CARIN Digital Insurance Card, published by HL7 International / Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-digital-insurance-card/ and changes regularly. See the Directory of published versions

Summary of Benefits and Coverage

Use Case - Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC) is a legally required document under the Affordable Care Act (ACA) that serves as a standardized, easy-to-understand summary of what a health insurance plan covers and what costs a patient may incur. The SBC breaks down complex insurance terms and coverage details into a clear format, helping patients understand what services are included, what’s excluded, and how much they might pay for common medical scenarios. By providing consistent information across all plans, the SBC empowers patients to make choices based on their health needs and financial situation. It helps them evaluate trade-offs between premiums, deductibles, copayments, and coverage levels.

Scenario 1: Sharing SBC with Provider

Payer has an SBC available as part of their current health insurance. Payer makes it available through a digital insurance card. Patient could share this information via their digital insurance card with a provider. Provider would be able to confirm health care coverage.

Scenario 2: Patient is price shopping for health care services

Patient is interested in scheduling an acute care visit. Patient shares the digital insurance card with the acute care provider. Provider could inform the patient if their care would be covered and a cost estimate for services.

Scenario 3: Pharmaceutical support hub

Patient is interested in scheduling an acute care visit. Patient shares the digital insurance card with the pharmaceutical support hub. The pharmaceutical support hub could help guide the patient towards available patient financial assistance support for medication.