CARIN Digital Insurance Card
2.0.0 - STU 2.0

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

## Resource Profile: SBCInsurancePlan - Detailed Descriptions

Page standards status: Informative

Definitions for the sbc-insurance-plan resource profile.

- Differential Elements Table
- Key Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. InsurancePlan
2. InsurancePlan.extension
Slicing | This element introduces a set of slices on `InsurancePlan.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
4. InsurancePlan.extension:sbcMetadata
Slice Name | sbcMetadata
Definition | Contains minimum essential coverage indicator, minimum value indicator, abortion coverage disclosure, and SBC version date
Short | SBC regulatory metadata
Control | 0..1
Type | Extension(SBC Metadata Extension) (Complex Extension)
Must Support | true
6. InsurancePlan.extension:excludedServices
Slice Name | excludedServices
Definition | Services that are NOT covered by this plan, as displayed in the 'Excluded Services & Other Covered Services' section of the SBC
Short | Excluded services list
Control | 0..1
Type | Extension(Excluded Services Extension) (Complex Extension)
Must Support | true
8. InsurancePlan.identifier
Definition | Unique identifier for the plan, such as the 14-16 digit HIOS ID (5-digit HIOS ID + 2-digit State + 3-digit Product Iteration + 4-digit Plan Iteration + 2-digit Variant)
Short | Business identifier for the insurance plan (e.g., HIOS ID)
Note | This is a business identifier, not a resource identifier (see discussion)
Must Support | true
10. InsurancePlan.status
Control | 1..?
Must Support | true
Fixed Value | `active`
12. InsurancePlan.name
Definition | The official name of the health insurance plan as it appears in the SBC header
Short | Plan name as displayed on SBC
Control | 1..?
Must Support | true
14. InsurancePlan.period
Definition | The time period during which this plan is or was available. Maps to the Coverage Period displayed in the SBC header
Short | Coverage period
Control | 1..?
Must Support | true
16. InsurancePlan.ownedBy
Definition | The health insurance issuer or employer that owns/offers this plan
Short | Plan issuer organization
Control | 1..?
Must Support | true
18. InsurancePlan.administeredBy
Short | Plan administrator
Must Support | true
20. InsurancePlan.contact
Definition | Contact information including phone numbers, website addresses, and other contact methods required by SBC regulations for questions, provider lists, formulary, and uniform glossary access
Short | Contact information for plan questions
Control | 1..?
Must Support | true
22. InsurancePlan.coverage
Definition | Details of benefit coverage for different categories of services. Each coverage entry should represent one or more of the 27 required SBC benefit categories
Short | Benefit coverage details
Control | 1..?
Must Support | true
24. InsurancePlan.coverage.type
Definition | High-level categorization of coverage type
Short | Type of coverage (e.g., medical, pharmacy)
Binding | Unless not suitable, these codes SHALL be taken from SBC Benefit Category Value Set (extensible to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Must Support | true
26. InsurancePlan.coverage.network
Short | Provider networks for this coverage
Must Support | true
28. InsurancePlan.coverage.benefit
Definition | Individual benefit types within this coverage category, corresponding to the 27 SBC benefit categories
Short | Specific benefits covered
Must Support | true
30. InsurancePlan.coverage.benefit.extension
Slicing | This element introduces a set of slices on `InsurancePlan.coverage.benefit.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
32. InsurancePlan.coverage.benefit.extension:limitation
Slice Name | limitation
Definition | Specific limitations, exceptions, or additional context for this benefit as displayed in the SBC
Short | Limitations and exceptions
Control | 0..*
Type | Extension(Benefit Limitation Extension) (Extension Type: string)
Must Support | true
34. InsurancePlan.coverage.benefit.type
Definition | The specific benefit category from the SBC's 27 required categories
Short | Benefit category code
Binding | The codes SHALL be taken from SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Must Support | true
36. InsurancePlan.coverage.benefit.requirement
Definition | Text describing requirements such as prior authorization, referral requirements, or other access limitations
Short | Requirements for accessing benefit
Must Support | true
38. InsurancePlan.plan
Definition | Specific plan offerings with detailed cost-sharing information for each of the 27 SBC benefit categories
Short | Health insurance plan details
Control | 1..?
Must Support | true
40. InsurancePlan.plan.type
Definition | The type of health insurance plan as displayed in the SBC header (e.g., HMO, PPO, POS, EPO, HDHP, Indemnity)
Short | Plan type (HMO, PPO, POS, EPO, etc.)
Binding | Unless not suitable, these codes SHALL be taken from SBC Plan Type Value Set (extensible to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-plan-type` )
Must Support | true
42. InsurancePlan.plan.coverageArea
Short | Geographic coverage area
Must Support | true
44. InsurancePlan.plan.network
Short | Provider networks for this plan
Must Support | true
46. InsurancePlan.plan.generalCost
Definition | Plan-level costs such as overall deductibles and out-of-pocket maximums that apply across benefit categories
Short | Overall plan costs
Must Support | true
48. InsurancePlan.plan.generalCost.type
Short | Type of cost (deductible, out-of-pocket max)
Must Support | true
50. InsurancePlan.plan.generalCost.cost
Short | Cost amount
Must Support | true
52. InsurancePlan.plan.generalCost.comment
Must Support | true
54. InsurancePlan.plan.specificCost
Definition | Cost-sharing information (copays, coinsurance, deductibles) for each of the 27 SBC benefit categories, with separate amounts for in-network and out-of-network services
Short | Cost-sharing by benefit category
Control | 1..?
Must Support | true
56. InsurancePlan.plan.specificCost.category
Definition | The specific SBC benefit category to which these costs apply
Short | Benefit category code
Binding | The codes SHALL be taken from SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Must Support | true
58. InsurancePlan.plan.specificCost.benefit
Short | Specific benefit with costs
Control | 1..?
Must Support | true
60. InsurancePlan.plan.specificCost.benefit.extension
Slicing | This element introduces a set of slices on `InsurancePlan.plan.specificCost.benefit.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
62. InsurancePlan.plan.specificCost.benefit.extension:limitation
Slice Name | limitation
Short | Benefit-specific limitations
Control | 0..*
Type | Extension(Benefit Limitation Extension) (Extension Type: string)
Must Support | true
64. InsurancePlan.plan.specificCost.benefit.type
Short | Benefit type code
Binding | The codes SHALL be taken from SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Must Support | true
66. InsurancePlan.plan.specificCost.benefit.cost
Definition | Cost-sharing information including copays, coinsurance, and deductibles. Must include separate entries for in-network and out-of-network services where applicable
Short | Cost-sharing amounts
Control | 2..?
Must Support | true
68. InsurancePlan.plan.specificCost.benefit.cost.type
Definition | The type of cost-sharing: copayment (fixed dollar amount), coinsurance (percentage), or deductible
Short | Type of cost (copay, coinsurance, deductible)
Must Support | true
70. InsurancePlan.plan.specificCost.benefit.cost.applicability
Definition | Whether this cost applies to in-network services, out-of-network services, or other scenarios
Short | Network applicability (in-network, out-of-network)
Control | 1..?
Must Support | true
72. InsurancePlan.plan.specificCost.benefit.cost.value
Definition | The actual cost-sharing amount (dollar amount for copay, percentage for coinsurance)
Short | Cost amount
Control | 1..?
Must Support | true

Guidance on how to interpret the contents of this table can be foundhere

0. InsurancePlan
Definition | Details of a Health Insurance product/plan provided by an organization.
Short | Details of a Health Insurance product/plan provided by an organization
Control | 0..*
Is Modifier | false
Summary | false
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one (`(identifier.count() + name.count()) > 0`) ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one ((identifier.count() + name.count()) > 0)
2. InsurancePlan.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. InsurancePlan.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `InsurancePlan.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
6. InsurancePlan.extension:sbcMetadata
Slice Name | sbcMetadata
Definition | Contains minimum essential coverage indicator, minimum value indicator, abortion coverage disclosure, and SBC version date
Short | SBC regulatory metadata
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(SBC Metadata Extension) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
8. InsurancePlan.extension:excludedServices
Slice Name | excludedServices
Definition | Services that are NOT covered by this plan, as displayed in the 'Excluded Services & Other Covered Services' section of the SBC
Short | Excluded services list
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(Excluded Services Extension) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
10. InsurancePlan.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
12. InsurancePlan.identifier
Definition | Unique identifier for the plan, such as the 14-16 digit HIOS ID (5-digit HIOS ID + 2-digit State + 3-digit Product Iteration + 4-digit Plan Iteration + 2-digit Variant) Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.
Short | Business identifier for the insurance plan (e.g., HIOS ID)Business Identifier for Product
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..* This element is affected by the following invariants: ipn-1
Type | Identifier
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. InsurancePlan.status
Definition | The current state of the health insurance product.
Short | draft | active | retired | unknown
Control | 10..1
Binding | The codes SHALL be taken from PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/publication-status|4.0.1` ) The lifecycle status of an artifact.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains codes which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI.
Meaning if Missing | Default interpretation is active.
Fixed Value | `active`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. InsurancePlan.name
Definition | The official name of the health insurance plan as it appears in the SBC header Official name of the health insurance product as designated by the owner.
Short | Plan name as displayed on SBCOfficial name
Comments | If the name of the product/plan changes, consider putting the old name in the alias column so that it can still be located through searches.
Control | 10..1 This element is affected by the following invariants: ipn-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. InsurancePlan.period
Definition | The time period during which this plan is or was available. Maps to the Coverage Period displayed in the SBC header The period of time that the health insurance product is available.
Short | Coverage periodWhen the product is available
Control | 10..1
Type | Period
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. InsurancePlan.ownedBy
Definition | The health insurance issuer or employer that owns/offers this plan The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers'.
Short | Plan issuer organization
Control | 10..1
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | true
Alternate Names | Payer
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. InsurancePlan.administeredBy
Definition | An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.
Short | Plan administratorProduct administrator
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. InsurancePlan.contact
Definition | Contact information including phone numbers, website addresses, and other contact methods required by SBC regulations for questions, provider lists, formulary, and uniform glossary access The contact for the health insurance product for a certain purpose.
Short | Contact information for plan questionsContact for the product
Comments | Where multiple contacts for the same purpose are provided there is a standard extension that can be used to determine which one is the preferred contact to use.
Control | 10..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Need to keep track of assigned contact points within bigger organization.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. InsurancePlan.contact.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
28. InsurancePlan.coverage
Definition | Details of benefit coverage for different categories of services. Each coverage entry should represent one or more of the 27 required SBC benefit categories Details about the coverage offered by the insurance product.
Short | Benefit coverage detailsCoverage details
Control | 10..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. InsurancePlan.coverage.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
32. InsurancePlan.coverage.type
Definition | High-level categorization of coverage type Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).
Short | Type of coverage (e.g., medical, pharmacy)
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For codes, see SBC Benefit Category Value Set (extensible to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. InsurancePlan.coverage.network
Definition | Reference to the network that providing the type of coverage.
Short | Provider networks for this coverageWhat networks provide coverage
Comments | Networks are represented as a hierarchy of organization resources.
Control | 0..*
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. InsurancePlan.coverage.benefit
Definition | Individual benefit types within this coverage category, corresponding to the 27 SBC benefit categories Specific benefits under this type of coverage.
Short | Specific benefits coveredList of benefits
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. InsurancePlan.coverage.benefit.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `InsurancePlan.coverage.benefit.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
40. InsurancePlan.coverage.benefit.extension:limitation
Slice Name | limitation
Definition | Specific limitations, exceptions, or additional context for this benefit as displayed in the SBC
Short | Limitations and exceptions
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Benefit Limitation Extension) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
42. InsurancePlan.coverage.benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
44. InsurancePlan.coverage.benefit.type
Definition | The specific benefit category from the SBC's 27 required categories Type of benefit (primary care; speciality care; inpatient; outpatient).
Short | Benefit category codeType of benefit
Control | 1..1
Binding | The codes SHALL be taken from For codes, see SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. InsurancePlan.coverage.benefit.requirement
Definition | Text describing requirements such as prior authorization, referral requirements, or other access limitations The referral requirements to have access/coverage for this benefit.
Short | Requirements for accessing benefitReferral requirements
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. InsurancePlan.plan
Definition | Specific plan offerings with detailed cost-sharing information for each of the 27 SBC benefit categories Details about an insurance plan.
Short | Health insurance plan detailsPlan details
Control | 10..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. InsurancePlan.plan.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
52. InsurancePlan.plan.type
Definition | The type of health insurance plan as displayed in the SBC header (e.g., HMO, PPO, POS, EPO, HDHP, Indemnity) Type of plan. For example, "Platinum" or "High Deductable".
Short | Plan type (HMO, PPO, POS, EPO, etc.)Type of plan
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from For codes, see SBC Plan Type Value Set (extensible to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-plan-type` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. InsurancePlan.plan.coverageArea
Definition | The geographic region in which a health insurance plan's benefits apply.
Short | Geographic coverage areaWhere product applies
Control | 0..*
Type | Reference(Location)
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. InsurancePlan.plan.network
Definition | Reference to the network that providing the type of coverage.
Short | Provider networks for this planWhat networks provide coverage
Comments | Networks are represented as a hierarchy of organization resources.
Control | 0..*
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. InsurancePlan.plan.generalCost
Definition | Plan-level costs such as overall deductibles and out-of-pocket maximums that apply across benefit categories Overall costs associated with the plan.
Short | Overall plan costsOverall costs
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. InsurancePlan.plan.generalCost.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
62. InsurancePlan.plan.generalCost.type
Definition | Type of cost.
Short | Type of cost (deductible, out-of-pocket max)
Control | 0..1
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. InsurancePlan.plan.generalCost.cost
Definition | Value of the cost.
Short | Cost amountCost value
Control | 0..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. InsurancePlan.plan.generalCost.comment
Definition | Additional information about the general costs associated with this plan.
Short | Additional cost information
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. InsurancePlan.plan.specificCost
Definition | Cost-sharing information (copays, coinsurance, deductibles) for each of the 27 SBC benefit categories, with separate amounts for in-network and out-of-network services Costs associated with the coverage provided by the product.
Short | Cost-sharing by benefit categorySpecific costs
Control | 10..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. InsurancePlan.plan.specificCost.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
72. InsurancePlan.plan.specificCost.category
Definition | The specific SBC benefit category to which these costs apply General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).
Short | Benefit category codeGeneral category of benefit
Control | 1..1
Binding | The codes SHALL be taken from For codes, see SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. InsurancePlan.plan.specificCost.benefit
Definition | List of the specific benefits under this category of benefit.
Short | Specific benefit with costsBenefits list
Control | 10..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. InsurancePlan.plan.specificCost.benefit.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `InsurancePlan.plan.specificCost.benefit.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
78. InsurancePlan.plan.specificCost.benefit.extension:limitation
Slice Name | limitation
Definition | Extension for documenting limitations and exceptions that apply to specific benefits in the SBC
Short | Benefit-specific limitations
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Benefit Limitation Extension) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. InsurancePlan.plan.specificCost.benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. InsurancePlan.plan.specificCost.benefit.type
Definition | Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).
Short | Benefit type codeType of specific benefit
Control | 1..1
Binding | The codes SHALL be taken from For codes, see SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. InsurancePlan.plan.specificCost.benefit.cost
Definition | Cost-sharing information including copays, coinsurance, and deductibles. Must include separate entries for in-network and out-of-network services where applicable List of the costs associated with a specific benefit.
Short | Cost-sharing amountsList of the costs
Control | 20..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. InsurancePlan.plan.specificCost.benefit.cost.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
88. InsurancePlan.plan.specificCost.benefit.cost.type
Definition | The type of cost-sharing: copayment (fixed dollar amount), coinsurance (percentage), or deductible Type of cost (copay; individual cap; family cap; coinsurance; deductible).
Short | Type of cost (copay, coinsurance, deductible)
Control | 1..1
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. InsurancePlan.plan.specificCost.benefit.cost.applicability
Definition | Whether this cost applies to in-network services, out-of-network services, or other scenarios Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).
Short | Network applicability (in-network, out-of-network)in-network | out-of-network | other
Control | 10..1
Binding | The codes SHALL be taken from BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 (required to `http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1` ) Whether the cost applies to in-network or out-of-network providers.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. InsurancePlan.plan.specificCost.benefit.cost.value
Definition | The actual cost-sharing amount (dollar amount for copay, percentage for coinsurance) The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).
Short | Cost amountThe actual cost value
Control | 10..1
Type | Quantity
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. InsurancePlan
Definition | Details of a Health Insurance product/plan provided by an organization.
Short | Details of a Health Insurance product/plan provided by an organization
Control | 0..*
Is Modifier | false
Summary | false
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (`contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (`contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`) ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one (`(identifier.count() + name.count()) > 0`)
2. InsurancePlan.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Logical id of this artifact
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
4. InsurancePlan.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. InsurancePlan.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. InsurancePlan.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. InsurancePlan.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short | Text summary of the resource, for human interpretation
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. InsurancePlan.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Short | Contained, inline Resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
14. InsurancePlan.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `InsurancePlan.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
16. InsurancePlan.extension:sbcMetadata
Slice Name | sbcMetadata
Definition | Contains minimum essential coverage indicator, minimum value indicator, abortion coverage disclosure, and SBC version date
Short | SBC regulatory metadata
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(SBC Metadata Extension) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. InsurancePlan.extension:excludedServices
Slice Name | excludedServices
Definition | Services that are NOT covered by this plan, as displayed in the 'Excluded Services & Other Covered Services' section of the SBC
Short | Excluded services list
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(Excluded Services Extension) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
20. InsurancePlan.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
22. InsurancePlan.identifier
Definition | Unique identifier for the plan, such as the 14-16 digit HIOS ID (5-digit HIOS ID + 2-digit State + 3-digit Product Iteration + 4-digit Plan Iteration + 2-digit Variant)
Short | Business identifier for the insurance plan (e.g., HIOS ID)
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..* This element is affected by the following invariants: ipn-1
Type | Identifier
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
24. InsurancePlan.status
Definition | The current state of the health insurance product.
Short | draft | active | retired | unknown
Control | 1..1
Binding | The codes SHALL be taken from PublicationStatus (required to `http://hl7.org/fhir/ValueSet/publication-status|4.0.1` ) The lifecycle status of an artifact.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains codes which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI.
Meaning if Missing | Default interpretation is active.
Fixed Value | `active`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
26. InsurancePlan.type
Definition | The kind of health insurance product.
Short | Kind of product
Control | 0..*
Binding | For example codes, see InsurancePlanType (example to `http://hl7.org/fhir/ValueSet/insuranceplan-type|4.0.1` ) Used to categorize the product/plan.
Type | CodeableConcept
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. InsurancePlan.name
Definition | The official name of the health insurance plan as it appears in the SBC header
Short | Plan name as displayed on SBC
Comments | If the name of the product/plan changes, consider putting the old name in the alias column so that it can still be located through searches.
Control | 1..1 This element is affected by the following invariants: ipn-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. InsurancePlan.alias
Definition | A list of alternate names that the product is known as, or was known as in the past.
Short | Alternate names
Comments | There are no dates associated with the alias/historic names, as this is not intended to track when names were used, but to assist in searching so that older names can still result in identifying the product/plan.
Control | 0..*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Over time products/plans go through many changes and can be known by different names. For searching knowing previous names that the product/plan was known by can be very useful.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. InsurancePlan.period
Definition | The time period during which this plan is or was available. Maps to the Coverage Period displayed in the SBC header
Short | Coverage period
Control | 1..1
Type | Period
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. InsurancePlan.ownedBy
Definition | The health insurance issuer or employer that owns/offers this plan
Short | Plan issuer organization
Control | 1..1
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | true
Alternate Names | Payer
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. InsurancePlan.administeredBy
Definition | An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.
Short | Plan administrator
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. InsurancePlan.coverageArea
Definition | The geographic region in which a health insurance product's benefits apply.
Short | Where product applies
Control | 0..*
Type | Reference(Location)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. InsurancePlan.contact
Definition | Contact information including phone numbers, website addresses, and other contact methods required by SBC regulations for questions, provider lists, formulary, and uniform glossary access
Short | Contact information for plan questions
Comments | Where multiple contacts for the same purpose are provided there is a standard extension that can be used to determine which one is the preferred contact to use.
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Need to keep track of assigned contact points within bigger organization.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
42. InsurancePlan.contact.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
44. InsurancePlan.contact.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
46. InsurancePlan.contact.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
48. InsurancePlan.contact.purpose
Definition | Indicates a purpose for which the contact can be reached.
Short | The type of contact
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ContactEntityType (extensible to `http://hl7.org/fhir/ValueSet/contactentity-type|4.0.1` ) The purpose for which you would contact a contact party.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to distinguish between multiple contact persons.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
50. InsurancePlan.contact.name
Definition | A name associated with the contact.
Short | A name associated with the contact
Control | 0..1
Type | HumanName
Is Modifier | false
Summary | false
Requirements | Need to be able to track the person by name.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
52. InsurancePlan.contact.telecom
Definition | A contact detail (e.g. a telephone number or an email address) by which the party may be contacted.
Short | Contact details (telephone, email, etc.) for a contact
Control | 0..*
Type | ContactPoint
Is Modifier | false
Summary | false
Requirements | People have (primary) ways to contact them in some way such as phone, email.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. InsurancePlan.contact.address
Definition | Visiting or postal addresses for the contact.
Short | Visiting or postal addresses for the contact
Control | 0..1
Type | Address
Is Modifier | false
Summary | false
Requirements | May need to keep track of a contact party's address for contacting, billing or reporting requirements.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. InsurancePlan.endpoint
Definition | The technical endpoints providing access to services operated for the health insurance product.
Short | Technical endpoint
Control | 0..*
Type | Reference(Endpoint)
Is Modifier | false
Summary | false
Requirements | Organizations have multiple systems that provide various services and need to be able to define the technical connection details for how to connect to them, and for what purpose.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. InsurancePlan.network
Definition | Reference to the network included in the health insurance product.
Short | What networks are Included
Comments | Networks are represented as a hierarchy of organization resources.
Control | 0..*
Type | Reference(Organization)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. InsurancePlan.coverage
Definition | Details of benefit coverage for different categories of services. Each coverage entry should represent one or more of the 27 required SBC benefit categories
Short | Benefit coverage details
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. InsurancePlan.coverage.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
64. InsurancePlan.coverage.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
66. InsurancePlan.coverage.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
68. InsurancePlan.coverage.type
Definition | High-level categorization of coverage type
Short | Type of coverage (e.g., medical, pharmacy)
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from SBC Benefit Category Value Set (extensible to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
70. InsurancePlan.coverage.network
Definition | Reference to the network that providing the type of coverage.
Short | Provider networks for this coverage
Comments | Networks are represented as a hierarchy of organization resources.
Control | 0..*
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
72. InsurancePlan.coverage.benefit
Definition | Individual benefit types within this coverage category, corresponding to the 27 SBC benefit categories
Short | Specific benefits covered
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
74. InsurancePlan.coverage.benefit.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
76. InsurancePlan.coverage.benefit.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `InsurancePlan.coverage.benefit.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
78. InsurancePlan.coverage.benefit.extension:limitation
Slice Name | limitation
Definition | Specific limitations, exceptions, or additional context for this benefit as displayed in the SBC
Short | Limitations and exceptions
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Benefit Limitation Extension) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
80. InsurancePlan.coverage.benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
82. InsurancePlan.coverage.benefit.type
Definition | The specific benefit category from the SBC's 27 required categories
Short | Benefit category code
Control | 1..1
Binding | The codes SHALL be taken from SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
84. InsurancePlan.coverage.benefit.requirement
Definition | Text describing requirements such as prior authorization, referral requirements, or other access limitations
Short | Requirements for accessing benefit
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
86. InsurancePlan.coverage.benefit.limit
Definition | The specific limits on the benefit.
Short | Benefit limits
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
88. InsurancePlan.coverage.benefit.limit.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
90. InsurancePlan.coverage.benefit.limit.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
92. InsurancePlan.coverage.benefit.limit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
94. InsurancePlan.coverage.benefit.limit.value
Definition | The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses.
Short | Maximum value allowed
Comments | May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”.
Control | 0..1
Type | Quantity
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
96. InsurancePlan.coverage.benefit.limit.code
Definition | The specific limit on the benefit.
Short | Benefit limit details
Comments | Use `CodeableConcept.text` element if the data is free (uncoded) text.
Control | 0..1
Type | CodeableConcept
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
98. InsurancePlan.plan
Definition | Specific plan offerings with detailed cost-sharing information for each of the 27 SBC benefit categories
Short | Health insurance plan details
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
100. InsurancePlan.plan.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
102. InsurancePlan.plan.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
104. InsurancePlan.plan.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
106. InsurancePlan.plan.identifier
Definition | Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.
Short | Business Identifier for Product
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
108. InsurancePlan.plan.type
Definition | The type of health insurance plan as displayed in the SBC header (e.g., HMO, PPO, POS, EPO, HDHP, Indemnity)
Short | Plan type (HMO, PPO, POS, EPO, etc.)
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from SBC Plan Type Value Set (extensible to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-plan-type` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
110. InsurancePlan.plan.coverageArea
Definition | The geographic region in which a health insurance plan's benefits apply.
Short | Geographic coverage area
Control | 0..*
Type | Reference(Location)
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
112. InsurancePlan.plan.network
Definition | Reference to the network that providing the type of coverage.
Short | Provider networks for this plan
Comments | Networks are represented as a hierarchy of organization resources.
Control | 0..*
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
114. InsurancePlan.plan.generalCost
Definition | Plan-level costs such as overall deductibles and out-of-pocket maximums that apply across benefit categories
Short | Overall plan costs
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
116. InsurancePlan.plan.generalCost.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
118. InsurancePlan.plan.generalCost.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
120. InsurancePlan.plan.generalCost.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
122. InsurancePlan.plan.generalCost.type
Definition | Type of cost.
Short | Type of cost (deductible, out-of-pocket max)
Control | 0..1
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
124. InsurancePlan.plan.generalCost.groupSize
Definition | Number of participants enrolled in the plan.
Short | Number of enrollees
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
126. InsurancePlan.plan.generalCost.cost
Definition | Value of the cost.
Short | Cost amount
Control | 0..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
128. InsurancePlan.plan.generalCost.comment
Definition | Additional information about the general costs associated with this plan.
Short | Additional cost information
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
130. InsurancePlan.plan.specificCost
Definition | Cost-sharing information (copays, coinsurance, deductibles) for each of the 27 SBC benefit categories, with separate amounts for in-network and out-of-network services
Short | Cost-sharing by benefit category
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
132. InsurancePlan.plan.specificCost.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
134. InsurancePlan.plan.specificCost.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
136. InsurancePlan.plan.specificCost.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
138. InsurancePlan.plan.specificCost.category
Definition | The specific SBC benefit category to which these costs apply
Short | Benefit category code
Control | 1..1
Binding | The codes SHALL be taken from SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
140. InsurancePlan.plan.specificCost.benefit
Definition | List of the specific benefits under this category of benefit.
Short | Specific benefit with costs
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
142. InsurancePlan.plan.specificCost.benefit.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
144. InsurancePlan.plan.specificCost.benefit.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `InsurancePlan.plan.specificCost.benefit.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
146. InsurancePlan.plan.specificCost.benefit.extension:limitation
Slice Name | limitation
Definition | Extension for documenting limitations and exceptions that apply to specific benefits in the SBC
Short | Benefit-specific limitations
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Benefit Limitation Extension) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
148. InsurancePlan.plan.specificCost.benefit.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
150. InsurancePlan.plan.specificCost.benefit.type
Definition | Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).
Short | Benefit type code
Control | 1..1
Binding | The codes SHALL be taken from SBC Benefit Category Value Set (required to `http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
152. InsurancePlan.plan.specificCost.benefit.cost
Definition | Cost-sharing information including copays, coinsurance, and deductibles. Must include separate entries for in-network and out-of-network services where applicable
Short | Cost-sharing amounts
Control | 2..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
154. InsurancePlan.plan.specificCost.benefit.cost.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
156. InsurancePlan.plan.specificCost.benefit.cost.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
158. InsurancePlan.plan.specificCost.benefit.cost.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
160. InsurancePlan.plan.specificCost.benefit.cost.type
Definition | The type of cost-sharing: copayment (fixed dollar amount), coinsurance (percentage), or deductible
Short | Type of cost (copay, coinsurance, deductible)
Control | 1..1
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
162. InsurancePlan.plan.specificCost.benefit.cost.applicability
Definition | Whether this cost applies to in-network services, out-of-network services, or other scenarios
Short | Network applicability (in-network, out-of-network)
Control | 1..1
Binding | The codes SHALL be taken from BenefitCostApplicability (required to `http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1` ) Whether the cost applies to in-network or out-of-network providers.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
164. InsurancePlan.plan.specificCost.benefit.cost.qualifiers
Definition | Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).
Short | Additional information about the cost
Control | 0..*
Type | CodeableConcept
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
166. InsurancePlan.plan.specificCost.benefit.cost.value
Definition | The actual cost-sharing amount (dollar amount for copay, percentage for coinsurance)
Short | Cost amount
Control | 1..1
Type | Quantity
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)