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
<InsurancePlan xmlns="http://hl7.org/fhir">
<id value="SBCExampleHMO"/>
<meta>
<profile
value="http://flexpa.com/fhir/sbc/StructureDefinition/sbc-insurance-plan"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: InsurancePlan SBCExampleHMO</b></p><a name="SBCExampleHMO"> </a><a name="hcSBCExampleHMO"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-sbc-insurance-plan.html">SBC Insurance Plan Profile</a></p></div><blockquote><p><b>SBC Metadata Extension</b></p><ul><li>sbcVersionDate: 2021-01-01</li><li>minimumEssentialCoverage: true</li><li>minimumValue: true</li></ul></blockquote><blockquote><p><b>Excluded Services Extension</b></p><p><b>serviceType</b>: <span title="Codes:">Cosmetic surgery</span></p><p><b>description</b>: Services for cosmetic purposes are not covered</p><blockquote><p><b>url</b></p>service</blockquote><p><b>serviceType</b>: <span title="Codes:">Weight loss programs</span></p><p><b>description</b>: Weight loss programs except when medically necessary</p><blockquote><p><b>url</b></p>service</blockquote></blockquote><p><b>identifier</b>: <code>https://www.cms.gov/CCIIO/Resources/Data-Resources/hios</code>/12345CA0010001-01</p><p><b>status</b>: Active</p><p><b>name</b>: Sample Health HMO Gold Plan</p><p><b>period</b>: 2025-01-01 --> 2025-12-31</p><p><b>ownedBy</b>: <a href="Organization-ExampleIssuerOrg.html">Sample Health Insurance Company</a></p><p><b>administeredBy</b>: <a href="Organization-ExampleIssuerOrg.html">Organization Sample Health Insurance Company</a></p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title="Codes:">General Questions</span></p><p><b>telecom</b>: ph: 1-800-123-4567, <a href="https://www.samplehealth.com">https://www.samplehealth.com</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title="Codes:">Uniform Glossary</span></p><p><b>telecom</b>: <a href="https://www.healthcare.gov/sbc-glossary/">https://www.healthcare.gov/sbc-glossary/</a></p></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}">health insurance plan policy</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category preventive-care}">Preventive Care/Screening/Immunization</span></p><p><b>requirement</b>: No prior authorization required for in-network preventive services</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category primary-care-visit}">Primary Care Visit</span></p><p><b>requirement</b>: No referral required</p></blockquote><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Limited to network specialists only; out-of-network not covered except in emergencies</p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category specialist-visit}">Specialist Visit</span></p><p><b>requirement</b>: Referral required from primary care physician</p></blockquote><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Copay waived if admitted to hospital</p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category emergency-room-care}">Emergency Room Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category hospital-inpatient}">Hospital Inpatient Care</span></p><p><b>requirement</b>: Prior authorization required for non-emergency admissions</p></blockquote></blockquote><blockquote><p><b>plan</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-plan-type HMO}">Health Maintenance Organization (HMO)</span></p><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title="Codes:">Individual Deductible</span></p><h3>Costs</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>1500</td><td>United States dollar</td></tr></table><p><b>comment</b>: Individual in-network deductible</p></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title="Codes:">Family Deductible</span></p><h3>Costs</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>3000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title="Codes:">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>6000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title="Codes:">Family Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style="display: none">*</td><td>12000</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category preventive-care}">Preventive Care/Screening/Immunization</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category preventive-care}">Preventive Care/Screening/Immunization</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">No charge</span></p><p><b>applicability</b>: <span title="Codes:">in-network</span></p><p><b>value</b>: 0 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Not covered</span></p><p><b>applicability</b>: <span title="Codes:">out-of-network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category primary-care-visit}">Primary Care Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category primary-care-visit}">Primary Care Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Copayment</span></p><p><b>applicability</b>: <span title="Codes:">in-network</span></p><p><b>value</b>: 25 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Not covered</span></p><p><b>applicability</b>: <span title="Codes:">out-of-network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category specialist-visit}">Specialist Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category specialist-visit}">Specialist Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Copayment</span></p><p><b>applicability</b>: <span title="Codes:">in-network</span></p><p><b>value</b>: 50 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Not covered</span></p><p><b>applicability</b>: <span title="Codes:">out-of-network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category emergency-room-care}">Emergency Room Care</span></p><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Copay waived if admitted</p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category emergency-room-care}">Emergency Room Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Copayment</span></p><p><b>applicability</b>: <span title="Codes:">in-network</span></p><p><b>value</b>: 350 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Copayment</span></p><p><b>applicability</b>: <span title="Codes:">out-of-network</span></p><p><b>value</b>: 350 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category generic-drugs}">Generic Drugs</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category generic-drugs}">Generic Drugs</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Copayment</span></p><p><b>applicability</b>: <span title="Codes:">in-network</span></p><p><b>value</b>: 10 USD</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Not covered</span></p><p><b>applicability</b>: <span title="Codes:">out-of-network</span></p><p><b>value</b>: 0 USD</p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category hospital-inpatient}">Hospital Inpatient Care</span></p><blockquote><p><b>benefit</b></p><p><b>Benefit Limitation Extension</b>: Prior authorization required</p><p><b>type</b>: <span title="Codes:{http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category hospital-inpatient}">Hospital Inpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Coinsurance</span></p><p><b>applicability</b>: <span title="Codes:">in-network</span></p><p><b>value</b>: 20 %</p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title="Codes:">Not covered</span></p><p><b>applicability</b>: <span title="Codes:">out-of-network</span></p><p><b>value</b>: 0 %</p></blockquote></blockquote></blockquote></blockquote></div>
</text>
<extension
url="http://flexpa.com/fhir/sbc/StructureDefinition/sbc-metadata">
<extension url="sbcVersionDate">
<valueDate value="2021-01-01"/>
</extension>
<extension url="minimumEssentialCoverage">
<valueBoolean value="true"/>
</extension>
<extension url="minimumValue">
<valueBoolean value="true"/>
</extension>
</extension>
<extension
url="http://flexpa.com/fhir/sbc/StructureDefinition/excluded-services">
<extension url="service">
<extension url="serviceType">
<valueCodeableConcept>
<text value="Cosmetic surgery"/>
</valueCodeableConcept>
</extension>
<extension url="description">
<valueString value="Services for cosmetic purposes are not covered"/>
</extension>
</extension>
<extension url="service">
<extension url="serviceType">
<valueCodeableConcept>
<text value="Weight loss programs"/>
</valueCodeableConcept>
</extension>
<extension url="description">
<valueString
value="Weight loss programs except when medically necessary"/>
</extension>
</extension>
</extension>
<identifier>
<system value="https://www.cms.gov/CCIIO/Resources/Data-Resources/hios"/>
<value value="12345CA0010001-01"/>
</identifier>
<status value="active"/>
<name value="Sample Health HMO Gold Plan"/>
<period>
<start value="2025-01-01"/>
<end value="2025-12-31"/>
</period>
<ownedBy>🔗
<reference value="Organization/ExampleIssuerOrg"/>
<display value="Sample Health Insurance Company"/>
</ownedBy>
<administeredBy>🔗
<reference value="Organization/ExampleIssuerOrg"/>
</administeredBy>
<contact>
<purpose>
<text value="General Questions"/>
</purpose>
<telecom>
<system value="phone"/>
<value value="1-800-123-4567"/>
</telecom>
<telecom>
<system value="url"/>
<value value="https://www.samplehealth.com"/>
</telecom>
</contact>
<contact>
<purpose>
<text value="Uniform Glossary"/>
</purpose>
<telecom>
<system value="url"/>
<value value="https://www.healthcare.gov/sbc-glossary/"/>
</telecom>
</contact>
<coverage>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="HIP"/>
<display value="health insurance plan policy"/>
</coding>
</type>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="preventive-care"/>
</coding>
</type>
<requirement
value="No prior authorization required for in-network preventive services"/>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="primary-care-visit"/>
</coding>
</type>
<requirement value="No referral required"/>
</benefit>
<benefit>
<extension
url="http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation">
<valueString
value="Limited to network specialists only; out-of-network not covered except in emergencies"/>
</extension>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="specialist-visit"/>
</coding>
</type>
<requirement value="Referral required from primary care physician"/>
</benefit>
<benefit>
<extension
url="http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation">
<valueString value="Copay waived if admitted to hospital"/>
</extension>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="emergency-room-care"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="hospital-inpatient"/>
</coding>
</type>
<requirement
value="Prior authorization required for non-emergency admissions"/>
</benefit>
</coverage>
<plan>
<type>
<coding>
<system value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-plan-type"/>
<code value="HMO"/>
</coding>
</type>
<generalCost>
<type>
<text value="Individual Deductible"/>
</type>
<cost>
<value value="1500"/>
<currency value="USD"/>
</cost>
<comment value="Individual in-network deductible"/>
</generalCost>
<generalCost>
<type>
<text value="Family Deductible"/>
</type>
<cost>
<value value="3000"/>
<currency value="USD"/>
</cost>
</generalCost>
<generalCost>
<type>
<text value="Individual Out-of-Pocket Maximum"/>
</type>
<cost>
<value value="6000"/>
<currency value="USD"/>
</cost>
</generalCost>
<generalCost>
<type>
<text value="Family Out-of-Pocket Maximum"/>
</type>
<cost>
<value value="12000"/>
<currency value="USD"/>
</cost>
</generalCost>
<specificCost>
<category>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="preventive-care"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="preventive-care"/>
</coding>
</type>
<cost>
<type>
<text value="No charge"/>
</type>
<applicability>
<text value="in-network"/>
</applicability>
<value>
<value value="0"/>
<unit value="USD"/>
</value>
</cost>
<cost>
<type>
<text value="Not covered"/>
</type>
<applicability>
<text value="out-of-network"/>
</applicability>
<value>
<value value="0"/>
<unit value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="primary-care-visit"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="primary-care-visit"/>
</coding>
</type>
<cost>
<type>
<text value="Copayment"/>
</type>
<applicability>
<text value="in-network"/>
</applicability>
<value>
<value value="25"/>
<unit value="USD"/>
</value>
</cost>
<cost>
<type>
<text value="Not covered"/>
</type>
<applicability>
<text value="out-of-network"/>
</applicability>
<value>
<value value="0"/>
<unit value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="specialist-visit"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="specialist-visit"/>
</coding>
</type>
<cost>
<type>
<text value="Copayment"/>
</type>
<applicability>
<text value="in-network"/>
</applicability>
<value>
<value value="50"/>
<unit value="USD"/>
</value>
</cost>
<cost>
<type>
<text value="Not covered"/>
</type>
<applicability>
<text value="out-of-network"/>
</applicability>
<value>
<value value="0"/>
<unit value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="emergency-room-care"/>
</coding>
</category>
<benefit>
<extension
url="http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation">
<valueString value="Copay waived if admitted"/>
</extension>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="emergency-room-care"/>
</coding>
</type>
<cost>
<type>
<text value="Copayment"/>
</type>
<applicability>
<text value="in-network"/>
</applicability>
<value>
<value value="350"/>
<unit value="USD"/>
</value>
</cost>
<cost>
<type>
<text value="Copayment"/>
</type>
<applicability>
<text value="out-of-network"/>
</applicability>
<value>
<value value="350"/>
<unit value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="generic-drugs"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="generic-drugs"/>
</coding>
</type>
<cost>
<type>
<text value="Copayment"/>
</type>
<applicability>
<text value="in-network"/>
</applicability>
<value>
<value value="10"/>
<unit value="USD"/>
</value>
</cost>
<cost>
<type>
<text value="Not covered"/>
</type>
<applicability>
<text value="out-of-network"/>
</applicability>
<value>
<value value="0"/>
<unit value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="hospital-inpatient"/>
</coding>
</category>
<benefit>
<extension
url="http://flexpa.com/fhir/sbc/StructureDefinition/benefit-limitation">
<valueString value="Prior authorization required"/>
</extension>
<type>
<coding>
<system
value="http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category"/>
<code value="hospital-inpatient"/>
</coding>
</type>
<cost>
<type>
<text value="Coinsurance"/>
</type>
<applicability>
<text value="in-network"/>
</applicability>
<value>
<value value="20"/>
<unit value="%"/>
</value>
</cost>
<cost>
<type>
<text value="Not covered"/>
</type>
<applicability>
<text value="out-of-network"/>
</applicability>
<value>
<value value="0"/>
<unit value="%"/>
</value>
</cost>
</benefit>
</specificCost>
</plan>
</InsurancePlan>