FHIR IG analytics| Package | sbc-fhir-ig |
| Resource Type | InsurancePlan |
| Id | InsurancePlan-SBCExampleHMO.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: InsurancePlan SBCExampleHMO
Profile: SBC Insurance Plan Profile
SBC Metadata Extension
- sbcVersionDate: 2021-01-01
- minimumEssentialCoverage: true
- minimumValue: true
Excluded Services Extension
serviceType: Cosmetic surgery
description: Services for cosmetic purposes are not covered
url
serviceserviceType: Weight loss programs
description: Weight loss programs except when medically necessary
url
service
identifier: https://www.cms.gov/CCIIO/Resources/Data-Resources/hios/12345CA001000101
status: Active
name: Sample Health HMO Gold Plan
period: 2025-01-01 --> 2025-12-31
ownedBy: Sample Health Insurance Company
administeredBy: Organization Sample Health Insurance Company
contact
purpose: General Questions
telecom: ph: 1-800-123-4567, https://www.samplehealth.com
contact
purpose: Uniform Glossary
coverage
type: health insurance plan policy
benefit
type: Preventive Care/Screening/Immunization
requirement: No prior authorization required for in-network preventive services
benefit
type: Primary Care Visit to Treat an Injury or Illness
requirement: No referral required
benefit
Benefit Limitation Extension: Limited to network specialists only; out-of-network not covered except in emergencies
type: Specialist Visit
requirement: Referral required from primary care physician
benefit
Benefit Limitation Extension: Copay waived if admitted to hospital
type: Emergency Room Care
benefit
type: Generic Drugs
benefit
type: Facility Fee (e.g., Hospital Room)
requirement: Prior authorization required for non-emergency admissions
plan
type: Health Maintenance Organization (HMO)
generalCost
type: Individual Deductible
Costs
Value Currency 1500 United States dollar comment: Individual in-network deductible
generalCost
type: Family Deductible
Costs
Value Currency 3000 United States dollar generalCost
type: Individual Out-of-Pocket Maximum
Costs
Value Currency 6000 United States dollar generalCost
type: Family Out-of-Pocket Maximum
Costs
Value Currency 12000 United States dollar specificCost
category: Preventive Care/Screening/Immunization
benefit
type: Preventive Care/Screening/Immunization
cost
type: No charge
applicability: In Network
value: 0 USD
cost
type: Not covered
applicability: Out of Network
value: 0 USD
specificCost
category: Primary Care Visit to Treat an Injury or Illness
benefit
type: Primary Care Visit to Treat an Injury or Illness
cost
type: Copayment
applicability: In Network
value: 25 USD
cost
type: Not covered
applicability: Out of Network
value: 0 USD
specificCost
category: Specialist Visit
benefit
type: Specialist Visit
cost
type: Copayment
applicability: In Network
value: 50 USD
cost
type: Not covered
applicability: Out of Network
value: 0 USD
specificCost
category: Emergency Room Care
benefit
Benefit Limitation Extension: Copay waived if admitted
type: Emergency Room Care
cost
type: Copayment
applicability: In Network
value: 350 USD
cost
type: Copayment
applicability: Out of Network
value: 350 USD
specificCost
category: Generic Drugs
benefit
type: Generic Drugs
cost
type: Copayment
applicability: In Network
value: 10 USD
cost
type: Not covered
applicability: Out of Network
value: 0 USD
specificCost
category: Facility Fee (e.g., Hospital Room)
benefit
Benefit Limitation Extension: Prior authorization required
type: Facility Fee (e.g., Hospital Room)
cost
type: Coinsurance
applicability: In Network
value: 20 %
cost
type: Not covered
applicability: Out of Network
value: 0 %
FHIR
FHIRsmith{
"resourceType": "InsurancePlan",
"id": "SBCExampleHMO",
"meta": {
"profile": [
"http://flexpa.com/fhir/sbc/StructureDefinition/sbc-insurance-plan"
]
},
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"extension": [
{
"url": "sbcVersionDate",
"valueDate": "2021-01-01"
},
{
"url": "minimumEssentialCoverage",
"valueBoolean": true
},
{
"url": "minimumValue",
"valueBoolean": true
}
],
"url": "http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata"
},
{
"extension": [
{
"extension": [
{
"url": "serviceType",
"valueCodeableConcept": {
"text": "Cosmetic surgery"
}
},
{
"url": "description",
"valueString": "Services for cosmetic purposes are not covered"
}
],
"url": "service"
},
{
"extension": [
{
"url": "serviceType",
"valueCodeableConcept": {
"text": "Weight loss programs"
}
},
{
"url": "description",
"valueString": "Weight loss programs except when medically necessary"
}
],
"url": "service"
}
],
"url": "http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services"
}
],
"identifier": [
{
"system": "https://www.cms.gov/CCIIO/Resources/Data-Resources/hios",
"value": "12345CA001000101"
}
],
"status": "active",
"name": "Sample Health HMO Gold Plan",
"period": {
"start": "2025-01-01",
"end": "2025-12-31"
},
"ownedBy": {
"reference": "Organization/ExampleIssuerOrg",
"display": "Sample Health Insurance Company"
},
"administeredBy": {
"reference": "Organization/ExampleIssuerOrg"
},
"contact": [
{
"purpose": {
"text": "General Questions"
},
"telecom": [
{
"system": "phone",
"value": "1-800-123-4567"
},
{
"system": "url",
"value": "https://www.samplehealth.com"
}
]
},
{
"purpose": {
"text": "Uniform Glossary"
},
"telecom": [
{
"system": "url",
"value": "https://www.healthcare.gov/sbc-glossary/"
}
]
}
],
"coverage": [
{
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "HIP",
"display": "health insurance plan policy"
}
]
},
"benefit": [
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "preventive-care"
}
]
},
"requirement": "No prior authorization required for in-network preventive services"
},
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "primary-care-visit"
}
]
},
"requirement": "No referral required"
},
{
"extension": [
{
"url": "http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation",
"valueString": "Limited to network specialists only; out-of-network not covered except in emergencies"
}
],
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "specialist-visit"
}
]
},
"requirement": "Referral required from primary care physician"
},
{
"extension": [
{
"url": "http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation",
"valueString": "Copay waived if admitted to hospital"
}
],
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "emergency-room-care"
}
]
}
},
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "generic-drugs"
}
]
}
},
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "hospital-facility-fee"
}
]
},
"requirement": "Prior authorization required for non-emergency admissions"
}
]
}
],
"plan": [
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-plan-type",
"code": "HMO"
}
]
},
"generalCost": [
{
"type": {
"text": "Individual Deductible"
},
"cost": {
"value": 1500,
"currency": "USD"
},
"comment": "Individual in-network deductible"
},
{
"type": {
"text": "Family Deductible"
},
"cost": {
"value": 3000,
"currency": "USD"
}
},
{
"type": {
"text": "Individual Out-of-Pocket Maximum"
},
"cost": {
"value": 6000,
"currency": "USD"
}
},
{
"type": {
"text": "Family Out-of-Pocket Maximum"
},
"cost": {
"value": 12000,
"currency": "USD"
}
}
],
"specificCost": [
{
"category": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "preventive-care"
}
]
},
"benefit": [
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "preventive-care"
}
]
},
"cost": [
{
"type": {
"text": "No charge"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "in-network",
"display": "In Network"
}
]
},
"value": {
"value": 0,
"unit": "USD"
}
},
{
"type": {
"text": "Not covered"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "out-of-network",
"display": "Out of Network"
}
]
},
"value": {
"value": 0,
"unit": "USD"
}
}
]
}
]
},
{
"category": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "primary-care-visit"
}
]
},
"benefit": [
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "primary-care-visit"
}
]
},
"cost": [
{
"type": {
"text": "Copayment"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "in-network",
"display": "In Network"
}
]
},
"value": {
"value": 25,
"unit": "USD"
}
},
{
"type": {
"text": "Not covered"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "out-of-network",
"display": "Out of Network"
}
]
},
"value": {
"value": 0,
"unit": "USD"
}
}
]
}
]
},
{
"category": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "specialist-visit"
}
]
},
"benefit": [
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "specialist-visit"
}
]
},
"cost": [
{
"type": {
"text": "Copayment"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "in-network",
"display": "In Network"
}
]
},
"value": {
"value": 50,
"unit": "USD"
}
},
{
"type": {
"text": "Not covered"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "out-of-network",
"display": "Out of Network"
}
]
},
"value": {
"value": 0,
"unit": "USD"
}
}
]
}
]
},
{
"category": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "emergency-room-care"
}
]
},
"benefit": [
{
"extension": [
{
"url": "http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation",
"valueString": "Copay waived if admitted"
}
],
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "emergency-room-care"
}
]
},
"cost": [
{
"type": {
"text": "Copayment"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "in-network",
"display": "In Network"
}
]
},
"value": {
"value": 350,
"unit": "USD"
}
},
{
"type": {
"text": "Copayment"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "out-of-network",
"display": "Out of Network"
}
]
},
"value": {
"value": 350,
"unit": "USD"
}
}
]
}
]
},
{
"category": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "generic-drugs"
}
]
},
"benefit": [
{
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "generic-drugs"
}
]
},
"cost": [
{
"type": {
"text": "Copayment"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "in-network",
"display": "In Network"
}
]
},
"value": {
"value": 10,
"unit": "USD"
}
},
{
"type": {
"text": "Not covered"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "out-of-network",
"display": "Out of Network"
}
]
},
"value": {
"value": 0,
"unit": "USD"
}
}
]
}
]
},
{
"category": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "hospital-facility-fee"
}
]
},
"benefit": [
{
"extension": [
{
"url": "http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation",
"valueString": "Prior authorization required"
}
],
"type": {
"coding": [
{
"system": "http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
"code": "hospital-facility-fee"
}
]
},
"cost": [
{
"type": {
"text": "Coinsurance"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "in-network",
"display": "In Network"
}
]
},
"value": {
"value": 20,
"unit": "%"
}
},
{
"type": {
"text": "Not covered"
},
"applicability": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/applicability",
"code": "out-of-network",
"display": "Out of Network"
}
]
},
"value": {
"value": 0,
"unit": "%"
}
}
]
}
]
}
]
}
]
}