect the differing cost shares."]
["Plan Sheets\n(Section 4)","Enter the cost-sharing information in the table. Guidance is provided below:\n(1) Upfront Visits or Copays?: Enter “Yes” if the upfront visits or upfront copays are applicable to the benefit category; otherwise, enter “No.” Upfront visits are associated with the “Begin Primary Care Cost-Sharing After a Set Number of Visits” field, and upfront copays are associated with the  “Begin Primary Care Deductible/Coinsurance After a Set Number of Copays” field.\n(2) Subject to Deductible?: If the member's cost-share for the benefit category depends on whether a deductible is met, select \"Yes\"; otherwise, select \"No.\"\n(3) Amount (Copays): Enter the amount of the copay, if applicable. Otherwise, leave the cell blank to indicate that a copay is not applicable.\n(4) Applies (Copays): If there is a copay, enter whether the copay applies before, after, or before and after the deductible. Note that if the benefit is subject to the deductible and copay applies before the deductible, first the copay applies to the allowed charge, and then the rest of the charge applies toward the deductible. In this case, the copay does not accumulate toward the deductible. If the whole amount that the member pays (the allowed charge) accumulates toward the deductible, you should select \"After Deductible.\"\n(5) Amount (Coinsurance): Enter the member's coinsurance (%) rate, not the carrier's portion. Otherwise, leave the cell blank to indicate that a coinsurance is not applicable."]
["Plan Sheets\n(Section 4)","(6) Applies (Coinsurance): Enter whether the coinsurance applies before, after, or before and after the deductible. Note that a coinsurance applying before the deductible has been met is a unique plan design (see below).\n(7) Accrues Toward Deductible (Copays or Coinsurance): If applicable, enter whether or not the copay or coinsurance paid by the member accrues toward meeting the deductible.\n(8) Comments: Whenever the plan design is not accommodated by the template (or other clarification is deemed necessary), add a note in the \"Comments\" column. You will select a note number, which you will then need to also select below, in the Notes section. Add your written comment in this Notes section, explaining what about your plan design is not captured in the template (or otherwise providing clarity).\n*** If the benefit is fully covered (no member cost share), enter \"No\" under \"Subject to Deductible?\" Enter \"0\" for the Copay \"Amount\" and \"Before and After Deductible\" in the \"Applies\" column.\n*** If there is no copay or no coinsurance applicable to a particular benefit, leave all three column entries under the particular header (\"Copays\" or \"Coinsurance\") blank. Make sure to delete any existing text from those columns.\n*** If the benefit is not covered by the plan, enter \"No\" under \"Subject to Deductible?,\" \"100%\" for the Coinsurance \"Amount,\" \"Before and After Deductible\" in the \"Applies\" column, and \"No\" in the \"Accrues Toward Deductible?\" column. Also, add a note to clarify that the benefit is not covered.\n*** If an individual benefit does not have tiered cost sharing within a plan with multiple tiers, enter the cost sharing features (e.g., copays, coinsurances, whether the deductible applies, etc.) identically to how they were entered in tier 1 when filling out other tiers."]
["Plan Sheets\n(Final Notes)","Review the unique plan design elements. The table below describes some (but not necessarily all) of the unique plan design elements that a plan may have. If any of these unique design elements is applicable to your plan, you will need to adjust your Actuarial Value Calculation in an actuarially justifiable way and provide the justification in a unique plan design justification rate filing exhibit. In such an exhibit, you must include all calculations, data or data sources, plan design descriptions, etc., necessary for thorough review."]
[]
[null,"Automatic Checks (Automatically Highlighted in Orange)"]
[null,"Column Header","Explanation (What Does Orange Highlighting Mean?)"]
[null,"Upfront Visits or Copays?","Cells in this column are highlighted whenever \"Yes\" is entered for a benefit other than \"Primary Care Visit to Treat an Injury or Illness.\""]
[null,"Subject to Deductible?","[Only for the \"Primary Care Visit to Treat an Injury or Illness\" benefit category] If \"Subject to Deductible?\" is \"No\" and \"Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?\" (Line 2.8) is not \"N/A,\" the Cell will be highlighted. This sort of design is not logically consistent and therefore should be corrected. Note that this combination of entries also causes an error in the AV Calculator."]
[null,"Copays: Applies","Cells in this column are highlighted whenever both a copay and coinsurance apply after the deductible (including when either or both apply before and after the deductible)."]
[null,"Copays: Accrues toward Deductible?","Cells in this column are highlighted whenever \"No\" is entered under \"Subject to Deductible?\" and \"Yes\" is entered under \"Accrues Toward Deductible?\""]
[null,"Coinsurance: Applies","Cells in this column are highlighted whenever it is indicated that a coinsurance applies before (or before and after) the deductible."]
[]
[null,"Manual Checks (Not Automatically Highlighted and Not Always Accommodated by the Template)"]
[null,"Column Header","Explanation"]
[null,"More Than 4 Drug Tiers","If the plan incorporates more than 4 tiers of drug cost shares, this is a unique design."]
[null,"Maximum Coinsurance","If a coinsurance is applied up to a limit for a benefit other than Specialty Drugs (Tier 4 Drugs), this is a unique plan design."]
[null,"Multiple Cost Share Tiers for One Benefit Category","The AV Calculator has certain benefit categories and allows one copay and/or coinsurance for each. If your plan involves subdividing the AV Calculator's benefit categories and providing different cost shares for each subcategory, this is a unique plan design. A unique plan design AV adjustment will be required; for example, a utilization-weighted blended copay and/or coinsurance may be appropriate."]
[]
["Plan Sheets","Review the cells that are greyed out.  Text in such cells will be red.  Delete all such text.  If you believe something is missing from the representation of the plan as shown in the template, please add a note explaining why. Also, review the \"Errors/Warnings\" columns. If there are any numbers in these columns, use the guidance in the \"Errors/Warnings\" section below to correct the issues."]
["Instructions","Press the \"Update Plan Worksheet Names\" button (found at the top of this sheet) to automatically rename all of the sheets to the HIOS Plan IDs entered on Line 1.1 in the plans' sheets. Note that you may press this button multiple times as you work through the templates if doing so make it easier for you to navigate throughout the document."]
["All","Delete any extra sheets before submitting the document in the rate filing. There should be exactly one sheet added for each plan you will be offering and one sheet for each CSR variation. Remove the Illustrative Example sheet before submitting both the Excel version and PDF version of this document.  Note that we do not recommend that you delete this Instructions worksheet, because doing so will also remove your ability to use the two buttons at the top in the case that any corrections are required."]
["All","Make a PDF copy of this document. Make sure that the PDF shows each and every sheet and cell in this document. You should check the PDF to be sure that this is the case and that no text is cut off due to formatting. If necessary, adjust the print area in the plan sheets to allow the text to show in the PDF."]
["All","Submit both the Excel version and PDF version of this document. Name the PDF version \"Benefit Components.pdf\" and name the Excel version \"Benefit Components Duplicate.xlsm.\""]
[]
["Errors/Warnings"]
["The \"Errors/Warnings\" columns in Section 4 of the plan sheets are designed to check for common mistakes in each row. Please review these columns and correct all errors. Specific guidance for each error is provided in the table below. If you receive an error and do not believe it should be an error, please add a note to clarify the plan design."]
[]
[null,"Errors/Warnings"]
[null,"Error/Warning Number","Explanation"]
[null,1,"Why is this error showing?\nThis error is shown whenever the \"Preventive Care/Screening/Immunization\" benefit category's cost sharing information is entered incorrectly.\n\nHow do I fix this error?\nThis benefit category should be entered to have a copay of $0 that applies \"Before and After the Deductible.\" No coinsurance information should be entered."]
[null,2,"Why is this error showing?\nThis error is shown whenever a logically inconsistent plan design was entered, whenever there is text in a cell that should be blank, and whenever an entry was expected in a cell but not entered.\n\nHow do I fix this error?\nMake sure that the row is filled out completely and that there is no red text in any grey cell. If only a copay or only a coinsurance is applicable to the benefit category, do not enter anything for the other cost share (i.e., leave all three corresponding columns blank). Make sure that all of the entries in the row follow the data validation rules (i.e., that they are options from the dropdown, numbers when they are supposed to be numbers, etc.)."]
[null,3,"Why is this error showing?\nThis error is shown whenever you have indicated that a benefit category is not subject to the deductible but have not indicated what cost share applies in both phases of cost sharing (i.e., before the deductible and after the deductible).\n\nHow do I fix this error?\nOne of the copay or the coinsurance must apply before and after the deductible, or one must apply before and one must apply after. Otherwise, you have not specified the cost share in all phases. For example, if a copay applies before the deductible and there is no member cost share after the deductible, enter the copay amount and select \"Before Deductible\" and enter a 0% coinsurance and select \"After Deductible.\" Common plan designs include the following:\n          Copay (Before and After Deductible)\n          Coinsurance (Before and After Deductible)\n          Copay (Before Deductible) and Coinsurance (After Deductible)"]
[null,4,"Why is this error showing?\nThis error is shown whenever the Deductible, Default Coinsurance, or MOOP entries are missing or inconsistent with the entries in Line 2.2 or Line 2.5.\n\nHow do I fix this error?\nMake sure that all yellow cells have entries and all grey cells are blank (i.e., no red text). If this would result in a misrepresentation of the plan's actual design, review the entries in Line 2.2 and Line 2.5.\n\nFor out-of-network tiers, if there is no applicable deductible, enter $0. If there is no applicable default coinsurance, enter 100%. If there is no applicable MOOP, enter \"UNLIMITED\"."]

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[null,"Benefit Components",null,null,"Worksheet\nControls"]
[]
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[]
["Section 1: Plan Information"]
["Line 1.1","HIOS Plan ID","12345WA0000001",null,"Line 1.3","Metal Level","Expanded Bronze",null,"Line 1.5","Exchange Status","On Exchange",null,"HIOS Plan ID",{"$f":"IF(cell_HIOSID=\"\",\"\",cell_HIOSID)","v":"12345WA0000001"},null,null,"Metal Level",{"$f":"IF(cell_MetalLevel=\"\",\"\",cell_MetalLevel)","v":"Expanded Bronze"},null,"Exchange Status",{"$f":"IF($K$6=\"\",\"\",$K$6)","v":"On Exchange"},null,null,"HIOS Plan ID",{"$f":"IF(cell_HIOSID=\"\",\"\",cell_HIOSID)","v":"12345WA0000001"},null,null,"Metal Level",{"$f":"IF(cell_MetalLevel=\"\",\"\",cell_MetalLevel)","v":"Expanded Bronze"},null,"Exchange Status",{"$f":"IF($K$6=\"\",\"\",$K$6)","v":"On Exchange"},null,null,"HIOS Plan ID",{"$f":"IF(cell_HIOSID=\"\",\"\",cell_HIOSID)","v":"12345WA0000001"},null,null,"Metal Level",{"$f":"IF(cell_MetalLevel=\"\",\"\",cell_MetalLevel)","v":"Expanded Bronze"},null,"Exchange Status",{"$f":"IF($K$6=\"\",\"\",$K$6)","v":"On Exchange"}]
["Line 1.2","Plan Name","Plan 1",null,"Line 1.4","Cost-Share Reduction (CSR) Plan?",null,null,"Line 1.6","New or Renewing","Renewing",null,"Plan Name",{"$f":"IF(cell_PlanName=\"\",\"\",cell_PlanName)","v":"Plan 1"},null,null,"Cost-Share Reduction (CSR) Plan?",{"$f":"IF(cell_CSR=\"\",\"\",cell_CSR)","v":""},null,"New or Renewing",{"$f":"IF($K$7=\"\",\"\",$K$7)","v":"Renewing"},null,null,"Plan Name",{"$f":"IF(cell_PlanName=\"\",\"\",cell_PlanName)","v":"Plan 1"},null,null,"Cost-Share Reduction (CSR) Plan?",{"$f":"IF(cell_CSR=\"\",\"\",cell_CSR)","v":""},null,"New or Renewing",{"$f":"IF($K$7=\"\",\"\",$K$7)","v":"Renewing"},null,null,"Plan Name",{"$f":"IF(cell_PlanName=\"\",\"\",cell_PlanName)","v":"Plan 1"},null,null,"Cost-Share Reduction (CSR) Plan?",{"$f":"IF(cell_CSR=\"\",\"\",cell_CSR)","v":""},null,"New or Renewing",{"$f":"IF($K$7=\"\",\"\",$K$7)","v":"Renewing"}]
[]
["Section 2: Plan Design Information",null,null,null,"Section 3: Network and Tier Information"]
["Line 2.1","Unique Plan Design","Yes",null,"Line 3.1","Network Type","PPO"]
["Line 2.2","Use Integrated Medical & Drug Deductible?","No",null,"Line 3.2","Network Name","Network A"]
["Line 2.3","Apply Inpatient Copay per Day?","No",null,"Line 3.3","In-Network Tiers (#)",2]
["Line 2.4","Apply Skilled Nursing Facility Copay per Day?","No",null,"Line 3.4","Tier 1 Utilization",0.8,{"$f":"IF(SUM(G13:G15)<>1,\"<- The sum of the tier utilizations should be 100%.\",\"\")","v":""}]
["Line 2.5","Separate MOOP for Medical & Drug Spending?","No",null,"Line 3.5","Tier 2 Utilization",0.2]
["Line 2.6","Maximum Number of Days for Charging an IP Copay","N/A",null,"Line 3.6","Tier 3 Utilization"]
["Line 2.7","Begin Primary Care Cost-Sharing After a Set Number of Visits",3,null,"Line 3.7","Out-of-Network Benefits?","No"]
["Line 2.8","Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?","N/A"]
["Line 2.9","HSA Plan?","No",{"$f":"IF(C18=\"Yes\",IFERROR(IF(FIND(\"HSA\",cell_PlanName)>0,\"\",\"\"),\"<- Check Plan Name.\"),\"\")","v":""}]
["Line 2.10","HSA Employer Contribution Amount"]
["Line 2.11","Different Cost-Sharing for Virtual vs Non-Virtual Care?","No",{"$f":"IF(C20=\"Yes\",\"<- Provide Explanation in Note 1 (at the bottom of the page).\",\"\")","v":""}]
["Line 2.12","Pediatric Dental Embedded?","No"]
["Line 2.13","Includes Non-EHBs?","Yes"]
[]
["Section 4: Cost-Share Designs"]
["Line 4.1","In-Network Tier 1:","Classic Network",null,null,null,null,null,null,null,null,null,"In-Network Tier 2:","Value Network",null,null,null,null,null,null,null,null,null,"In-Network Tier 3:","[Insert Tier Name/Description]",null,null,null,null,null,null,null,null,null,"Out-of-Network:","[Insert Tier Name/Description]"]
[]
[null,null,"Medical","Drug","Combined","Errors/Warnings",null,null,null,null,null,null,null,"Medical","Drug","Combined","Errors/Warnings",null,null,null,null,null,null,null,"Medical","Drug","Combined","Errors/Warnings",null,null,null,null,null,null,null,"Medical","Drug","Combined","Errors/Warnings"]
[null,"Deductible",3000,1500,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(C28)=FALSE,ISBLANK(D28)=FALSE,ISBLANK(E28))),AND($C$11=\"No\",OR(ISBLANK(C28),ISBLANK(D28),ISBLANK(E28)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Deductible",3000,1500,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(N28)=FALSE,ISBLANK(O28)=FALSE,ISBLANK(P28))),AND($C$11=\"No\",OR(ISBLANK(N28),ISBLANK(O28),ISBLANK(P28)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Deductible",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(Y28)=FALSE,ISBLANK(Z28)=FALSE,ISBLANK(AA28))),AND($C$11=\"No\",OR(ISBLANK(Y28),ISBLANK(Z28),ISBLANK(AA28)=FALSE))),\"4\",\"\")","v":"4"},null,null,null,null,null,null,"Deductible",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(AJ28)=FALSE,ISBLANK(AK28)=FALSE,ISBLANK(AL28))),AND($C$11=\"No\",OR(ISBLANK(AJ28),ISBLANK(AK28),ISBLANK(AL28)=FALSE))),\"4\",\"\")","v":"4"}]
[null,"Default Coinsurance",0.3,0.5,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(C29)=FALSE,ISBLANK(D29)=FALSE,ISBLANK(E29))),AND($C$11=\"No\",OR(ISBLANK(C29),ISBLANK(D29),ISBLANK(E29)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Default Coinsurance",0.3,0.5,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(N29)=FALSE,ISBLANK(O29)=FALSE,ISBLANK(P29))),AND($C$11=\"No\",OR(ISBLANK(N29),ISBLANK(O29),ISBLANK(P29)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Default Coinsurance",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(Y29)=FALSE,ISBLANK(Z29)=FALSE,ISBLANK(AA29))),AND($C$11=\"No\",OR(ISBLANK(Y29),ISBLANK(Z29),ISBLANK(AA29)=FALSE))),\"4\",\"\")","v":"4"},null,null,null,null,null,null,"Default Coinsurance",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(AJ29)=FALSE,ISBLANK(AK29)=FALSE,ISBLANK(AL29))),AND($C$11=\"No\",OR(ISBLANK(AJ29),ISBLANK(AK29),ISBLANK(AL29)=FALSE))),\"4\",\"\")","v":"4"}]
[null,"MOOP",null,null,8000,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(C30)=FALSE,ISBLANK(D30)=FALSE,ISBLANK(E30))),AND($C$14=\"Yes\",OR(ISBLANK(C30),ISBLANK(D30),ISBLANK(E30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(C30)=FALSE,ISBLANK(D30)=FALSE,ISBLANK(E30)))),\"4\",\"\")","v":""},null,null,null,null,null,null,"MOOP",null,null,8000,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(N30)=FALSE,ISBLANK(O30)=FALSE,ISBLANK(P30))),AND($C$14=\"Yes\",OR(ISBLANK(N30),ISBLANK(O30),ISBLANK(P30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(N30)=FALSE,ISBLANK(O30)=FALSE,ISBLANK(P30)))),\"4\",\"\")","v":""},null,null,null,null,null,null,"MOOP",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(Y30)=FALSE,ISBLANK(Z30)=FALSE,ISBLANK(AA30))),AND($C$14=\"Yes\",OR(ISBLANK(Y30),ISBLANK(Z30),ISBLANK(AA30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(Y30)=FALSE,ISBLANK(Z30)=FALSE,ISBLANK(AA30)))),\"4\",\"\")","v":"4"},null,null,null,null,null,null,"MOOP",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(AJ30)=FALSE,ISBLANK(AK30)=FALSE,ISBLANK(AL30))),AND($C$14=\"Yes\",OR(ISBLANK(AJ30),ISBLANK(AK30),ISBLANK(AL30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(AJ30)=FALSE,ISBLANK(AK30)=FALSE,ISBLANK(AL30)))),\"4\",\"\")","v":"4"}]
[]
[null,null,null,null,null,"Copays",null,null,"Coinsurance",null,null,null,null,null,null,null,"Copays",null,null,"Coinsurance",null,null,null,null,null,null,null,"Copays",null,null,"Coinsurance",null,null,null,null,null,null,null,"Copays",null,null,"Coinsurance"]
[null,"Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/"]
[null,"Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings"]
[null,"Emergency Room Services","No","Yes",200,"Before and After Deductible",null,0.3,"After Deductible",null,"Note 1",{"$f":"IF(OR(ISBLANK(D35),AND(ISBLANK(E35),ISBLANK(H35))),\"2\",IF(AND(B35=\"Preventive Care/Screening/Immunization\",OR(D35<>\"No\",E35<>0,F35<>\"Before and After Deductible\",ISBLANK(G35)=FALSE,ISBLANK(H35)=FALSE,ISBLANK(I35)=FALSE,ISBLANK(J35)=FALSE)),\"1\",\"\")&IF(LEN(IF(AND(B35=\"Preventive Care/Screening/Immunization\",OR(D35<>\"No\",E35<>0,F35<>\"Before and After Deductible\",ISBLANK(G35)=FALSE,ISBLANK(H35)=FALSE,ISBLANK(I35)=FALSE,ISBLANK(J35)=FALSE)),\"1\",\"\"))=0,IF(OR(COUNTIF(C35:J35,\"Select\")>0,OR(AND(C35<>\"Yes\",C35<>\"No\",ISBLANK(C35)=FALSE),AND(D35<>\"Yes\",D35<>\"No\",ISBLANK(D35)=FALSE),AND(G35<>\"Yes\",G35<>\"No\",ISBLANK(G35)=FALSE),AND(J35<>\"Yes\",J35<>\"No\",ISBLANK(J35)=FALSE),AND(F35<>\"After Deductible\",F35<>\"Before Deductible\",F35<>\"Before and After Deductible\",ISBLANK(F35)=FALSE),AND(I35<>\"After Deductible\",I35<>\"Before 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[null,"Primary Care Visit to Treat an Injury or Illness","Yes","No",50,"Before and After Deductible","No",null,null,null,"Note 3","","Primary Care Visit to Treat an Injury or Illness","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Primary Care Visit to Treat an Injury or Illness","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Primary Care Visit to Treat an Injury or Illness","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Specialist Visit","Yes","Yes",75,"After Deductible",null,null,null,null,"Note 3","","Specialist Visit","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Specialist Visit","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Specialist Visit","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Mental Health & Substance Use Disorder Office Visits","Yes","No",50,"Before and After Deductible","No",null,null,null,"Note 3","","Mental Health & Substance Abuse Disorder Office Visits","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Mental Health & Substance Abuse Disorder Office Visits","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder Office Visits","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Mental Health & Substance Use Disorder All Other OP Services","No","Yes",null,null,null,0.3,"After Deductible",null,null,"","Mental Health & Substance Abuse Disorder All Other OP Services","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Mental Health & Substance Abuse Disorder All Other OP Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder All Other OP Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Imaging (CT/PET Scans, MRIs)","No","Yes",100,"Before and After Deductible",null,null,null,null,null,"","Imaging (CT/PET Scans, MRIs)","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Imaging (CT/PET Scans, MRIs)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Imaging (CT/PET Scans, MRIs)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Rehabilitative Speech Therapy","No","No",80,"Before and After Deductible","No",null,null,null,null,"","Rehabilitative Speech Therapy","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Rehabilitative Speech Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Speech Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Rehabilitative Occupational and Rehabilitative Physical Therapy","No","No",80,"Before and After Deductible","No",null,null,null,null,"","Rehabilitative Occupational and Rehabilitative Physical Therapy","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Rehabilitative Occupational and Rehabilitative Physical Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Occupational and Rehabilitative Physical Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Preventive Care/Screening/Immunization","No","No",0,"Before and After Deductible",null,null,null,null,null,"","Preventive Care/Screening/Immunization","No","No",0,"Before and After Deductible",null,null,null,null,null,"","Preventive Care/Screening/Immunization","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Preventive Care/Screening/Immunization","Select","Select",null,"Select","Select",null,"Select","Select",null,{"$f":"IF(OR(ISBLANK(AK44),AND(ISBLANK(AL44),ISBLANK(AO44))),\"2\",IF(AND(AI44=\"Preventive Care/Screening/Immunization*****\",OR(AK44<>\"No\",AL44<>0,AM44<>\"Before and After Deductible\",ISBLANK(AN44)=FALSE,ISBLANK(AO44)=FALSE,ISBLANK(AP44)=FALSE,ISBLANK(AQ44)=FALSE)),\"1\",\"\")&IF(LEN(IF(AND(AI44=\"Preventive Care/Screening/Immunization*****\",OR(AK44<>\"No\",AL44<>0,AM44<>\"Before and After 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Deductible\",ISBLANK(AN44)=FALSE),AND(AO44=0,ISBLANK(AQ44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AQ44)=FALSE),AND(AP44=\"After Deductible\",ISBLANK(AQ44)=FALSE)),\"2\",\"\"))=0),IF(AND(AK44=\"No\",OR(AND(AM44<>\"Before and After Deductible\",ISBLANK(AP44)),AND(AP44<>\"Before and After Deductible\",ISBLANK(AM44)),AND(AM44<>\"Before and After Deductible\",AM44=AP44))),\"3\",\"\"),IF(AND(AK44=\"No\",OR(AND(AM44<>\"Before and After Deductible\",ISBLANK(AP44)),AND(AP44<>\"Before and After Deductible\",ISBLANK(AM44)),AND(AM44<>\"Before and After Deductible\",AM44=AP44))),\", 3\",\"\")))","v":"2"}]
[null,"Laboratory Outpatient and Professional Services","No","No",null,null,null,0.3,"Before and After Deductible","No",null,"","Laboratory Outpatient and Professional Services","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Laboratory Outpatient and Professional Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Laboratory Outpatient and Professional Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"X-rays and Diagnostic Imaging","No","No",null,null,null,0.3,"Before and After Deductible","No",null,"","X-rays and Diagnostic Imaging","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","X-rays and Diagnostic Imaging","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","X-rays and Diagnostic Imaging","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Skilled Nursing Facility","No","Yes",75,"After Deductible",null,null,null,null,null,"","Skilled Nursing Facility","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Skilled Nursing Facility","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Skilled Nursing Facility","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","No","Yes",100,"After Deductible",null,null,null,null,null,"","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Outpatient Surgery Physician/Surgical Services","No","Yes",100,"After Deductible",null,null,null,null,null,"","Outpatient Surgery Physician/Surgical Services","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Outpatient Surgery Physician/Surgical Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Surgery Physician/Surgical Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Urgent Care","No","No",80,"Before and After Deductible","No",null,null,null,null,"","Urgent Care","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Urgent Care","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Urgent Care","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Emergency Transportation","No","Yes",75,"After Deductible",null,null,null,null,null,"","Emergency Transportation","No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"","Emergency Transportation","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Emergency Transportation","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Other EHB Categories",null,null,null,null,null,null,null,null,null,null,"Other EHB Categories",null,null,null,null,null,null,null,null,null,null,"Other EHB Categories",null,null,null,null,null,null,null,null,null,null,"Other EHB Categories"]
[null,"Outpatient Facility Fee - Designated Centers Only","No","No",0,"Before and After Deductible",null,null,null,null,"Note 2",{"$f":"IF(OR(ISBLANK(D53),AND(ISBLANK(E53),ISBLANK(H53))),\"2\",IF(AND(B53=\"Preventive Care/Screening/Immunization\",OR(D53<>\"No\",E53<>0,F53<>\"Before and After Deductible\",ISBLANK(G53)=FALSE,ISBLANK(H53)=FALSE,ISBLANK(I53)=FALSE,ISBLANK(J53)=FALSE)),\"1\",\"\")&IF(LEN(IF(AND(B53=\"Preventive Care/Screening/Immunization\",OR(D53<>\"No\",E53<>0,F53<>\"Before and After Deductible\",ISBLANK(G53)=FALSE,ISBLANK(H53)=FALSE,ISBLANK(I53)=FALSE,ISBLANK(J53)=FALSE)),\"1\",\"\"))=0,IF(OR(COUNTIF(C53:J53,\"Select\")>0,OR(AND(C53<>\"Yes\",C53<>\"No\",ISBLANK(C53)=FALSE),AND(D53<>\"Yes\",D53<>\"No\",ISBLANK(D53)=FALSE),AND(G53<>\"Yes\",G53<>\"No\",ISBLANK(G53)=FALSE),AND(J53<>\"Yes\",J53<>\"No\",ISBLANK(J53)=FALSE),AND(F53<>\"After Deductible\",F53<>\"Before Deductible\",F53<>\"Before and After Deductible\",ISBLANK(F53)=FALSE),AND(I53<>\"After 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[]
[null,"Non-EHB Benefits",null,null,null,null,null,null,null,null,null,null,"Non-EHB Benefits",null,null,null,null,null,null,null,null,null,null,"Non-EHB Benefits",null,null,null,null,null,null,null,null,null,null,"Non-EHB Benefits"]
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[null,"Adult Dental Exam","No","No",50,"Before and After Deductible","No",null,null,null,null,"",{"$f":"TEXT(B57,)","v":"Adult Dental Exam"},"No","Yes",null,null,null,0.3,"Before and After Deductible",null,null,"",{"$f":"TEXT(B57,)","v":"Adult Dental Exam"},null,null,null,null,null,null,null,null,null,"2",{"$f":"TEXT(B57,)","v":"Adult Dental Exam"},null,null,null,null,null,null,null,null,null,"2"]
[]
[null,"Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/"]
[null,"(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings"]
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Deductible\",ISBLANK(AE62)),AND(AE62<>\"Before and After Deductible\",ISBLANK(AB62)),AND(AB62<>\"Before and After Deductible\",AB62=AE62))),\"3\",\"\"),IF(AND(Z62=\"No\",OR(AND(AB62<>\"Before and After Deductible\",ISBLANK(AE62)),AND(AE62<>\"Before and After Deductible\",ISBLANK(AB62)),AND(AB62<>\"Before and After Deductible\",AB62=AE62))),\", 3\",\"\")))","v":"2"},"Preferred Brand Drugs (Tier 2)",null,"Select",null,"Select","Select",null,"Select","Select",null,{"$f":"IF(OR(ISBLANK(AK62),AND(ISBLANK(AL62),ISBLANK(AO62))),\"2\",IF(AND(AI62=\"Preventive Care/Screening/Immunization\",OR(AK62<>\"No\",AL62<>0,AM62<>\"Before and After Deductible\",ISBLANK(AN62)=FALSE,ISBLANK(AO62)=FALSE,ISBLANK(AP62)=FALSE,ISBLANK(AQ62)=FALSE)),\"1\",\"\")&IF(LEN(IF(AND(AI62=\"Preventive Care/Screening/Immunization\",OR(AK62<>\"No\",AL62<>0,AM62<>\"Before and After 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Deductible\",ISBLANK(AP62)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL62)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO62)<0,TRUE,FALSE),TRUE)),OR(AND(AK62=\"Yes\",ISBLANK(AL62)=FALSE,ISBLANK(AM62)),AND(AK62=\"Yes\",ISBLANK(AO62)=FALSE,ISBLANK(AP62))),OR(OR(AND(AK62=\"No\",ISBLANK(AL62)=FALSE,ISBLANK(AM62)),AND(AK62=\"No\",AL62<>0,ISBLANK(AM62)=FALSE,AM62<>\"After Deductible\",ISBLANK(AN62))),OR(AND(AK62=\"No\",ISBLANK(AO62)=FALSE,ISBLANK(AP62)),AND(AK62=\"No\",AO62<>0,ISBLANK(AP62)=FALSE,AP62<>\"After Deductible\",ISBLANK(AQ62)))),AND(ISBLANK(AL62),ISBLANK(AM62)=FALSE),AND(ISBLANK(AO62),ISBLANK(AP62)=FALSE),AND(AL62=0,ISBLANK(AN62)=FALSE),AND(AK62=\"Yes\",ISBLANK(AN62)=FALSE),AND(AM62=\"After Deductible\",ISBLANK(AN62)=FALSE),AND(AO62=0,ISBLANK(AQ62)=FALSE),AND(AK62=\"Yes\",ISBLANK(AQ62)=FALSE),AND(AP62=\"After Deductible\",ISBLANK(AQ62)=FALSE)),\", 2\",\"\"))&IF(AND(LEN(IF(AND(AI62=\"Preventive Care/Screening/Immunization\",OR(AK62<>\"No\",AL62<>0,AM62<>\"Before and After Deductible\",ISBLANK(AN62)=FALSE,ISBLANK(AO62)=FALSE,ISBLANK(AP62)=FALSE,ISBLANK(AQ62)=FALSE)),\"1\",\"\"))=0,LEN(IF(OR(COUNTIF(AJ62:AQ62,\"Select\")>0,OR(IFERROR(IF(_xlfn.NUMBERVALUE(AJ62)<0,TRUE,FALSE),TRUE),AND(AK62<>\"Yes\",AK62<>\"No\",ISBLANK(AK62)=FALSE),AND(AN62<>\"Yes\",AN62<>\"No\",ISBLANK(AN62)=FALSE),AND(AQ62<>\"Yes\",AQ62<>\"No\",ISBLANK(AQ62)=FALSE),AND(AM62<>\"After Deductible\",AM62<>\"Before Deductible\",AM62<>\"Before and After Deductible\",ISBLANK(AM62)=FALSE),AND(AP62<>\"After Deductible\",AP62<>\"Before Deductible\",AP62<>\"Before and After Deductible\",ISBLANK(AP62)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL62)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO62)<0,TRUE,FALSE),TRUE)),OR(AND(AK62=\"Yes\",ISBLANK(AL62)=FALSE,ISBLANK(AM62)),AND(AK62=\"Yes\",ISBLANK(AO62)=FALSE,ISBLANK(AP62))),OR(OR(AND(AK62=\"No\",ISBLANK(AL62)=FALSE,ISBLANK(AM62)),AND(AK62=\"No\",AL62<>0,ISBLANK(AM62)=FALSE,AM62<>\"After 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[null,"Non-Preferred Brand Drugs (Tier 3)",null,"Yes",100,"After Deductible",null,null,null,null,null,"","Non-Preferred Brand Drugs (Tier 3)",null,"Yes",null,null,null,0.5,"After Deductible",null,null,"","Non-Preferred Brand Drugs (Tier 3)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Non-Preferred Brand Drugs (Tier 3)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Specialty Drugs (Tier 4)",null,"Yes",null,null,null,0.5,"After Deductible",null,null,"","Specialty Drugs (Tier 4)",null,"Yes",null,null,null,0.5,"After Deductible",null,null,"","Specialty Drugs (Tier 4)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Specialty Drugs (Tier 4)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2"]
[]
["Notes"]
["Note 1","In this plan, when a copay and coinsurance both apply in the same range, the copay applies first, and the coinsurance applies to the remaining allowed charges. The copays don't accrue toward the deductible."]
["Note 2","Outpatient facility fees are fully covered for designated facilities."]
["Note 3","The 3 upfront visits can be used for primary care visits, specialist visits, of mental health office visits."]
["Note 4","Virtual PCP visits use half the copay as in-person PCP visits."]

{"sheet":"Blank (Do Not Alter)","index":2,"n_rows":63,"n_cols":45,"rows_kept":63,"cut":false,"hidden":true,"merged":[]}
[null,"Benefit Components",null,null,"Worksheet\nControls"]
[]
[null,"Company:",null,null,"Market:",null,"Plan Year:",2024,null,null,null,null,"Company:",{"$f":"cell_Company","v":0},null,null,"Market:",{"$f":"cell_Market","v":0},null,"Plan Year:",{"$f":"cell_PlanYear","v":2024},null,null,"Company:",{"$f":"cell_Company","v":0},null,null,"Market:",{"$f":"cell_Market","v":0},null,"Plan Year:",{"$f":"cell_PlanYear","v":2024},null,null,"Company:",{"$f":"cell_Company","v":0},null,null,"Market:",{"$f":"cell_Market","v":0},null,"Plan Year:",{"$f":"cell_PlanYear","v":2024}]
[]
["Section 1: Plan Information"]
["Line 1.1","HIOS Plan ID",null,null,"Line 1.3","Metal Level","Select",null,"Line 1.5","Exchange Status","Select",null,"HIOS Plan ID",{"$f":"IF(cell_HIOSID=\"\",\"\",cell_HIOSID)","v":""},null,null,"Metal Level",{"$f":"IF(cell_MetalLevel=\"\",\"\",cell_MetalLevel)","v":"Select"},null,"Exchange Status",{"$f":"IF($K$6=\"\",\"\",$K$6)","v":"Select"},null,null,"HIOS Plan ID",{"$f":"IF(cell_HIOSID=\"\",\"\",cell_HIOSID)","v":""},null,null,"Metal Level",{"$f":"IF(cell_MetalLevel=\"\",\"\",cell_MetalLevel)","v":"Select"},null,"Exchange Status",{"$f":"IF($K$6=\"\",\"\",$K$6)","v":"Select"},null,null,"HIOS Plan ID",{"$f":"IF(cell_HIOSID=\"\",\"\",cell_HIOSID)","v":""},null,null,"Metal Level",{"$f":"IF(cell_MetalLevel=\"\",\"\",cell_MetalLevel)","v":"Select"},null,"Exchange Status",{"$f":"IF($K$6=\"\",\"\",$K$6)","v":"Select"}]
["Line 1.2","Plan Name",null,null,"Line 1.4","Cost-Share Reduction (CSR) Plan?","Select",null,"Line 1.6","New or Renewing","Select",null,"Plan Name",{"$f":"IF(cell_PlanName=\"\",\"\",cell_PlanName)","v":""},null,null,"Cost-Share Reduction (CSR) Plan?",{"$f":"IF(cell_CSR=\"\",\"\",cell_CSR)","v":"Select"},null,"New or Renewing",{"$f":"IF($K$7=\"\",\"\",$K$7)","v":"Select"},null,null,"Plan Name",{"$f":"IF(cell_PlanName=\"\",\"\",cell_PlanName)","v":""},null,null,"Cost-Share Reduction (CSR) Plan?",{"$f":"IF(cell_CSR=\"\",\"\",cell_CSR)","v":"Select"},null,"New or Renewing",{"$f":"IF($K$7=\"\",\"\",$K$7)","v":"Select"},null,null,"Plan Name",{"$f":"IF(cell_PlanName=\"\",\"\",cell_PlanName)","v":""},null,null,"Cost-Share Reduction (CSR) Plan?",{"$f":"IF(cell_CSR=\"\",\"\",cell_CSR)","v":"Select"},null,"New or Renewing",{"$f":"IF($K$7=\"\",\"\",$K$7)","v":"Select"}]
[]
["Section 2: Plan Design Information",null,null,null,"Section 3: Network and Tier Information"]
["Line 2.1","Unique Plan Design","Select",null,"Line 3.1","Network Type"]
["Line 2.2","Use Integrated Medical & Drug Deductible?","Select",null,"Line 3.2","Network Name"]
["Line 2.3","Apply Inpatient Copay per Day?","Select",null,"Line 3.3","In-Network Tiers (#)","Select"]
["Line 2.4","Apply Skilled Nursing Facility Copay per Day?","Select",null,"Line 3.4","Tier 1 Utilization",null,{"$f":"IF(SUM(G13:G15)<>1,\"<- The sum of the tier utilizations should be 100%.\",\"\")","v":"<- The sum of the tier utilizations should be 100%."}]
["Line 2.5","Separate MOOP for Medical & Drug Spending?","Select",null,"Line 3.5","Tier 2 Utilization"]
["Line 2.6","Maximum Number of Days for Charging an IP Copay","Select",null,"Line 3.6","Tier 3 Utilization"]
["Line 2.7","Begin Primary Care Cost-Sharing After a Set Number of Visits","Select",null,"Line 3.7","Out-of-Network Benefits?","Select"]
["Line 2.8","Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?","Select"]
["Line 2.9","HSA Plan?","Select",{"$f":"IF(C18=\"Yes\",IFERROR(IF(FIND(\"HSA\",cell_PlanName)>0,\"\",\"\"),\"<- Check Plan Name.\"),\"\")","v":""}]
["Line 2.10","HSA Employer Contribution Amount"]
["Line 2.11","Different Cost-Sharing for Virtual vs Non-Virtual Care?","Select",{"$f":"IF(C20=\"Yes\",\"<- Provide Explanation in Note 1 (at the bottom of the page).\",\"\")","v":""}]
["Line 2.12","Pediatric Dental Embedded?","Select"]
["Line 2.13","Includes Non-EHBs?","Select"]
[]
["Section 4: Cost-Share Designs"]
["Line 4.1","In-Network Tier 1:","[Insert Tier Name/Description]",null,null,null,null,null,null,null,null,null,"In-Network Tier 2:","[Insert Tier Name/Description]",null,null,null,null,null,null,null,null,null,"In-Network Tier 3:","[Insert Tier Name/Description]",null,null,null,null,null,null,null,null,null,"Out-of-Network:","[Insert Tier Name/Description]"]
[]
[null,null,"Medical","Drug","Combined","Errors/Warnings",null,null,null,null,null,null,null,"Medical","Drug","Combined","Errors/Warnings",null,null,null,null,null,null,null,"Medical","Drug","Combined","Errors/Warnings",null,null,null,null,null,null,null,"Medical","Drug","Combined","Errors/Warnings"]
[null,"Deductible",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(C28)=FALSE,ISBLANK(D28)=FALSE,ISBLANK(E28))),AND($C$11=\"No\",OR(ISBLANK(C28),ISBLANK(D28),ISBLANK(E28)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Deductible",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(N28)=FALSE,ISBLANK(O28)=FALSE,ISBLANK(P28))),AND($C$11=\"No\",OR(ISBLANK(N28),ISBLANK(O28),ISBLANK(P28)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Deductible",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(Y28)=FALSE,ISBLANK(Z28)=FALSE,ISBLANK(AA28))),AND($C$11=\"No\",OR(ISBLANK(Y28),ISBLANK(Z28),ISBLANK(AA28)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Deductible",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(AJ28)=FALSE,ISBLANK(AK28)=FALSE,ISBLANK(AL28))),AND($C$11=\"No\",OR(ISBLANK(AJ28),ISBLANK(AK28),ISBLANK(AL28)=FALSE))),\"4\",\"\")","v":""}]
[null,"Default Coinsurance",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(C29)=FALSE,ISBLANK(D29)=FALSE,ISBLANK(E29))),AND($C$11=\"No\",OR(ISBLANK(C29),ISBLANK(D29),ISBLANK(E29)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Default Coinsurance",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(N29)=FALSE,ISBLANK(O29)=FALSE,ISBLANK(P29))),AND($C$11=\"No\",OR(ISBLANK(N29),ISBLANK(O29),ISBLANK(P29)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Default Coinsurance",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(Y29)=FALSE,ISBLANK(Z29)=FALSE,ISBLANK(AA29))),AND($C$11=\"No\",OR(ISBLANK(Y29),ISBLANK(Z29),ISBLANK(AA29)=FALSE))),\"4\",\"\")","v":""},null,null,null,null,null,null,"Default Coinsurance",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(AJ29)=FALSE,ISBLANK(AK29)=FALSE,ISBLANK(AL29))),AND($C$11=\"No\",OR(ISBLANK(AJ29),ISBLANK(AK29),ISBLANK(AL29)=FALSE))),\"4\",\"\")","v":""}]
[null,"MOOP",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(C30)=FALSE,ISBLANK(D30)=FALSE,ISBLANK(E30))),AND($C$14=\"Yes\",OR(ISBLANK(C30),ISBLANK(D30),ISBLANK(E30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(C30)=FALSE,ISBLANK(D30)=FALSE,ISBLANK(E30)))),\"4\",\"\")","v":""},null,null,null,null,null,null,"MOOP",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(N30)=FALSE,ISBLANK(O30)=FALSE,ISBLANK(P30))),AND($C$14=\"Yes\",OR(ISBLANK(N30),ISBLANK(O30),ISBLANK(P30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(N30)=FALSE,ISBLANK(O30)=FALSE,ISBLANK(P30)))),\"4\",\"\")","v":""},null,null,null,null,null,null,"MOOP",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(Y30)=FALSE,ISBLANK(Z30)=FALSE,ISBLANK(AA30))),AND($C$14=\"Yes\",OR(ISBLANK(Y30),ISBLANK(Z30),ISBLANK(AA30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(Y30)=FALSE,ISBLANK(Z30)=FALSE,ISBLANK(AA30)))),\"4\",\"\")","v":""},null,null,null,null,null,null,"MOOP",null,null,null,{"$f":"IF(OR(AND($C$11=\"Yes\",OR(ISBLANK(AJ30)=FALSE,ISBLANK(AK30)=FALSE,ISBLANK(AL30))),AND($C$14=\"Yes\",OR(ISBLANK(AJ30),ISBLANK(AK30),ISBLANK(AL30)=FALSE)),AND($C$14=\"No\",OR(ISBLANK(AJ30)=FALSE,ISBLANK(AK30)=FALSE,ISBLANK(AL30)))),\"4\",\"\")","v":""}]
[]
[null,null,null,null,null,"Copays",null,null,"Coinsurance",null,null,null,null,null,null,null,"Copays",null,null,"Coinsurance",null,null,null,null,null,null,null,"Copays",null,null,"Coinsurance",null,null,null,null,null,null,null,"Copays",null,null,"Coinsurance"]
[null,"Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Medical","Upfront Visits","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/"]
[null,"Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","Benefits","or Copays?","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings"]
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and After Deductible\",ISBLANK(I35)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(E35)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(H35)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(C35)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",D35=\"Yes\"),ISBLANK(C35)),TRUE,FALSE),OR(AND(D35=\"Yes\",ISBLANK(E35)=FALSE,ISBLANK(F35)),AND(D35=\"Yes\",ISBLANK(H35)=FALSE,ISBLANK(I35))),OR(OR(AND(D35=\"No\",ISBLANK(E35)=FALSE,ISBLANK(F35)),AND(D35=\"No\",E35<>0,ISBLANK(F35)=FALSE,F35<>\"After Deductible\",ISBLANK(G35))),OR(AND(D35=\"No\",ISBLANK(H35)=FALSE,ISBLANK(I35)),AND(D35=\"No\",H35<>0,ISBLANK(I35)=FALSE,I35<>\"After Deductible\",ISBLANK(J35)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),D35<>\"Yes\"),ISBLANK(C35)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(C35)=FALSE),AND(ISBLANK(E35),ISBLANK(F35)=FALSE),AND(ISBLANK(H35),ISBLANK(I35)=FALSE),AND(E35=0,ISBLANK(G35)=FALSE),AND(D35=\"Yes\",ISBLANK(G35)=FALSE),AND(F35=\"After 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Deductible\",ISBLANK(AP36)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL36)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO36)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(AJ36)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",AK36=\"Yes\"),ISBLANK(AJ36)),TRUE,FALSE),OR(AND(AK36=\"Yes\",ISBLANK(AL36)=FALSE,ISBLANK(AM36)),AND(AK36=\"Yes\",ISBLANK(AO36)=FALSE,ISBLANK(AP36))),OR(OR(AND(AK36=\"No\",ISBLANK(AL36)=FALSE,ISBLANK(AM36)),AND(AK36=\"No\",AL36<>0,ISBLANK(AM36)=FALSE,AM36<>\"After Deductible\",ISBLANK(AN36))),OR(AND(AK36=\"No\",ISBLANK(AO36)=FALSE,ISBLANK(AP36)),AND(AK36=\"No\",AO36<>0,ISBLANK(AP36)=FALSE,AP36<>\"After Deductible\",ISBLANK(AQ36)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),AK36<>\"Yes\"),ISBLANK(AJ36)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(AJ36)=FALSE),AND(ISBLANK(AL36),ISBLANK(AM36)=FALSE),AND(ISBLANK(AO36),ISBLANK(AP36)=FALSE),AND(AL36=0,ISBLANK(AN36)=FALSE),AND(AK36=\"Yes\",ISBLANK(AN36)=FALSE),AND(AM36=\"After Deductible\",ISBLANK(AN36)=FALSE),AND(AO36=0,ISBLANK(AQ36)=FALSE),AND(AK36=\"Yes\",ISBLANK(AQ36)=FALSE),AND(AP36=\"After Deductible\",ISBLANK(AQ36)=FALSE)),\"2\",\"\"),IF(OR(COUNTIF(AJ36:AQ36,\"Select\")>0,OR(AND(AJ36<>\"Yes\",AJ36<>\"No\",ISBLANK(AJ36)=FALSE),AND(AK36<>\"Yes\",AK36<>\"No\",ISBLANK(AK36)=FALSE),AND(AN36<>\"Yes\",AN36<>\"No\",ISBLANK(AN36)=FALSE),AND(AQ36<>\"Yes\",AQ36<>\"No\",ISBLANK(AQ36)=FALSE),AND(AM36<>\"After Deductible\",AM36<>\"Before Deductible\",AM36<>\"Before and After Deductible\",ISBLANK(AM36)=FALSE),AND(AP36<>\"After Deductible\",AP36<>\"Before Deductible\",AP36<>\"Before and After Deductible\",ISBLANK(AP36)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL36)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO36)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(AJ36)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",AK36=\"Yes\"),ISBLANK(AJ36)),TRUE,FALSE),OR(AND(AK36=\"Yes\",ISBLANK(AL36)=FALSE,ISBLANK(AM36)),AND(AK36=\"Yes\",ISBLANK(AO36)=FALSE,ISBLANK(AP36))),OR(OR(AND(AK36=\"No\",ISBLANK(AL36)=FALSE,ISBLANK(AM36)),AND(AK36=\"No\",AL36<>0,ISBLANK(AM36)=FALSE,AM36<>\"After Deductible\",ISBLANK(AN36))),OR(AND(AK36=\"No\",ISBLANK(AO36)=FALSE,ISBLANK(AP36)),AND(AK36=\"No\",AO36<>0,ISBLANK(AP36)=FALSE,AP36<>\"After Deductible\",ISBLANK(AQ36)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),AK36<>\"Yes\"),ISBLANK(AJ36)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(AJ36)=FALSE),AND(ISBLANK(AL36),ISBLANK(AM36)=FALSE),AND(ISBLANK(AO36),ISBLANK(AP36)=FALSE),AND(AL36=0,ISBLANK(AN36)=FALSE),AND(AK36=\"Yes\",ISBLANK(AN36)=FALSE),AND(AM36=\"After Deductible\",ISBLANK(AN36)=FALSE),AND(AO36=0,ISBLANK(AQ36)=FALSE),AND(AK36=\"Yes\",ISBLANK(AQ36)=FALSE),AND(AP36=\"After Deductible\",ISBLANK(AQ36)=FALSE)),\", 2\",\"\"))&IF(AND(LEN(IF(AND(AI36=\"Preventive Care/Screening/Immunization\",OR(AK36<>\"No\",AL36<>0,AM36<>\"Before and After Deductible\",ISBLANK(AN36)=FALSE,ISBLANK(AO36)=FALSE,ISBLANK(AP36)=FALSE,ISBLANK(AQ36)=FALSE)),\"1\",\"\"))=0,LEN(IF(OR(COUNTIF(AJ36:AQ36,\"Select\")>0,OR(AND(AJ36<>\"Yes\",AJ36<>\"No\",ISBLANK(AJ36)=FALSE),AND(AK36<>\"Yes\",AK36<>\"No\",ISBLANK(AK36)=FALSE),AND(AN36<>\"Yes\",AN36<>\"No\",ISBLANK(AN36)=FALSE),AND(AQ36<>\"Yes\",AQ36<>\"No\",ISBLANK(AQ36)=FALSE),AND(AM36<>\"After Deductible\",AM36<>\"Before Deductible\",AM36<>\"Before and After Deductible\",ISBLANK(AM36)=FALSE),AND(AP36<>\"After Deductible\",AP36<>\"Before Deductible\",AP36<>\"Before and After Deductible\",ISBLANK(AP36)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL36)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO36)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(AJ36)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",AK36=\"Yes\"),ISBLANK(AJ36)),TRUE,FALSE),OR(AND(AK36=\"Yes\",ISBLANK(AL36)=FALSE,ISBLANK(AM36)),AND(AK36=\"Yes\",ISBLANK(AO36)=FALSE,ISBLANK(AP36))),OR(OR(AND(AK36=\"No\",ISBLANK(AL36)=FALSE,ISBLANK(AM36)),AND(AK36=\"No\",AL36<>0,ISBLANK(AM36)=FALSE,AM36<>\"After Deductible\",ISBLANK(AN36))),OR(AND(AK36=\"No\",ISBLANK(AO36)=FALSE,ISBLANK(AP36)),AND(AK36=\"No\",AO36<>0,ISBLANK(AP36)=FALSE,AP36<>\"After Deductible\",ISBLANK(AQ36)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),AK36<>\"Yes\"),ISBLANK(AJ36)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(AJ36)=FALSE),AND(ISBLANK(AL36),ISBLANK(AM36)=FALSE),AND(ISBLANK(AO36),ISBLANK(AP36)=FALSE),AND(AL36=0,ISBLANK(AN36)=FALSE),AND(AK36=\"Yes\",ISBLANK(AN36)=FALSE),AND(AM36=\"After Deductible\",ISBLANK(AN36)=FALSE),AND(AO36=0,ISBLANK(AQ36)=FALSE),AND(AK36=\"Yes\",ISBLANK(AQ36)=FALSE),AND(AP36=\"After Deductible\",ISBLANK(AQ36)=FALSE)),\"2\",\"\"))=0),IF(AND(AK36=\"No\",OR(AND(AM36<>\"Before and After Deductible\",ISBLANK(AP36)),AND(AP36<>\"Before and After Deductible\",ISBLANK(AM36)),AND(AM36<>\"Before and After Deductible\",AM36=AP36))),\"3\",\"\"),IF(AND(AK36=\"No\",OR(AND(AM36<>\"Before and After Deductible\",ISBLANK(AP36)),AND(AP36<>\"Before and After Deductible\",ISBLANK(AM36)),AND(AM36<>\"Before and After Deductible\",AM36=AP36))),\", 3\",\"\")))","v":"2"}]
[null,"Primary Care Visit to Treat an Injury or Illness","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Primary Care Visit to Treat an Injury or Illness","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Primary Care Visit to Treat an Injury or Illness","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Primary Care Visit to Treat an Injury or Illness","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Specialist Visit","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Specialist Visit","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Specialist Visit","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Specialist Visit","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Mental Health & Substance Use Disorder Office Visits","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder Office Visits","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder Office Visits","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder Office Visits","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Mental Health & Substance Use Disorder All Other OP Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder All Other OP Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder All Other OP Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Mental Health & Substance Abuse Disorder All Other OP Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Imaging (CT/PET Scans, MRIs)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Imaging (CT/PET Scans, MRIs)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Imaging (CT/PET Scans, MRIs)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Imaging (CT/PET Scans, MRIs)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Rehabilitative Speech Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Speech Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Speech Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Speech Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Rehabilitative Occupational and Rehabilitative Physical Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Occupational and Rehabilitative Physical Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Occupational and Rehabilitative Physical Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Rehabilitative Occupational and Rehabilitative Physical Therapy","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Preventive Care/Screening/Immunization","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Preventive Care/Screening/Immunization","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Preventive Care/Screening/Immunization","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Preventive Care/Screening/Immunization","Select","Select",null,"Select","Select",null,"Select","Select",null,{"$f":"IF(OR(ISBLANK(AK44),AND(ISBLANK(AL44),ISBLANK(AO44))),\"2\",IF(AND(AI44=\"Preventive Care/Screening/Immunization*****\",OR(AK44<>\"No\",AL44<>0,AM44<>\"Before and After Deductible\",ISBLANK(AN44)=FALSE,ISBLANK(AO44)=FALSE,ISBLANK(AP44)=FALSE,ISBLANK(AQ44)=FALSE)),\"1\",\"\")&IF(LEN(IF(AND(AI44=\"Preventive Care/Screening/Immunization*****\",OR(AK44<>\"No\",AL44<>0,AM44<>\"Before and After Deductible\",ISBLANK(AN44)=FALSE,ISBLANK(AO44)=FALSE,ISBLANK(AP44)=FALSE,ISBLANK(AQ44)=FALSE)),\"1\",\"\"))=0,IF(OR(COUNTIF(AJ44:AQ44,\"Select\")>0,OR(AND(AJ44<>\"Yes\",AJ44<>\"No\",ISBLANK(AJ44)=FALSE),AND(AK44<>\"Yes\",AK44<>\"No\",ISBLANK(AK44)=FALSE),AND(AN44<>\"Yes\",AN44<>\"No\",ISBLANK(AN44)=FALSE),AND(AQ44<>\"Yes\",AQ44<>\"No\",ISBLANK(AQ44)=FALSE),AND(AM44<>\"After Deductible\",AM44<>\"Before Deductible\",AM44<>\"Before and After Deductible\",ISBLANK(AM44)=FALSE),AND(AP44<>\"After Deductible\",AP44<>\"Before Deductible\",AP44<>\"Before and After Deductible\",ISBLANK(AP44)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL44)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO44)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(AJ44)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",AK44=\"Yes\"),ISBLANK(AJ44)),TRUE,FALSE),OR(AND(AK44=\"Yes\",ISBLANK(AL44)=FALSE,ISBLANK(AM44)),AND(AK44=\"Yes\",ISBLANK(AO44)=FALSE,ISBLANK(AP44))),OR(OR(AND(AK44=\"No\",ISBLANK(AL44)=FALSE,ISBLANK(AM44)),AND(AK44=\"No\",AL44<>0,ISBLANK(AM44)=FALSE,AM44<>\"After Deductible\",ISBLANK(AN44))),OR(AND(AK44=\"No\",ISBLANK(AO44)=FALSE,ISBLANK(AP44)),AND(AK44=\"No\",AO44<>0,ISBLANK(AP44)=FALSE,AP44<>\"After Deductible\",ISBLANK(AQ44)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),AK44<>\"Yes\"),ISBLANK(AJ44)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(AJ44)=FALSE),AND(ISBLANK(AL44),ISBLANK(AM44)=FALSE),AND(ISBLANK(AO44),ISBLANK(AP44)=FALSE),AND(AL44=0,ISBLANK(AN44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AN44)=FALSE),AND(AM44=\"After Deductible\",ISBLANK(AN44)=FALSE),AND(AO44=0,ISBLANK(AQ44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AQ44)=FALSE),AND(AP44=\"After Deductible\",ISBLANK(AQ44)=FALSE)),\"2\",\"\"),IF(OR(COUNTIF(AJ44:AQ44,\"Select\")>0,OR(AND(AJ44<>\"Yes\",AJ44<>\"No\",ISBLANK(AJ44)=FALSE),AND(AK44<>\"Yes\",AK44<>\"No\",ISBLANK(AK44)=FALSE),AND(AN44<>\"Yes\",AN44<>\"No\",ISBLANK(AN44)=FALSE),AND(AQ44<>\"Yes\",AQ44<>\"No\",ISBLANK(AQ44)=FALSE),AND(AM44<>\"After Deductible\",AM44<>\"Before Deductible\",AM44<>\"Before and After Deductible\",ISBLANK(AM44)=FALSE),AND(AP44<>\"After Deductible\",AP44<>\"Before Deductible\",AP44<>\"Before and After Deductible\",ISBLANK(AP44)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL44)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO44)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(AJ44)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",AK44=\"Yes\"),ISBLANK(AJ44)),TRUE,FALSE),OR(AND(AK44=\"Yes\",ISBLANK(AL44)=FALSE,ISBLANK(AM44)),AND(AK44=\"Yes\",ISBLANK(AO44)=FALSE,ISBLANK(AP44))),OR(OR(AND(AK44=\"No\",ISBLANK(AL44)=FALSE,ISBLANK(AM44)),AND(AK44=\"No\",AL44<>0,ISBLANK(AM44)=FALSE,AM44<>\"After Deductible\",ISBLANK(AN44))),OR(AND(AK44=\"No\",ISBLANK(AO44)=FALSE,ISBLANK(AP44)),AND(AK44=\"No\",AO44<>0,ISBLANK(AP44)=FALSE,AP44<>\"After Deductible\",ISBLANK(AQ44)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),AK44<>\"Yes\"),ISBLANK(AJ44)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(AJ44)=FALSE),AND(ISBLANK(AL44),ISBLANK(AM44)=FALSE),AND(ISBLANK(AO44),ISBLANK(AP44)=FALSE),AND(AL44=0,ISBLANK(AN44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AN44)=FALSE),AND(AM44=\"After Deductible\",ISBLANK(AN44)=FALSE),AND(AO44=0,ISBLANK(AQ44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AQ44)=FALSE),AND(AP44=\"After Deductible\",ISBLANK(AQ44)=FALSE)),\", 2\",\"\"))&IF(AND(LEN(IF(AND(AI44=\"Preventive Care/Screening/Immunization*****\",OR(AK44<>\"No\",AL44<>0,AM44<>\"Before and After Deductible\",ISBLANK(AN44)=FALSE,ISBLANK(AO44)=FALSE,ISBLANK(AP44)=FALSE,ISBLANK(AQ44)=FALSE)),\"1\",\"\"))=0,LEN(IF(OR(COUNTIF(AJ44:AQ44,\"Select\")>0,OR(AND(AJ44<>\"Yes\",AJ44<>\"No\",ISBLANK(AJ44)=FALSE),AND(AK44<>\"Yes\",AK44<>\"No\",ISBLANK(AK44)=FALSE),AND(AN44<>\"Yes\",AN44<>\"No\",ISBLANK(AN44)=FALSE),AND(AQ44<>\"Yes\",AQ44<>\"No\",ISBLANK(AQ44)=FALSE),AND(AM44<>\"After Deductible\",AM44<>\"Before Deductible\",AM44<>\"Before and After Deductible\",ISBLANK(AM44)=FALSE),AND(AP44<>\"After Deductible\",AP44<>\"Before Deductible\",AP44<>\"Before and After Deductible\",ISBLANK(AP44)=FALSE),IFERROR(IF(_xlfn.NUMBERVALUE(AL44)<0,TRUE,FALSE),TRUE),IFERROR(IF(_xlfn.NUMBERVALUE(AO44)<0,TRUE,FALSE),TRUE)),IF(AND(AND($C$16<>0,$C$16<>\"N/A\"),ISBLANK(AJ44)),TRUE,FALSE),IF(AND(AND($C$17<>0,$C$17<>\"N/A\",AK44=\"Yes\"),ISBLANK(AJ44)),TRUE,FALSE),OR(AND(AK44=\"Yes\",ISBLANK(AL44)=FALSE,ISBLANK(AM44)),AND(AK44=\"Yes\",ISBLANK(AO44)=FALSE,ISBLANK(AP44))),OR(OR(AND(AK44=\"No\",ISBLANK(AL44)=FALSE,ISBLANK(AM44)),AND(AK44=\"No\",AL44<>0,ISBLANK(AM44)=FALSE,AM44<>\"After Deductible\",ISBLANK(AN44))),OR(AND(AK44=\"No\",ISBLANK(AO44)=FALSE,ISBLANK(AP44)),AND(AK44=\"No\",AO44<>0,ISBLANK(AP44)=FALSE,AP44<>\"After Deductible\",ISBLANK(AQ44)))),AND(AND(OR($C$16=\"N/A\",$C$16=0),AK44<>\"Yes\"),ISBLANK(AJ44)=FALSE),AND(AND(OR($C$16=\"N/A\",$C$16=0),OR($C$17=\"N/A\",$C$17=0)),ISBLANK(AJ44)=FALSE),AND(ISBLANK(AL44),ISBLANK(AM44)=FALSE),AND(ISBLANK(AO44),ISBLANK(AP44)=FALSE),AND(AL44=0,ISBLANK(AN44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AN44)=FALSE),AND(AM44=\"After Deductible\",ISBLANK(AN44)=FALSE),AND(AO44=0,ISBLANK(AQ44)=FALSE),AND(AK44=\"Yes\",ISBLANK(AQ44)=FALSE),AND(AP44=\"After Deductible\",ISBLANK(AQ44)=FALSE)),\"2\",\"\"))=0),IF(AND(AK44=\"No\",OR(AND(AM44<>\"Before and After Deductible\",ISBLANK(AP44)),AND(AP44<>\"Before and After Deductible\",ISBLANK(AM44)),AND(AM44<>\"Before and After Deductible\",AM44=AP44))),\"3\",\"\"),IF(AND(AK44=\"No\",OR(AND(AM44<>\"Before and After Deductible\",ISBLANK(AP44)),AND(AP44<>\"Before and After Deductible\",ISBLANK(AM44)),AND(AM44<>\"Before and After Deductible\",AM44=AP44))),\", 3\",\"\")))","v":"2"}]
[null,"Laboratory Outpatient and Professional Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Laboratory Outpatient and Professional Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Laboratory Outpatient and Professional Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Laboratory Outpatient and Professional Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"X-rays and Diagnostic Imaging","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","X-rays and Diagnostic Imaging","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","X-rays and Diagnostic Imaging","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","X-rays and Diagnostic Imaging","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Skilled Nursing Facility","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Skilled Nursing Facility","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Skilled Nursing Facility","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Skilled Nursing Facility","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Facility Fee (e.g., Ambulatory Surgery Center)","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Outpatient Surgery Physician/Surgical Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Surgery Physician/Surgical Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Surgery Physician/Surgical Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Outpatient Surgery Physician/Surgical Services","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Urgent Care","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Urgent Care","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Urgent Care","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Urgent Care","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Emergency Transportation","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Emergency Transportation","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Emergency Transportation","Select","Select",null,"Select","Select",null,"Select","Select",null,"2","Emergency Transportation","Select","Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Other EHB Categories",null,null,null,null,null,null,null,null,null,null,"Other EHB Categories",null,null,null,null,null,null,null,null,null,null,"Other EHB Categories",null,null,null,null,null,null,null,null,null,null,"Other EHB Categories"]
[]
[null,"Non-EHB Benefits",null,null,null,null,null,null,null,null,null,null,"Non-EHB Benefits",null,null,null,null,null,null,null,null,null,null,"Non-EHB Benefits",null,null,null,null,null,null,null,null,null,null,"Non-EHB Benefits"]
[]
[null,"Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/","Drug Benefit Tiers","Maximum","Subject to","Amount","Applies","Accrues toward","Amount","Applies","Accrues toward","Comments","Errors/"]
[null,"(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings","(add/modify descriptions as necessary)","Coinsurance","Deductible?",null,null,"Deductible?",null,null,"Deductible?",null,"Warnings"]
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[null,"Preferred Brand Drugs (Tier 2)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Preferred Brand Drugs (Tier 2)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Preferred Brand Drugs (Tier 2)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Preferred Brand Drugs (Tier 2)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2"]
[null,"Non-Preferred Brand Drugs (Tier 3)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Non-Preferred Brand Drugs (Tier 3)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Non-Preferred Brand Drugs (Tier 3)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2","Non-Preferred Brand Drugs (Tier 3)",null,"Select",null,"Select","Select",null,"Select","Select",null,"2"]
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[]
["Notes"]

{"sheet":"Data Validation","index":3,"n_rows":14,"n_cols":21,"rows_kept":14,"cut":false,"hidden":true,"merged":[]}
["Metal Levels",null,"Benefit Applies…",null,"New or Renewing",null,"Unique Plan Design",null,"Tiers",null,"Numbers",null,"CSR Options",null,"Exchange Status",null,"Notes",null,"Blank",null,"Market"]
["Select",null,"Select",null,"Select",null,"Select",null,"Select",null,"Select",null,"Select",null,"Select",null,null,null,null,null,"Select"]
["Catastrophic",null,"Before Deductible",null,"New",null,"Yes",null,1,null,"N/A",null,"No",null,"On Exchange",null,"Note 1",null,null,null,"Individual"]
["Bronze",null,"After Deductible",null,"Renewing",null,"No",null,2,null,0,null,"73% AV Level Silver Plan",null,"Off Exchange",null,"Note 2",null,null,null,"Small Group"]
["Expanded Bronze",null,"Before and After Deductible",null,null,null,null,null,3,null,1,null,"87% AV Level Silver Plan",null,"Both On and Off Exchange",null,"Note 3"]
["Silver",null,null,null,null,null,null,null,null,null,2,null,"94% AV Level Silver Plan",null,null,null,"Note 4"]
["Gold",null,"Accrues…",null,null,null,null,null,null,null,3,null,null,null,null,null,"Note 5"]
["Platinum",null,"Select",null,null,null,null,null,null,null,4,null,null,null,null,null,"Note 6"]
[null,null,"Yes",null,null,null,null,null,null,null,5,null,null,null,null,null,"Note 7"]
[null,null,"No",null,null,null,null,null,null,null,6,null,null,null,null,null,"Note 8"]
[null,null,null,null,null,null,null,null,null,null,7,null,null,null,null,null,"Note 9"]
[null,null,null,null,null,null,null,null,null,null,8,null,null,null,null,null,"Note 10"]
[null,null,null,null,null,null,null,null,null,null,9]
[null,null,null,null,null,null,null,null,null,null,10]