Summary of Benefits and Coverage (SBC) FHIR Implementation Guide
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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

SBC to FHIR Mapping

SBC to FHIR Mapping

This page documents the detailed mapping from Summary of Benefits and Coverage (SBC) document sections to FHIR InsurancePlan elements.

Document Header and Plan Information

SBC Element FHIR Element Notes
Plan Name InsurancePlan.name Official plan name as it appears on SBC
Plan Type (HMO, PPO, etc.) InsurancePlan.plan.type Uses SBC Plan Type ValueSet
Coverage Period InsurancePlan.period Start and end dates
Plan Issuer InsurancePlan.ownedBy Reference to Organization
HIOS ID InsurancePlan.identifier 14-16 digit CMS identifier

Important Questions Section

The SBC "Important Questions" section contains seven mandatory Q&A items. These map to various FHIR elements:

SBC Question FHIR Element Notes
What is the overall deductible? InsurancePlan.plan.generalCost (type: "Individual Deductible") Separate entries for individual and family
Are there services covered before you meet your deductible? InsurancePlan.plan.specificCost.benefit.cost Benefits with $0 deductible or specific exceptions
Are there other deductibles for specific services? InsurancePlan.plan.specificCost Service-specific deductibles in cost array
What is the out-of-pocket limit? InsurancePlan.plan.generalCost (type: "Out-of-Pocket Maximum") Individual and family OOP limits
What is not included in the out-of-pocket limit? InsurancePlan.plan.generalCost.comment or extension Descriptive text
Will you pay less if you use a network provider? InsurancePlan.plan.specificCost.benefit.cost.applicability in-network vs out-of-network cost variations
Do you need a referral to see a specialist? InsurancePlan.coverage.benefit.requirement Text on specialist benefit

Benefit Categories (27 Required Categories)

All 27 SBC benefit categories map to the InsurancePlan structure through two interconnected sections:

Coverage Section

Maps to InsurancePlan.coverage.benefit:

  • Each benefit category is represented
  • Includes requirements (e.g., "referral required", "prior authorization required")
  • Uses BenefitLimitation extension for limitations and exceptions

Plan Cost Section

Maps to InsurancePlan.plan.specificCost:

  • Each benefit category has associated costs
  • Separate cost entries for in-network and out-of-network
  • Cost types: copayment, coinsurance, deductible

Example Mapping: Primary Care Visit

SBC Display:

Primary Care Visit to Treat an Illness or Injury
In-Network: $25 copay
Out-of-Network: Not covered

FHIR Representation:

coverage.benefit[x]
  .type = #primary-care-visit
  .requirement = "No referral required"

plan.specificCost[x]
  .category = #primary-care-visit
  .benefit[0]
    .type = #primary-care-visit
    .cost[0]
      .type.text = "Copayment"
      .applicability.text = "in-network"
      .value = 25 USD
    .cost[1]
      .type.text = "Not covered"
      .applicability.text = "out-of-network"
      .value = 0 USD

Excluded Services & Other Covered Services

The SBC includes a two-column section listing excluded services and other covered services beyond the main categories.

SBC Element FHIR Element Notes
Excluded Services ExcludedServices extension Array of services not covered
Each excluded service extension.service.serviceType and .description CodeableConcept + descriptive text
Other Covered Services Additional coverage.benefit entries Services beyond the 27 required categories

Limitations and Exceptions

Throughout the SBC, limitations and exceptions are noted for specific benefits:

SBC Element FHIR Element Notes
Benefit-specific limitations BenefitLimitation extension on coverage.benefit E.g., "Preauthorization required"
Cost-specific limitations BenefitLimitation extension on plan.specificCost.benefit E.g., "Copay waived if admitted"

Contact Information

The SBC requires multiple contact points for consumers:

SBC Element FHIR Element Notes
Questions phone number InsurancePlan.contact[0].telecom (purpose: "General Questions") Primary contact
Website InsurancePlan.contact[0].telecom (system: url) Plan website
Provider list location InsurancePlan.contact.telecom URL or phone for network directory
Formulary location InsurancePlan.contact.telecom URL or phone for drug list
Uniform glossary InsurancePlan.contact.telecom Typically healthcare.gov/sbc-glossary/

Regulatory Disclosures

Several SBC-specific regulatory disclosures use the SBC Metadata extension:

SBC Element FHIR Element Notes
Minimum Essential Coverage statement SBCMetadata extension .minimumEssentialCoverage Boolean indicator
Minimum Value statement SBCMetadata extension .minimumValue Boolean indicator
Abortion coverage disclosure (QHP only) SBCMetadata extension .abortionCoverage CodeableConcept
SBC template version date SBCMetadata extension .sbcVersionDate Date (e.g., 2021-01-01)

Coverage Examples (Not Yet Implemented)

The SBC requires three standardized coverage examples:

  1. Having a baby (normal delivery)
  2. Managing type 2 diabetes (routine maintenance)
  3. Simple fracture (emergency room visit)

Future Implementation Options:

  • Custom extension on InsurancePlan
  • Separate Claim or ExplanationOfBenefit profile
  • Referenced example resources

Note: Coverage examples are not included in the current version of this IG

Important Design Principles

  1. Maximize use of base InsurancePlan elements - Extensions only where truly necessary
  2. Network distinctions are critical - Always include both in-network and out-of-network costs via .applicability
  3. All 27 benefit categories should be represented - Even if "Not covered" or "$0"
  4. Consumer-readable text is important - Use .requirement, .comment, and extension strings for explanations
  5. Regulatory compliance - Map all mandatory SBC elements to maintain compliance

Unmapped SBC Elements

Some SBC elements are better represented in IG documentation than in instance data:

  • Disclaimers ("This is only a summary…")
  • Continuation rights descriptions (COBRA, state continuation)
  • Grievance and appeals processes
  • Language access taglines (for non-English speakers)
  • "Why This Matters" language (consumer education text from template)

These elements provide important consumer information but are standardized boilerplate that doesn't vary by plan.

Validation Considerations

Implementations should validate:

  • All 27 benefit categories are present in plan.specificCost
  • Each benefit has at least 2 cost entries (in-network and out-of-network)
  • Required metadata elements are populated (name, period, ownedBy)
  • Contact information includes at minimum a phone number and website
  • Cost values use appropriate units (USD for copays, % for coinsurance)