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: SBC Insurance Plan Profile ( Experimental )

Official URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan | Version: 2.0.0
Standards status: Informative | Computable Name: SBCInsurancePlan

Profile of InsurancePlan resource for representing Summary of Benefits and Coverage (SBC) documents as required under ACA Section 2715 and implementing regulations at 45 CFR 147.200, 29 CFR 2590.715-2715, and 26 CFR 54.9815-2715

To represent Summary of Benefits and Coverage documents in structured FHIR format, enabling machine-readable representation of the 27 required benefit categories, cost-sharing information, network distinctions, and regulatory disclosures

Usages:

- Refer to this Profile: Additional Insurance Card Information
- Examples for this Profile: Sample Health HMO Gold Plan

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from InsurancePlan

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
InsurancePlan |  | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:sbcMetadata | S | 0..1 | (Complex) | SBC regulatory metadata URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
extension:excludedServices | S | 0..1 | (Complex) | Excluded services list URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
identifier | S | 0..* | Identifier | Business identifier for the insurance plan (e.g., HIOS ID)
status | S | 1..1 | code | draft | active | retired | unknown Fixed Value: active
name | S | 1..1 | string | Plan name as displayed on SBC
period | S | 1..1 | Period | Coverage period
ownedBy | S | 1..1 | Reference(Organization) | Plan issuer organization
administeredBy | S | 0..1 | Reference(Organization) | Plan administrator
contact | S | 1..* | BackboneElement | Contact information for plan questions
coverage | S | 1..* | BackboneElement | Benefit coverage details
type | S | 1..1 | CodeableConcept | Type of coverage (e.g., medical, pharmacy) Binding: SBC Benefit Category Value Set (extensible)
network | S | 0..* | Reference(Organization) | Provider networks for this coverage
benefit | S | 1..* | BackboneElement | Specific benefits covered
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Limitations and exceptions URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
type | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
requirement | S | 0..1 | string | Requirements for accessing benefit
plan | S | 1..* | BackboneElement | Health insurance plan details
type | S | 0..1 | CodeableConcept | Plan type (HMO, PPO, POS, EPO, etc.) Binding: SBC Plan Type Value Set (extensible)
coverageArea | S | 0..* | Reference(Location) | Geographic coverage area
network | S | 0..* | Reference(Organization) | Provider networks for this plan
generalCost | S | 0..* | BackboneElement | Overall plan costs
type | S | 0..1 | CodeableConcept | Type of cost (deductible, out-of-pocket max)
cost | S | 0..1 | Money | Cost amount
comment | S | 0..1 | string | Additional cost information
specificCost | S | 1..* | BackboneElement | Cost-sharing by benefit category
category | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
benefit | S | 1..* | BackboneElement | Specific benefit with costs
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Benefit-specific limitations URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
type | S | 1..1 | CodeableConcept | Benefit type code Binding: SBC Benefit Category Value Set (required)
cost | S | 2..* | BackboneElement | Cost-sharing amounts
type | S | 1..1 | CodeableConcept | Type of cost (copay, coinsurance, deductible)
applicability | S | 1..1 | CodeableConcept | Network applicability (in-network, out-of-network)
value | S | 1..1 | Quantity | Cost amount
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
InsurancePlan.coverage.​type | Base | extensible | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.coverage.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.type | Base | extensible | SBC Plan Type Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​category | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:sbcMetadata | S | 0..1 | (Complex) | SBC regulatory metadata URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
extension:excludedServices | S | 0..1 | (Complex) | Excluded services list URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ C | 0..* | Identifier | Business identifier for the insurance plan (e.g., HIOS ID)
status | ?!S Σ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active
name | S Σ C | 1..1 | string | Plan name as displayed on SBC
period | S | 1..1 | Period | Coverage period
ownedBy | S Σ | 1..1 | Reference(Organization) | Plan issuer organization
administeredBy | S Σ | 0..1 | Reference(Organization) | Plan administrator
contact | S | 1..* | BackboneElement | Contact information for plan questions
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
coverage | S | 1..* | BackboneElement | Benefit coverage details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of coverage (e.g., medical, pharmacy) Binding: SBC Benefit Category Value Set (extensible)
network | S | 0..* | Reference(Organization) | Provider networks for this coverage
benefit | S | 1..* | BackboneElement | Specific benefits covered
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Limitations and exceptions URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
requirement | S | 0..1 | string | Requirements for accessing benefit
plan | S | 1..* | BackboneElement | Health insurance plan details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 0..1 | CodeableConcept | Plan type (HMO, PPO, POS, EPO, etc.) Binding: SBC Plan Type Value Set (extensible)
coverageArea | S Σ | 0..* | Reference(Location) | Geographic coverage area
network | S | 0..* | Reference(Organization) | Provider networks for this plan
generalCost | S | 0..* | BackboneElement | Overall plan costs
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 0..1 | CodeableConcept | Type of cost (deductible, out-of-pocket max)
cost | S | 0..1 | Money | Cost amount
comment | S | 0..1 | string | Additional cost information
specificCost | S | 1..* | BackboneElement | Cost-sharing by benefit category
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
benefit | S | 1..* | BackboneElement | Specific benefit with costs
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Benefit-specific limitations URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit type code Binding: SBC Benefit Category Value Set (required)
cost | S | 2..* | BackboneElement | Cost-sharing amounts
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of cost (copay, coinsurance, deductible)
applicability | S | 1..1 | CodeableConcept | Network applicability (in-network, out-of-network) Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
value | S | 1..1 | Quantity | Cost amount
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std.
InsurancePlan.coverage.​type | Base | extensible | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.coverage.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.type | Base | extensible | SBC Plan Type Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​category | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability | Base | required | Benefit cost applicability | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | InsurancePlan | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | InsurancePlan | 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 | error | InsurancePlan | 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 | error | InsurancePlan | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | InsurancePlan | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
ipn-1 | error | InsurancePlan | The organization SHALL at least have a name or an idendtifier, and possibly more than one | `(identifier.count() + name.count()) > 0`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:sbcMetadata | S | 0..1 | (Complex) | SBC regulatory metadata URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
extension:excludedServices | S | 0..1 | (Complex) | Excluded services list URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ C | 0..* | Identifier | Business identifier for the insurance plan (e.g., HIOS ID)
status | ?!S Σ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active
type | Σ | 0..* | CodeableConcept | Kind of product Binding: InsurancePlanType (example): Used to categorize the product/plan.
name | S Σ C | 1..1 | string | Plan name as displayed on SBC
alias |  | 0..* | string | Alternate names
period | S | 1..1 | Period | Coverage period
ownedBy | S Σ | 1..1 | Reference(Organization) | Plan issuer organization
administeredBy | S Σ | 0..1 | Reference(Organization) | Plan administrator
coverageArea | Σ | 0..* | Reference(Location) | Where product applies
contact | S | 1..* | BackboneElement | Contact information for plan questions
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
purpose |  | 0..1 | CodeableConcept | The type of contact Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
name |  | 0..1 | HumanName | A name associated with the contact
telecom |  | 0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact
address |  | 0..1 | Address | Visiting or postal addresses for the contact
endpoint |  | 0..* | Reference(Endpoint) | Technical endpoint
network |  | 0..* | Reference(Organization) | What networks are Included
coverage | S | 1..* | BackboneElement | Benefit coverage details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of coverage (e.g., medical, pharmacy) Binding: SBC Benefit Category Value Set (extensible)
network | S | 0..* | Reference(Organization) | Provider networks for this coverage
benefit | S | 1..* | BackboneElement | Specific benefits covered
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Limitations and exceptions URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
requirement | S | 0..1 | string | Requirements for accessing benefit
limit |  | 0..* | BackboneElement | Benefit limits
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
value |  | 0..1 | Quantity | Maximum value allowed
code |  | 0..1 | CodeableConcept | Benefit limit details
plan | S | 1..* | BackboneElement | Health insurance plan details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
identifier | Σ | 0..* | Identifier | Business Identifier for Product
type | S | 0..1 | CodeableConcept | Plan type (HMO, PPO, POS, EPO, etc.) Binding: SBC Plan Type Value Set (extensible)
coverageArea | S Σ | 0..* | Reference(Location) | Geographic coverage area
network | S | 0..* | Reference(Organization) | Provider networks for this plan
generalCost | S | 0..* | BackboneElement | Overall plan costs
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 0..1 | CodeableConcept | Type of cost (deductible, out-of-pocket max)
groupSize |  | 0..1 | positiveInt | Number of enrollees
cost | S | 0..1 | Money | Cost amount
comment | S | 0..1 | string | Additional cost information
specificCost | S | 1..* | BackboneElement | Cost-sharing by benefit category
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
benefit | S | 1..* | BackboneElement | Specific benefit with costs
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Benefit-specific limitations URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit type code Binding: SBC Benefit Category Value Set (required)
cost | S | 2..* | BackboneElement | Cost-sharing amounts
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of cost (copay, coinsurance, deductible)
applicability | S | 1..1 | CodeableConcept | Network applicability (in-network, out-of-network) Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers |  | 0..* | CodeableConcept | Additional information about the cost
value | S | 1..1 | Quantity | Cost amount
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
InsurancePlan.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std.
InsurancePlan.type | Base | example | Insurance plan type | 📍4.0.1 | FHIR Std.
InsurancePlan.contact.​purpose | Base | extensible | Contact entity type | 📍4.0.1 | FHIR Std.
InsurancePlan.coverage.​type | Base | extensible | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.coverage.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.type | Base | extensible | SBC Plan Type Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​category | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability | Base | required | Benefit cost applicability | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | InsurancePlan | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | InsurancePlan | 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 | error | InsurancePlan | 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 | error | InsurancePlan | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | InsurancePlan | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
ipn-1 | error | InsurancePlan | The organization SHALL at least have a name or an idendtifier, and possibly more than one | `(identifier.count() + name.count()) > 0`

This structure is derived from InsurancePlan

Summary

Mandatory: 11 elements
Must-Support: 33 elements
Fixed: 1 element

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
- http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
- http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation

Differential View

This structure is derived from InsurancePlan

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
InsurancePlan |  | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:sbcMetadata | S | 0..1 | (Complex) | SBC regulatory metadata URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
extension:excludedServices | S | 0..1 | (Complex) | Excluded services list URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
identifier | S | 0..* | Identifier | Business identifier for the insurance plan (e.g., HIOS ID)
status | S | 1..1 | code | draft | active | retired | unknown Fixed Value: active
name | S | 1..1 | string | Plan name as displayed on SBC
period | S | 1..1 | Period | Coverage period
ownedBy | S | 1..1 | Reference(Organization) | Plan issuer organization
administeredBy | S | 0..1 | Reference(Organization) | Plan administrator
contact | S | 1..* | BackboneElement | Contact information for plan questions
coverage | S | 1..* | BackboneElement | Benefit coverage details
type | S | 1..1 | CodeableConcept | Type of coverage (e.g., medical, pharmacy) Binding: SBC Benefit Category Value Set (extensible)
network | S | 0..* | Reference(Organization) | Provider networks for this coverage
benefit | S | 1..* | BackboneElement | Specific benefits covered
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Limitations and exceptions URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
type | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
requirement | S | 0..1 | string | Requirements for accessing benefit
plan | S | 1..* | BackboneElement | Health insurance plan details
type | S | 0..1 | CodeableConcept | Plan type (HMO, PPO, POS, EPO, etc.) Binding: SBC Plan Type Value Set (extensible)
coverageArea | S | 0..* | Reference(Location) | Geographic coverage area
network | S | 0..* | Reference(Organization) | Provider networks for this plan
generalCost | S | 0..* | BackboneElement | Overall plan costs
type | S | 0..1 | CodeableConcept | Type of cost (deductible, out-of-pocket max)
cost | S | 0..1 | Money | Cost amount
comment | S | 0..1 | string | Additional cost information
specificCost | S | 1..* | BackboneElement | Cost-sharing by benefit category
category | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
benefit | S | 1..* | BackboneElement | Specific benefit with costs
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Benefit-specific limitations URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
type | S | 1..1 | CodeableConcept | Benefit type code Binding: SBC Benefit Category Value Set (required)
cost | S | 2..* | BackboneElement | Cost-sharing amounts
type | S | 1..1 | CodeableConcept | Type of cost (copay, coinsurance, deductible)
applicability | S | 1..1 | CodeableConcept | Network applicability (in-network, out-of-network)
value | S | 1..1 | Quantity | Cost amount
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
InsurancePlan.coverage.​type | Base | extensible | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.coverage.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.type | Base | extensible | SBC Plan Type Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​category | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:sbcMetadata | S | 0..1 | (Complex) | SBC regulatory metadata URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
extension:excludedServices | S | 0..1 | (Complex) | Excluded services list URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ C | 0..* | Identifier | Business identifier for the insurance plan (e.g., HIOS ID)
status | ?!S Σ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active
name | S Σ C | 1..1 | string | Plan name as displayed on SBC
period | S | 1..1 | Period | Coverage period
ownedBy | S Σ | 1..1 | Reference(Organization) | Plan issuer organization
administeredBy | S Σ | 0..1 | Reference(Organization) | Plan administrator
contact | S | 1..* | BackboneElement | Contact information for plan questions
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
coverage | S | 1..* | BackboneElement | Benefit coverage details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of coverage (e.g., medical, pharmacy) Binding: SBC Benefit Category Value Set (extensible)
network | S | 0..* | Reference(Organization) | Provider networks for this coverage
benefit | S | 1..* | BackboneElement | Specific benefits covered
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Limitations and exceptions URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
requirement | S | 0..1 | string | Requirements for accessing benefit
plan | S | 1..* | BackboneElement | Health insurance plan details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 0..1 | CodeableConcept | Plan type (HMO, PPO, POS, EPO, etc.) Binding: SBC Plan Type Value Set (extensible)
coverageArea | S Σ | 0..* | Reference(Location) | Geographic coverage area
network | S | 0..* | Reference(Organization) | Provider networks for this plan
generalCost | S | 0..* | BackboneElement | Overall plan costs
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 0..1 | CodeableConcept | Type of cost (deductible, out-of-pocket max)
cost | S | 0..1 | Money | Cost amount
comment | S | 0..1 | string | Additional cost information
specificCost | S | 1..* | BackboneElement | Cost-sharing by benefit category
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
benefit | S | 1..* | BackboneElement | Specific benefit with costs
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Benefit-specific limitations URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit type code Binding: SBC Benefit Category Value Set (required)
cost | S | 2..* | BackboneElement | Cost-sharing amounts
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of cost (copay, coinsurance, deductible)
applicability | S | 1..1 | CodeableConcept | Network applicability (in-network, out-of-network) Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
value | S | 1..1 | Quantity | Cost amount
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std.
InsurancePlan.coverage.​type | Base | extensible | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.coverage.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.type | Base | extensible | SBC Plan Type Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​category | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability | Base | required | Benefit cost applicability | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | InsurancePlan | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | InsurancePlan | 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 | error | InsurancePlan | 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 | error | InsurancePlan | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | InsurancePlan | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
ipn-1 | error | InsurancePlan | The organization SHALL at least have a name or an idendtifier, and possibly more than one | `(identifier.count() + name.count()) > 0`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:sbcMetadata | S | 0..1 | (Complex) | SBC regulatory metadata URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
extension:excludedServices | S | 0..1 | (Complex) | Excluded services list URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S Σ C | 0..* | Identifier | Business identifier for the insurance plan (e.g., HIOS ID)
status | ?!S Σ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active
type | Σ | 0..* | CodeableConcept | Kind of product Binding: InsurancePlanType (example): Used to categorize the product/plan.
name | S Σ C | 1..1 | string | Plan name as displayed on SBC
alias |  | 0..* | string | Alternate names
period | S | 1..1 | Period | Coverage period
ownedBy | S Σ | 1..1 | Reference(Organization) | Plan issuer organization
administeredBy | S Σ | 0..1 | Reference(Organization) | Plan administrator
coverageArea | Σ | 0..* | Reference(Location) | Where product applies
contact | S | 1..* | BackboneElement | Contact information for plan questions
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
purpose |  | 0..1 | CodeableConcept | The type of contact Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
name |  | 0..1 | HumanName | A name associated with the contact
telecom |  | 0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact
address |  | 0..1 | Address | Visiting or postal addresses for the contact
endpoint |  | 0..* | Reference(Endpoint) | Technical endpoint
network |  | 0..* | Reference(Organization) | What networks are Included
coverage | S | 1..* | BackboneElement | Benefit coverage details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of coverage (e.g., medical, pharmacy) Binding: SBC Benefit Category Value Set (extensible)
network | S | 0..* | Reference(Organization) | Provider networks for this coverage
benefit | S | 1..* | BackboneElement | Specific benefits covered
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Limitations and exceptions URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
requirement | S | 0..1 | string | Requirements for accessing benefit
limit |  | 0..* | BackboneElement | Benefit limits
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
value |  | 0..1 | Quantity | Maximum value allowed
code |  | 0..1 | CodeableConcept | Benefit limit details
plan | S | 1..* | BackboneElement | Health insurance plan details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
identifier | Σ | 0..* | Identifier | Business Identifier for Product
type | S | 0..1 | CodeableConcept | Plan type (HMO, PPO, POS, EPO, etc.) Binding: SBC Plan Type Value Set (extensible)
coverageArea | S Σ | 0..* | Reference(Location) | Geographic coverage area
network | S | 0..* | Reference(Organization) | Provider networks for this plan
generalCost | S | 0..* | BackboneElement | Overall plan costs
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 0..1 | CodeableConcept | Type of cost (deductible, out-of-pocket max)
groupSize |  | 0..1 | positiveInt | Number of enrollees
cost | S | 0..1 | Money | Cost amount
comment | S | 0..1 | string | Additional cost information
specificCost | S | 1..* | BackboneElement | Cost-sharing by benefit category
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Benefit category code Binding: SBC Benefit Category Value Set (required)
benefit | S | 1..* | BackboneElement | Specific benefit with costs
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:limitation | S | 0..* | string | Benefit-specific limitations URL: http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Benefit type code Binding: SBC Benefit Category Value Set (required)
cost | S | 2..* | BackboneElement | Cost-sharing amounts
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S | 1..1 | CodeableConcept | Type of cost (copay, coinsurance, deductible)
applicability | S | 1..1 | CodeableConcept | Network applicability (in-network, out-of-network) Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
qualifiers |  | 0..* | CodeableConcept | Additional information about the cost
value | S | 1..1 | Quantity | Cost amount
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
InsurancePlan.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std.
InsurancePlan.type | Base | example | Insurance plan type | 📍4.0.1 | FHIR Std.
InsurancePlan.contact.​purpose | Base | extensible | Contact entity type | 📍4.0.1 | FHIR Std.
InsurancePlan.coverage.​type | Base | extensible | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.coverage.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.type | Base | extensible | SBC Plan Type Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​category | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.type | Base | required | SBC Benefit Category Value Set | 📦2.0.0 | This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability | Base | required | Benefit cost applicability | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | InsurancePlan | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | InsurancePlan | 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 | error | InsurancePlan | 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 | error | InsurancePlan | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | InsurancePlan | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
ipn-1 | error | InsurancePlan | The organization SHALL at least have a name or an idendtifier, and possibly more than one | `(identifier.count() + name.count()) > 0`

This structure is derived from InsurancePlan

Summary

Mandatory: 11 elements
Must-Support: 33 elements
Fixed: 1 element

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata
- http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services
- http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation

Other representations of profile: CSV, Excel, Schematron