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

Summary of Benefits and Coverage (SBC) Integration

Page standards status: Informative

Summary of Benefits and Coverage (SBC) FHIR Implementation Guide

Overview

This Implementation Guide (IG) defines a FHIR profile for representing Summary of Benefits and Coverage (SBC) documents as structured data using the InsurancePlan resource. The SBC is a standardized disclosure document required under the Affordable Care Act (ACA) Section 2715 and implementing regulations.

Purpose

The SBC framework was established to provide consumers with clear, standardized information about health insurance benefits and costs. While SBC regulations prescribe detailed content requirements, they do not specify machine-readable data formats. This IG addresses that gap by:

  • Defining a structured FHIR representation of SBC documents
  • Enabling machine-readable representation of the 27 required benefit categories
  • Supporting programmatic access to cost-sharing information (copays, coinsurance, deductibles)
  • Preserving network distinctions (in-network vs. out-of-network)
  • Maintaining regulatory compliance with SBC content requirements

Regulatory Context

The SBC is jointly regulated by three federal agencies:

  • Department of Health and Human Services (HHS) through CMS and CCIIO - enforces requirements for health insurance issuers (45 CFR 147.200)
  • Department of Labor (DOL) through EBSA - enforces requirements for ERISA-covered group health plans (29 CFR 2590.715-2715)
  • Department of the Treasury through IRS - enforces via excise taxes (26 CFR 54.9815-2715)

The statutory authority stems from Section 2715 of the Public Health Service Act, added by ACA Section 1001(5), codified at 42 U.S.C. § 300gg-15.

Key Features

27 Required Benefit Categories

The profile supports all 27 benefit categories mandated by SBC regulations:

  1. Preventive care/screening/immunization
  2. Primary care visits
  3. Specialist visits
  4. Diagnostic tests
  5. Imaging (CT/PET/MRI)
  6. Generic drugs
  7. Preferred brand drugs
  8. Non-preferred brand drugs
  9. Specialty drugs
  10. Facility fees
  11. Physician/surgeon fees
  12. Emergency room care
  13. Emergency medical transportation
  14. Urgent care
  15. Hospital outpatient care
  16. Hospital inpatient care
  17. Mental/behavioral health outpatient services
  18. Mental/behavioral health inpatient services
  19. Pregnancy services
  20. Childbirth/delivery
  21. Pregnancy home health care
  22. Rehabilitation services
  23. Habilitation services
  24. Skilled nursing care
  25. Durable medical equipment
  26. Hospice services
  27. Children’s eye exams
  28. Children’s glasses
  29. Children’s dental check-ups

Cost-Sharing Representation

The profile represents cost-sharing through the InsurancePlan plan.specificCost structure:

  • Copayments - Fixed dollar amounts per service
  • Coinsurance - Percentage of costs paid by the member
  • Deductibles - Amounts to be paid before benefits apply
  • Network distinctions - Separate costs for in-network and out-of-network services

SBC-Specific Extensions

While the profile prioritizes using base InsurancePlan elements, it defines minimal extensions for SBC-specific content:

  • SBC Metadata Extension - Minimum essential coverage indicator, minimum value indicator, abortion coverage disclosure
  • Excluded Services Extension - Services not covered by the plan
  • Benefit Limitation Extension - Limitations and exceptions for specific benefits

Scope

This IG currently focuses on the core benefit and cost-sharing structure of SBC documents. Future versions may include:

  • Coverage examples (standardized scenarios: having a baby, managing diabetes, simple fracture)
  • Additional regulatory disclosures
  • Language access and translation metadata
  • Links to uniform glossary definitions

Target Audience

  • Health insurance issuers creating SBC documents
  • Health plan administrators
  • Consumer-facing health applications
  • Health IT vendors building plan comparison tools
  • Researchers analyzing health plan benefits

Getting Started

Authors and Contributors

This IG is maintained by the SBC FHIR Project.

This implementation guide is provided for educational and interoperability purposes. Organizations using this IG remain responsible for compliance with all applicable SBC regulations at 45 CFR 147.200, 29 CFR 2590.715-2715, and 26 CFR 54.9815-2715.