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

Profiles

Profiles

This page provides an overview of the profiles defined in this implementation guide.

SBC InsurancePlan Profile

Profile: SBCInsurancePlan

Purpose: Constrains the base FHIR InsurancePlan resource to represent Summary of Benefits and Coverage (SBC) documents as required under ACA Section 2715.

Key Constraints

1. Required Elements:
   • name - Plan name must be provided
   • status - Fixed to "active"
   • period - Coverage period must be specified
   • ownedBy - Plan issuer organization required
   • contact - At least one contact method required
   • plan - At least one plan with cost details required
   • plan.specificCost - Cost-sharing for benefit categories required
2. Must Support Elements:
   • All required elements plus:
   • identifier - Business identifiers (e.g., HIOS ID)
   • coverage.benefit - Benefit category details
   • plan.generalCost - Overall deductibles and OOP limits
   • Extensions for SBC-specific metadata
3. Terminology Bindings:
   • coverage.benefit.type - Required binding to SBC Benefit Category ValueSet
   • plan.type - Extensible binding to SBC Plan Type ValueSet
   • plan.specificCost.category - Required binding to SBC Benefit Category ValueSet
   • plan.specificCost.benefit.type - Required binding to SBC Benefit Category ValueSet
4. Cardinality Requirements:
   • plan.specificCost.benefit.cost - Minimum of 2 (to capture both in-network and out-of-network)
   • Each cost entry must specify .applicability (in-network vs out-of-network)

Usage Notes

Representing General Plan Costs

Use plan.generalCost for plan-wide costs that aren't specific to individual benefits:

plan.generalCost[0]
  .type.text = "Individual Deductible"
  .cost.value = 1500
  .cost.currency = #USD

plan.generalCost[1]
  .type.text = "Individual Out-of-Pocket Maximum"
  .cost.value = 6000
  .cost.currency = #USD

Representing Benefit-Specific Costs

Use plan.specificCost for each of the 27 SBC benefit categories:

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

Representing "Not Covered" Benefits

For benefits not covered by the plan, still create entries with $0 or appropriate indicator:

plan.specificCost.benefit.cost
  .type.text = "Not covered"
  .applicability.text = "out-of-network"
  .value.value = 0

Representing Coinsurance

For percentage-based cost-sharing, use the % unit:

plan.specificCost.benefit.cost
  .type.text = "Coinsurance"
  .applicability.text = "in-network"
  .value.value = 20
  .value.unit = "%"

Adding Limitations and Requirements

Use the benefit requirement field and limitation extension:

coverage.benefit[x]
  .type = #specialist-visit
  .requirement = "Referral required from primary care physician"
  .extension[limitation].valueString = "Limited to network specialists only"

Extensions

The profile uses three extensions defined in this IG:

1. SBC Metadata Extension

Captures regulatory disclosures:

extension[sbcMetadata]
  .extension[sbcVersionDate].valueDate = "2021-01-01"
  .extension[minimumEssentialCoverage].valueBoolean = true
  .extension[minimumValue].valueBoolean = true
  .extension[abortionCoverage].valueCodeableConcept = ...

2. Excluded Services Extension

Documents services not covered:

extension[excludedServices]
  .extension[service][0]
    .extension[serviceType].valueCodeableConcept.text = "Cosmetic surgery"
    .extension[description].valueString = "Services for cosmetic purposes are not covered"

3. Benefit Limitation Extension

Provides benefit-specific limitations:

coverage.benefit.extension[limitation].valueString = "Prior authorization required for non-emergency admissions"

Validation Rules

Implementations should ensure:

1. All 27 SBC benefit categories are represented in plan.specificCost
2. Each benefit has costs for both in-network and out-of-network (even if "not covered")
3. Contact information includes at minimum phone and web URL
4. Cost values use consistent currency (USD recommended)
5. Percentage-based coinsurance uses "%" unit
6. Fixed copayments use currency code (e.g., "USD")

Relationship to Other Standards

This profile is designed to complement, not replace:

• US Core - May reference US Core Organization for issuers
• Da Vinci PDex Plan Net - Network organizations could use Plan-Net profiles
• CARIN Blue Button - Patient-specific coverage uses Coverage resource
• Transparency in Coverage - Price transparency uses separate machine-readable files

The SBC profile focuses on plan-level benefit summaries for consumer comparison, while other standards address different use cases (provider directories, claims data, pricing).

Future Enhancements

Potential future additions to this profile:

• Coverage example scenarios (having a baby, managing diabetes, simple fracture)
• Language and translation metadata
• Links to uniform glossary term definitions
• Network tier distinctions (preferred vs standard in-network)
• Formulary tier details for prescription drugs
• Quantitative limits on benefits (e.g., "30 visits per year")