Administrative Incubator
0.1.0 - International flag

Administrative Incubator, published by HL7 International / Patient Administration. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/admin-incubator/ and changes regularly. See the Directory of published versions

Resource: Insurance Plan

Official URL: http://hl7.org/fhir/StructureDefinition/InsurancePlan Version: 0.1.0
Standards status: Trial-use Draft as of 2021-01-02 Maturity Level: 1 Computable Name: InsurancePlan
Other Identifiers: OID:2.16.840.1.113883.4.642.5.1354

Details of a Health Insurance plan provided by an organization under an InsuranceProduct.

Scope and Usage

Insurance offerings will be fully described by the combination of both InsurancePlan (the costs) and InsuranceProduct (the benefits). However, some systems may only need to represent the InsurancePlan, so that Coverage resources can describe which plan is associated with a given beneficiary. In that case, there will be some other system that is responsible for tracking the benefits associated with the plan.

An InsurancePlan pairs the health insurance coverage benefits under an InsuranceProduct with the particular cost sharing structure offered to a consumer. A given InsuranceProduct may comprise multiple InsurancePlans.

Boundaries and Relationships

​ InsuranceProduct describes a list of covered benefits and networks as well as details about who administers the product and applicable coverage areas.

InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct referenced in InsurancePlan.product.

​ A Coverage resource establishes the link between an InsurancePlan and a beneficiary and optionally a subscriber.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Resource Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan 0..* DomainResource Plan details

Elements defined in Ancestors:id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier Business Identifier for Plan
... type 0..1 CodeableConcept Classification of Plan
... product Σ 0..1 Reference(Insurance Product) The product that this plan is available under
... network 0..* Reference(Organization) What networks provide coverage
... generalCost 0..* BackboneElement Overall costs
.... type 0..1 CodeableConcept Classification of specific cost
.... groupSize 0..1 positiveInt Number of enrollees
.... cost 0..1 Money Cost value
.... comment 0..1 string Additional cost information
... specificCost 0..* BackboneElement Individual cost elements
.... category 1..1 CodeableConcept General category of benefit
.... benefit 0..* BackboneElement Benefits list
..... type 1..1 CodeableConcept Classification of benefit provided
..... cost 0..* BackboneElement List of the costs
...... type 1..1 CodeableConcept Classification of specific cost
...... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
...... qualifier 0..* CodeableConcept Additional information about the cost
...... value 0..1 Quantity The actual cost value

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.specificCost.​benefit.cost.applicability Base required Benefit Cost Applicability 📦6.0.0-ballot3 FHIR Std. 
<InsurancePlan xmlns="http://hl7.org/fhir"> ​​doco
 ​<id value="[id]"/><!-- 0..1 ​* ​Logical id of this artifact  -->
 ​<meta><!-- ​I 0..1 ​* ​Metadata about the resource  --></meta>
 ​<implicitRules value="[uri]"/><!-- ​I 0..1 ​* ​A set of rules under which this content was created  -->
 ​<language value="[code]"/><!-- ​I 0..1 ​* Language of the resource content  -->
 ​<text><!-- ​I 0..1 ​* ​Text summary of the resource, for human interpretation  --></text>
 ​<contained><!-- 0..* ​* ​Contained, inline Resources  --></contained>
 ​<extension><!-- See Extensions  ​Additional content defined by implementations  --></extension>
 ​<modifierExtension><!-- ​I 0..* ​* ​Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- 0..* ​* ​Business Identifier for Plan  --></identifier>
 <type><!-- 0..1 ​* ​Classification of Plan  --></type>
 <product><!-- 0..1 ​* ​The product that this plan is available under  --></product>
 <coverageArea><!-- 0..* ​* ​Where product-plan applies  --></coverageArea>
 <network><!-- 0..* ​* ​What networks provide coverage  --></network>
 <generalCost> ​I 0..* ​*  <!-- ​I 0..* Overall costs -->
  ​<id value="[id]"/><!-- 0..1 ​* ​Unique id for inter-element referencing   -->
  ​<extension><!-- See Extensions  ​Additional content defined by implementations   --></extension>
  ​<modifierExtension><!-- ​I 0..* ​* ​Extensions that cannot be ignored even if unrecognized   --></modifierExtension>
  <type><!-- 0..1 ​* ​Classification of specific cost   --></type>
  <groupSize value="[positiveInt]"/><!-- 0..1 ​* ​Number of enrollees   -->
  <cost><!-- 0..1 ​* ​Cost value   --></cost>
  <comment value="[string]"/><!-- 0..1 ​* ​Additional cost information   -->
 </generalCost>
 <specificCost> ​I 0..* ​*  <!-- ​I 0..* Individual cost elements -->
  ​<id value="[id]"/><!-- 0..1 ​* ​Unique id for inter-element referencing   -->
  ​<extension><!-- See Extensions  ​Additional content defined by implementations   --></extension>
  ​<modifierExtension><!-- ​I 0..* ​* ​Extensions that cannot be ignored even if unrecognized   --></modifierExtension>
  <category><!-- 1..1 ​* ​General category of benefit   --></category>
  <benefit> ​I 0..* ​*  <!-- ​I 0..* Benefits list -->
   ​<id value="[id]"/><!-- 0..1 ​* ​Unique id for inter-element referencing    -->
   ​<extension><!-- See Extensions  ​Additional content defined by implementations    --></extension>
   ​<modifierExtension><!-- ​I 0..* ​* ​Extensions that cannot be ignored even if unrecognized    --></modifierExtension>
   <type><!-- 1..1 ​* ​Classification of benefit provided    --></type>
   <cost> ​I 0..* ​*  <!-- ​I 0..* List of the costs -->
    ​<id value="[id]"/><!-- 0..1 ​* ​Unique id for inter-element referencing     -->
    ​<extension><!-- See Extensions  ​Additional content defined by implementations     --></extension>
    ​<modifierExtension><!-- ​I 0..* ​* ​Extensions that cannot be ignored even if unrecognized     --></modifierExtension>
    <type><!-- 1..1 ​* ​Classification of specific cost     --></type>
    <applicability><!-- 0..1 ​* in-network | out-of-network | other     --></applicability>
    <qualifier><!-- 0..* ​* ​Additional information about the cost     --></qualifier>
    <value><!-- 0..1 ​* ​The actual cost value     --></value>
   </cost>
  </benefit>
 </specificCost>
</InsurancePlan>

​
{​​doco
  "resourceType" : "InsurancePlan",
  "id" : "<id>", // 0..1 ​Logical id of this artifact
  "meta" : { Meta }, // ​I 0..1 ​Metadata about the resource
  "implicitRules" : "<uri>", // ​I 0..1 ​A set of rules under which this content was created
  "language" : "<code>", // ​I 0..1 Language of the resource content
  "text" : { Narrative }, // ​I 0..1 ​Text summary of the resource, for human interpretation
  "contained" : [{ ​Resource }], // 0..* ​Contained, inline Resources
  (Extensions - see JSON page)
  (Modifier Extensions - see JSON page)
  "identifier" : [{ Identifier }], // 0..* ​Business Identifier for Plan
  "type" : { CodeableConcept }, // 0..1 ​Classification of Plan
  "product" : { Reference(InsuranceProduct) }, // 0..1 ​The product that this plan is available under
  "coverageArea" : [{ Reference(Location) }], // 0..* ​Where product-plan applies
  "network" : [{ Reference(Organization) }], // 0..* ​What networks provide coverage
  "generalCost" : [{ BackboneElement }], // ​I 0..* ​Overall costs
    "id" : "<id>", // 0..1 ​Unique id for inter-element referencing
  (Extensions - see JSON page)
  (Modifier Extensions - see JSON page)
    "type" : { CodeableConcept }, // 0..1 ​Classification of specific cost
    "groupSize" : "<positiveInt>", // 0..1 ​Number of enrollees
    "cost" : { Money }, // 0..1 ​Cost value
    "comment" : "<string>" // 0..1 ​Additional cost information
  }
  "specificCost" : [{ BackboneElement }] // ​I 0..* ​Individual cost elements
    "id" : "<id>", // 0..1 ​Unique id for inter-element referencing
  (Extensions - see JSON page)
  (Modifier Extensions - see JSON page)
    "category" : { CodeableConcept }, // 1..1 ​General category of benefit
    "benefit" : [{ BackboneElement }] // ​I 0..* ​Benefits list
      "id" : "<id>", // 0..1 ​Unique id for inter-element referencing
  (Extensions - see JSON page)
  (Modifier Extensions - see JSON page)
      "type" : { CodeableConcept }, // 1..1 ​Classification of benefit provided
      "cost" : [{ BackboneElement }] // ​I 0..* ​List of the costs
        "id" : "<id>", // 0..1 ​Unique id for inter-element referencing
  (Extensions - see JSON page)
  (Modifier Extensions - see JSON page)
        "type" : { CodeableConcept }, // 1..1 ​Classification of specific cost
        "applicability" : { CodeableConcept }, // 0..1 in-network | out-of-network | other
        "qualifier" : [{ CodeableConcept }], // 0..* ​Additional information about the cost
        "value" : { Quantity } // 0..1 ​The actual cost value
      }
    }
  }
}

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


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

  fhir:id [ id ] ; # 0..1 Logical id of this artifact
  fhir:meta [ Meta ] ; # 0..1 ​I Metadata about the resource
  fhir:implicitRules [ uri ] ; # 0..1 ​I A set of rules under which this content was created
  fhir:language [ code ] ; # 0..1 ​I Language of the resource content
  fhir:text [ Narrative ] ; # 0..1 ​I Text summary of the resource, for human interpretation
  fhir:contained  ( [ Resource ] ... ) ; # 0..* Contained, inline Resources
  fhir:extension  ( [ Extension ] ... ) ; # 0..* ​I Additional content defined by implementations
  fhir:modifierExtension  ( [ Extension ] ... ) ; # 0..* ​I Extensions that cannot be ignored
  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  ( [ BackboneElement ] ... ) ; # 0..* ​I Overall costs
  fhir:specificCost  ( [ BackboneElement ] ... ) ; # 0..* ​I Individual cost elements
]

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. InsurancePlan 0..* DomainResource Plan details

Elements defined in Ancestors:id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier Business Identifier for Plan
... type 0..1 CodeableConcept Classification of Plan
... product Σ 0..1 Reference(Insurance Product) The product that this plan is available under
... network 0..* Reference(Organization) What networks provide coverage
... generalCost 0..* BackboneElement Overall costs
.... type 0..1 CodeableConcept Classification of specific cost
.... groupSize 0..1 positiveInt Number of enrollees
.... cost 0..1 Money Cost value
.... comment 0..1 string Additional cost information
... specificCost 0..* BackboneElement Individual cost elements
.... category 1..1 CodeableConcept General category of benefit
.... benefit 0..* BackboneElement Benefits list
..... type 1..1 CodeableConcept Classification of benefit provided
..... cost 0..* BackboneElement List of the costs
...... type 1..1 CodeableConcept Classification of specific cost
...... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
...... qualifier 0..* CodeableConcept Additional information about the cost
...... value 0..1 Quantity The actual cost value

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.specificCost.​benefit.cost.applicability Base required Benefit Cost Applicability 📦6.0.0-ballot3 FHIR Std.

 

Other representations of resource: CSV, Excel

Notes:

Notes:

Name Type Description Expression
coverage-area reference

Location(s) insurance product is intended for/available to

 InsurancePlan.coverageArea
identifier token

External identifiers for this item

 InsurancePlan.identifier
network reference

The product this plan is available to

 InsurancePlan.network
product reference

The product this plan is available to

 InsurancePlan.product
type token

A code for the type of insurance plan

 InsurancePlan.type