# SBC FHIR Examples - CARIN Digital Insurance Card v2.0.0

* [**Table of Contents**](toc.md)
* [**Use Cases**](Use_Case.md)
* **SBC FHIR Examples**

## SBC FHIR Examples

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| :--- |
| *Page standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) |

# Examples

This page provides examples of how to use the SBC InsurancePlan profile to represent Summary of Benefits and Coverage documents.

## Example: Sample HMO Health Plan

**Resource:** [SBCExampleHMO](InsurancePlan-SBCExampleHMO.md)

This example demonstrates a Health Maintenance Organization (HMO) plan with typical SBC content including:

### Plan Identification

* **Plan Name:** Sample Health HMO Gold Plan
* **Plan Type:** HMO
* **Coverage Period:** January 1, 2025 - December 31, 2025
* **HIOS ID:** 12345CA0010001-01
* **Issuer:** Sample Health Insurance Company

### General Plan Costs

| | | |
| :--- | :--- | :--- |
| Deductible | $1,500 | $3,000 |
| Out-of-Pocket Maximum | $6,000 | $12,000 |

### Benefit Categories with Cost-Sharing

The example includes six representative benefit categories demonstrating different cost-sharing patterns:

#### 1. Preventive Care

* **In-Network:** No charge
* **Out-of-Network:** Not covered
* **Requirement:** No prior authorization required for in-network preventive services

#### 2. Primary Care Visit

* **In-Network:** $25 copay
* **Out-of-Network:** Not covered
* **Requirement:** No referral required

#### 3. Specialist Visit

* **In-Network:** $50 copay
* **Out-of-Network:** Not covered
* **Requirement:** Referral required from primary care physician
* **Limitation:** Limited to network specialists only; out-of-network not covered except in emergencies

#### 4. Emergency Room Care

* **In-Network:** $350 copay
* **Out-of-Network:** $350 copay (same as in-network)
* **Limitation:** Copay waived if admitted to hospital

#### 5. Generic Drugs

* **In-Network:** $10 copay
* **Out-of-Network:** Not covered

#### 6. Hospital Inpatient Care

* **In-Network:** 20% coinsurance
* **Out-of-Network:** Not covered
* **Requirement:** Prior authorization required for non-emergency admissions
* **Limitation:** Prior authorization required

### Excluded Services

The example demonstrates how to document services not covered:

* **Cosmetic surgery** - Services for cosmetic purposes are not covered
* **Weight loss programs** - Weight loss programs except when medically necessary

### Regulatory Metadata

The example includes SBC-specific regulatory disclosures:

* **SBC Version Date:** January 1, 2021 (current template version)
* **Minimum Essential Coverage:** Yes
* **Minimum Value:** Yes

### Contact Information

Multiple contact points are provided:

* **General Questions:** 1-800-123-4567, https://www.samplehealth.com
* **Uniform Glossary:** https://www.healthcare.gov/sbc-glossary/

## Example Patterns

### Pattern 1: No Charge for Preventive Care

Preventive care is typically covered at no cost for in-network services under ACA requirements:

```
{
  "category": {
    "coding": [{
      "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
      "code": "preventive-care"
    }]
  },
  "benefit": [{
    "type": {
      "coding": [{
        "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
        "code": "preventive-care"
      }]
    },
    "cost": [
      {
        "type": { "text": "No charge" },
        "applicability": { "text": "in-network" },
        "value": { "value": 0, "unit": "USD" }
      },
      {
        "type": { "text": "Not covered" },
        "applicability": { "text": "out-of-network" },
        "value": { "value": 0, "unit": "USD" }
      }
    ]
  }]
}

```

### Pattern 2: Fixed Copayment

Most office visits use fixed copayment amounts:

```
{
  "cost": [{
    "type": { "text": "Copayment" },
    "applicability": { "text": "in-network" },
    "value": { "value": 25, "unit": "USD" }
  }]
}

```

### Pattern 3: Percentage Coinsurance

Hospital services often use coinsurance (percentage):

```
{
  "cost": [{
    "type": { "text": "Coinsurance" },
    "applicability": { "text": "in-network" },
    "value": { "value": 20, "unit": "%" }
  }]
}

```

### Pattern 4: Not Covered Services

HMO plans typically don’t cover out-of-network except emergencies:

```
{
  "cost": [{
    "type": { "text": "Not covered" },
    "applicability": { "text": "out-of-network" },
    "value": { "value": 0, "unit": "USD" }
  }]
}

```

### Pattern 5: Same Cost In and Out of Network

Emergency services must be covered equally regardless of network:

```
{
  "cost": [
    {
      "type": { "text": "Copayment" },
      "applicability": { "text": "in-network" },
      "value": { "value": 350, "unit": "USD" }
    },
    {
      "type": { "text": "Copayment" },
      "applicability": { "text": "out-of-network" },
      "value": { "value": 350, "unit": "USD" }
    }
  ]
}

```

### Pattern 6: Adding Limitations

Use the BenefitLimitation extension for requirements and restrictions:

```
{
  "benefit": [{
    "extension": [{
      "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation",
      "valueString": "Prior authorization required"
    }]
  }]
}

```

## Additional Example Scenarios

### PPO Plan Example

A PPO plan would differ from the HMO example by:

* **Plan Type:** `#PPO` instead of `#HMO`
* **Out-of-Network Coverage:** Typically covered but at higher cost
* **No Referral Requirements:** Usually not required for specialists
* **Different Cost Structure:**

```
{
  "type": "Specialist Visit",
  "cost": [
    {
      "applicability": "in-network",
      "value": { "value": 50, "unit": "USD" }
    },
    {
      "applicability": "out-of-network",
      "value": { "value": 100, "unit": "USD" }
    }
  ]
}

```

### High Deductible Health Plan (HDHP) Example

An HDHP would feature:

* **Plan Type:** `#HDHP`
* **Higher Deductibles:** $3,000+ individual
* **Lower Premiums:** (not shown in SBC)
* **HSA Eligibility:** Noted in metadata
* **Different Cost-Sharing Pattern:**

```
{
  "generalCost": [
    {
      "type": { "text": "Individual Deductible" },
      "cost": { "value": 3000, "currency": "USD" }
    }
  ],
  "specificCost": [{
    "benefit": [{
      "type": "primary-care-visit",
      "cost": [{
        "type": { "text": "Subject to deductible, then coinsurance" },
        "applicability": { "text": "in-network" }
      }]
    }]
  }]
}

```

### Pharmacy Benefits Example

Drug coverage typically has tiered cost-sharing:

```
{
  "specificCost": [
    {
      "category": "generic-drugs",
      "benefit": [{
        "cost": [{
          "type": { "text": "Copayment" },
          "applicability": { "text": "in-network" },
          "value": { "value": 10, "unit": "USD" }
        }]
      }]
    },
    {
      "category": "preferred-brand-drugs",
      "benefit": [{
        "cost": [{
          "type": { "text": "Copayment" },
          "applicability": { "text": "in-network" },
          "value": { "value": 40, "unit": "USD" }
        }]
      }]
    },
    {
      "category": "non-preferred-brand-drugs",
      "benefit": [{
        "cost": [{
          "type": { "text": "Copayment" },
          "applicability": { "text": "in-network" },
          "value": { "value": 70, "unit": "USD" }
        }]
      }]
    },
    {
      "category": "specialty-drugs",
      "benefit": [{
        "cost": [{
          "type": { "text": "Coinsurance" },
          "applicability": { "text": "in-network" },
          "value": { "value": 30, "unit": "%" }
        }]
      }]
    }
  ]
}

```

## Complete SBC Representation

A production-ready SBC representation should include:

1. **All 27 benefit categories**in`plan.specificCost`
1. **Both network applicabilities**(in-network and out-of-network) for each benefit
1. **General costs**(deductibles, OOP maximums) in`plan.generalCost`
1. **Contact information**for questions, provider lists, formulary, glossary
1. **Regulatory metadata**(minimum essential coverage, minimum value)
1. **Excluded services**list
1. **Requirements and limitations**for each benefit as applicable
1. **Plan identification**(name, type, period, HIOS ID)

The example provided demonstrates the structure with 6 benefit categories. A complete implementation would expand this to all 27 categories with appropriate cost-sharing for each.

## Testing and Validation

When creating SBC InsurancePlan instances, validate:

1. ✓ Status is “active”
1. ✓ Name, period, and ownedBy are populated
1. ✓ At least one contact with phone and URL
1. ✓ Plan type is from SBC Plan Type ValueSet
1. ✓ All 27 benefit categories present in specificCost
1. ✓ Each benefit has at least 2 cost entries (in/out of network)
1. ✓ Cost applicability is specified for each cost
1. ✓ Currency is consistent (e.g., all USD)
1. ✓ Percentage values use “%” unit
1. ✓ Dollar amounts use currency code

## Next Steps

After reviewing these examples:

* Explore the [SBC InsurancePlan Profile](StructureDefinition-sbc-insurance-plan.md) for detailed element definitions
* Review the [SBC to FHIR Mapping](sbc-mapping.md) for comprehensive mapping guidance
* Check the [Terminology](sbc-terminology.md) page for all 27 benefit category codes

