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8.34 Resource InsurancePlan - Content

Patient Administration icon Work GroupMaturity Level: 1 Trial UseSecurity Category: Business Compartments: No defined compartments

Details about an insurance plan.

A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. A given payer’s products typically differ by network type and/or coverage benefits. A plan pairs the health insurance coverage benefits under a product with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans.

InsurancePlan describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.

TBD.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan TUDomainResourcePlan details

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierBusiness Identifier for Plan

... type 0..1CodeableConceptClassification of Plan
... product Σ0..1Reference(InsuranceProduct)The product that this plan is available under
... network 0..*Reference(Organization)What networks provide coverage

... generalCost 0..*BackboneElementOverall costs

.... type 0..1CodeableConceptClassification of specific cost
.... groupSize 0..1positiveIntNumber of enrollees
.... cost 0..1MoneyCost value
.... comment 0..1stringAdditional cost information
... specificCost 0..*BackboneElementIndividual cost elements

.... category 1..1CodeableConceptGeneral category of benefit
.... benefit 0..*BackboneElementBenefits list

..... type 1..1CodeableConceptClassification of benefit provided
..... cost 0..*BackboneElementList of the costs

...... type 1..1CodeableConceptClassification of specific cost
...... applicability 0..1CodeableConceptin-network | out-of-network | other
Binding: Benefit Cost Applicability (Required)
...... qualifier 0..*CodeableConceptAdditional information about the cost

...... value 0..1QuantityThe actual cost value

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

InsurancePlan (DomainResource)Identifiers, such as the plan ID and/or group ID associated with the insurance planidentifier : Identifier [0..*]Type of plan. For example, "Platinum" or "High Deductable"type : CodeableConcept [0..1]The product that this plan is available underproduct : Reference [0..1] « InsuranceProduct »The geographic region in which a health insurance plan's benefits applycoverageArea : Reference [0..*] « Location »Reference to the network that providing the type of coveragenetwork : Reference [0..*] « Organization »GeneralCostType of costtype : CodeableConcept [0..1]Number of participants enrolled in the plangroupSize : positiveInt [0..1]Value of the costcost : Money [0..1]Additional information about the general costs associated with this plancomment : string [0..1]SpecificCostGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)category : CodeableConcept [1..1]PlanBenefitType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)type : CodeableConcept [1..1]CostType of cost (copay; individual cap; family cap; coinsurance; deductible)type : CodeableConcept [1..1]Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)applicability : CodeableConcept [0..1] « null (Strength=Required)BenefitCostApplicability! »Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)qualifier : CodeableConcept [0..*]The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance)value : Quantity [0..1]Overall costs associated with the plangeneralCost[0..*]List of the costs associated with a specific benefitcost[0..*]List of the specific benefits under this category of benefitbenefit[0..*]Costs associated with the coverage provided by the product-planspecificCost[0..*]

XML Template

<InsurancePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier>
 <type><!-- 0..1 CodeableConcept Classification of Plan --></type>
 <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product>
 <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea>
 <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
 <generalCost>  <!-- 0..* Overall costs -->
  <type><!-- 0..1 CodeableConcept Classification of specific cost --></type>
  <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
  <cost><!-- 0..1 Money Cost value --></cost>
  <comment value="[string]"/><!-- 0..1 Additional cost information -->
 </generalCost>
 <specificCost>  <!-- 0..* Individual cost elements -->
  <category><!-- 1..1 CodeableConcept General category of benefit --></category>
  <benefit>  <!-- 0..* Benefits list -->
   <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type>
   <cost>  <!-- 0..* List of the costs -->
    <type><!-- 1..1 CodeableConcept Classification of specific cost --></type>
    <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
    <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier>
    <value><!-- 0..1 Quantity The actual cost value --></value>
   </cost>
  </benefit>
 </specificCost>
</InsurancePlan>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan
  fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan
  fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
  fhir:generalCost ( [ # 0..* Overall costs
    fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost
    fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees
    fhir:cost [ Money ] ; # 0..1 Cost value
    fhir:comment [ string ] ; # 0..1 Additional cost information
  ] ... ) ;
  fhir:specificCost ( [ # 0..* Individual cost elements
    fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit
    fhir:benefit ( [ # 0..* Benefits list
      fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided
      fhir:cost ( [ # 0..* List of the costs
        fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost
        fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other
        fhir:qualifier  ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost
        fhir:value [ Quantity ] ; # 0..1 The actual cost value
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
]

Changes from both R4 and R4B

InsurancePlan
InsurancePlan.type
  • Max Cardinality changed from * to 1
InsurancePlan.product
  • Added Element
InsurancePlan.generalCost
  • Added Element
InsurancePlan.generalCost.type
  • Added Element
InsurancePlan.generalCost.groupSize
  • Added Element
InsurancePlan.generalCost.cost
  • Added Element
InsurancePlan.generalCost.comment
  • Added Element
InsurancePlan.specificCost
  • Added Element
InsurancePlan.specificCost.category
  • Added Mandatory Element
InsurancePlan.specificCost.benefit
  • Added Element
InsurancePlan.specificCost.benefit.type
  • Added Mandatory Element
InsurancePlan.specificCost.benefit.cost
  • Added Element
InsurancePlan.specificCost.benefit.cost.type
  • Added Mandatory Element
InsurancePlan.specificCost.benefit.cost.applicability
  • Added Element
InsurancePlan.specificCost.benefit.cost.qualifier
  • Added Element
InsurancePlan.specificCost.benefit.cost.value
  • Added Element
InsurancePlan.status
  • Deleted
InsurancePlan.name
  • Deleted
InsurancePlan.alias
  • Deleted
InsurancePlan.period
  • Deleted
InsurancePlan.ownedBy
  • Deleted
InsurancePlan.administeredBy
  • Deleted
InsurancePlan.contact
  • Deleted
InsurancePlan.endpoint
  • Deleted
InsurancePlan.coverage
  • Deleted
InsurancePlan.plan
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan TUDomainResourcePlan details

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ0..*IdentifierBusiness Identifier for Plan

... type 0..1CodeableConceptClassification of Plan
... product Σ0..1Reference(InsuranceProduct)The product that this plan is available under
... network 0..*Reference(Organization)What networks provide coverage

... generalCost 0..*BackboneElementOverall costs

.... type 0..1CodeableConceptClassification of specific cost
.... groupSize 0..1positiveIntNumber of enrollees
.... cost 0..1MoneyCost value
.... comment 0..1stringAdditional cost information
... specificCost 0..*BackboneElementIndividual cost elements

.... category 1..1CodeableConceptGeneral category of benefit
.... benefit 0..*BackboneElementBenefits list

..... type 1..1CodeableConceptClassification of benefit provided
..... cost 0..*BackboneElementList of the costs

...... type 1..1CodeableConceptClassification of specific cost
...... applicability 0..1CodeableConceptin-network | out-of-network | other
Binding: Benefit Cost Applicability (Required)
...... qualifier 0..*CodeableConceptAdditional information about the cost

...... value 0..1QuantityThe actual cost value

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

InsurancePlan (DomainResource)Identifiers, such as the plan ID and/or group ID associated with the insurance planidentifier : Identifier [0..*]Type of plan. For example, "Platinum" or "High Deductable"type : CodeableConcept [0..1]The product that this plan is available underproduct : Reference [0..1] « InsuranceProduct »The geographic region in which a health insurance plan's benefits applycoverageArea : Reference [0..*] « Location »Reference to the network that providing the type of coveragenetwork : Reference [0..*] « Organization »GeneralCostType of costtype : CodeableConcept [0..1]Number of participants enrolled in the plangroupSize : positiveInt [0..1]Value of the costcost : Money [0..1]Additional information about the general costs associated with this plancomment : string [0..1]SpecificCostGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)category : CodeableConcept [1..1]PlanBenefitType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)type : CodeableConcept [1..1]CostType of cost (copay; individual cap; family cap; coinsurance; deductible)type : CodeableConcept [1..1]Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)applicability : CodeableConcept [0..1] « null (Strength=Required)BenefitCostApplicability! »Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)qualifier : CodeableConcept [0..*]The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance)value : Quantity [0..1]Overall costs associated with the plangeneralCost[0..*]List of the costs associated with a specific benefitcost[0..*]List of the specific benefits under this category of benefitbenefit[0..*]Costs associated with the coverage provided by the product-planspecificCost[0..*]

XML Template

<InsurancePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier>
 <type><!-- 0..1 CodeableConcept Classification of Plan --></type>
 <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product>
 <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea>
 <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
 <generalCost>  <!-- 0..* Overall costs -->
  <type><!-- 0..1 CodeableConcept Classification of specific cost --></type>
  <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
  <cost><!-- 0..1 Money Cost value --></cost>
  <comment value="[string]"/><!-- 0..1 Additional cost information -->
 </generalCost>
 <specificCost>  <!-- 0..* Individual cost elements -->
  <category><!-- 1..1 CodeableConcept General category of benefit --></category>
  <benefit>  <!-- 0..* Benefits list -->
   <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type>
   <cost>  <!-- 0..* List of the costs -->
    <type><!-- 1..1 CodeableConcept Classification of specific cost --></type>
    <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
    <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier>
    <value><!-- 0..1 Quantity The actual cost value --></value>
   </cost>
  </benefit>
 </specificCost>
</InsurancePlan>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan
  fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan
  fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
  fhir:generalCost ( [ # 0..* Overall costs
    fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost
    fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees
    fhir:cost [ Money ] ; # 0..1 Cost value
    fhir:comment [ string ] ; # 0..1 Additional cost information
  ] ... ) ;
  fhir:specificCost ( [ # 0..* Individual cost elements
    fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit
    fhir:benefit ( [ # 0..* Benefits list
      fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided
      fhir:cost ( [ # 0..* List of the costs
        fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost
        fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other
        fhir:qualifier  ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost
        fhir:value [ Quantity ] ; # 0..1 The actual cost value
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
]

Changes from both R4 and R4B

InsurancePlan
InsurancePlan.type
  • Max Cardinality changed from * to 1
InsurancePlan.product
  • Added Element
InsurancePlan.generalCost
  • Added Element
InsurancePlan.generalCost.type
  • Added Element
InsurancePlan.generalCost.groupSize
  • Added Element
InsurancePlan.generalCost.cost
  • Added Element
InsurancePlan.generalCost.comment
  • Added Element
InsurancePlan.specificCost
  • Added Element
InsurancePlan.specificCost.category
  • Added Mandatory Element
InsurancePlan.specificCost.benefit
  • Added Element
InsurancePlan.specificCost.benefit.type
  • Added Mandatory Element
InsurancePlan.specificCost.benefit.cost
  • Added Element
InsurancePlan.specificCost.benefit.cost.type
  • Added Mandatory Element
InsurancePlan.specificCost.benefit.cost.applicability
  • Added Element
InsurancePlan.specificCost.benefit.cost.qualifier
  • Added Element
InsurancePlan.specificCost.benefit.cost.value
  • Added Element
InsurancePlan.status
  • Deleted
InsurancePlan.name
  • Deleted
InsurancePlan.alias
  • Deleted
InsurancePlan.period
  • Deleted
InsurancePlan.ownedBy
  • Deleted
InsurancePlan.administeredBy
  • Deleted
InsurancePlan.contact
  • Deleted
InsurancePlan.endpoint
  • Deleted
InsurancePlan.coverage
  • Deleted
InsurancePlan.plan
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

PathValueSetTypeDocumentation
InsurancePlan.specificCost.benefit.cost.applicability BenefitCostApplicability Required

Whether the cost applies to in-network or out-of-network providers.

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionExpressionIn Common
coverage-areareferenceLocation(s) insurance product is intended for/available toInsurancePlan.coverageArea
identifiertokenExternal identifiers for this itemInsurancePlan.identifier
networkreferenceThe product this plan is available toInsurancePlan.network
productreferenceThe product this plan is available toInsurancePlan.product
typetokenA code for the type of insurance planInsurancePlan.type