Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
0.1.0 - ci-build
Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
0.1.0 - ci-build
Summary of Benefits and Coverage (SBC) FHIR Implementation Guide, published by SBC FHIR Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/jdjkelly/fhir-sbc/ and changes regularly. See the Directory of published versions
Profile: SBC Insurance Plan Profile
SBC Metadata Extension
- sbcVersionDate: 2021-01-01
- minimumEssentialCoverage: true
- minimumValue: true
Excluded Services Extension
serviceType: Cosmetic surgery
description: Services for cosmetic purposes are not covered
url
serviceserviceType: Weight loss programs
description: Weight loss programs except when medically necessary
url
service
identifier: https://www.cms.gov/CCIIO/Resources/Data-Resources/hios/12345CA0010001-01
status: Active
name: Sample Health HMO Gold Plan
period: 2025-01-01 --> 2025-12-31
ownedBy: Sample Health Insurance Company
administeredBy: Organization Sample Health Insurance Company
contact
purpose: General Questions
telecom: ph: 1-800-123-4567, https://www.samplehealth.com
contact
purpose: Uniform Glossary
coverage
type: health insurance plan policy
benefit
type: Preventive Care/Screening/Immunization
requirement: No prior authorization required for in-network preventive services
benefit
type: Primary Care Visit
requirement: No referral required
benefit
Benefit Limitation Extension: Limited to network specialists only; out-of-network not covered except in emergencies
type: Specialist Visit
requirement: Referral required from primary care physician
benefit
Benefit Limitation Extension: Copay waived if admitted to hospital
type: Emergency Room Care
benefit
type: Hospital Inpatient Care
requirement: Prior authorization required for non-emergency admissions
plan
type: Health Maintenance Organization (HMO)
generalCost
type: Individual Deductible
Costs
Value Currency 1500 United States dollar comment: Individual in-network deductible
generalCost
type: Family Deductible
Costs
Value Currency 3000 United States dollar generalCost
type: Individual Out-of-Pocket Maximum
Costs
Value Currency 6000 United States dollar generalCost
type: Family Out-of-Pocket Maximum
Costs
Value Currency 12000 United States dollar specificCost
category: Preventive Care/Screening/Immunization
benefit
type: Preventive Care/Screening/Immunization
cost
type: No charge
applicability: in-network
value: 0 USD
cost
type: Not covered
applicability: out-of-network
value: 0 USD
specificCost
category: Primary Care Visit
benefit
type: Primary Care Visit
cost
type: Copayment
applicability: in-network
value: 25 USD
cost
type: Not covered
applicability: out-of-network
value: 0 USD
specificCost
category: Specialist Visit
benefit
type: Specialist Visit
cost
type: Copayment
applicability: in-network
value: 50 USD
cost
type: Not covered
applicability: out-of-network
value: 0 USD
specificCost
category: Emergency Room Care
benefit
Benefit Limitation Extension: Copay waived if admitted
type: Emergency Room Care
cost
type: Copayment
applicability: in-network
value: 350 USD
cost
type: Copayment
applicability: out-of-network
value: 350 USD
specificCost
category: Generic Drugs
benefit
type: Generic Drugs
cost
type: Copayment
applicability: in-network
value: 10 USD
cost
type: Not covered
applicability: out-of-network
value: 0 USD
specificCost
category: Hospital Inpatient Care
benefit
Benefit Limitation Extension: Prior authorization required
type: Hospital Inpatient Care
cost
type: Coinsurance
applicability: in-network
value: 20 %
cost
type: Not covered
applicability: out-of-network
value: 0 %