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

Examples

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

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

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://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category",
      "code": "preventive-care"
    }]
  },
  "benefit": [{
    "type": {
      "coding": [{
        "system": "http://flexpa.com/fhir/sbc/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://flexpa.com/fhir/sbc/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
2. Both network applicabilities (in-network and out-of-network) for each benefit
3. General costs (deductibles, OOP maximums) in plan.generalCost
4. Contact information for questions, provider lists, formulary, glossary
5. Regulatory metadata (minimum essential coverage, minimum value)
6. Excluded services list
7. Requirements and limitations for each benefit as applicable
8. 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"
2. ✓ Name, period, and ownedBy are populated
3. ✓ At least one contact with phone and URL
4. ✓ Plan type is from SBC Plan Type ValueSet
5. ✓ All 27 benefit categories present in specificCost
6. ✓ Each benefit has at least 2 cost entries (in/out of network)
7. ✓ Cost applicability is specified for each cost
8. ✓ Currency is consistent (e.g., all USD)
9. ✓ Percentage values use "%" unit
10. ✓ Dollar amounts use currency code

Next Steps

After reviewing these examples:

• Explore the SBC InsurancePlan Profile for detailed element definitions
• Review the SBC to FHIR Mapping for comprehensive mapping guidance
• Check the Terminology page for all 27 benefit category codes