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

Terminology

Terminology

This page describes the code systems and value sets defined in this implementation guide for representing SBC documents.

Code Systems

SBC Benefit Category Code System

URL: http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category

Purpose: Defines codes for the 27 benefit categories required in Summary of Benefits and Coverage documents per ACA Section 2715 regulations.

Status: Draft

Content: Complete (all codes defined)

Codes

Code	Display	Definition
preventive-care	Preventive Care/Screening/Immunization	Preventive care services, health screenings, and immunizations
primary-care-visit	Primary Care Visit	Visits to primary care physicians to treat illness or injury
specialist-visit	Specialist Visit	Visits to specialist physicians
diagnostic-test	Diagnostic Test	X-rays and diagnostic imaging other than CT/PET/MRI
imaging	Imaging (CT/PET/MRI)	Advanced imaging services including CT scans, PET scans, and MRIs
generic-drugs	Generic Drugs	Generic prescription medications
preferred-brand-drugs	Preferred Brand Drugs	Brand-name prescription medications on the preferred drug list
non-preferred-brand-drugs	Non-Preferred Brand Drugs	Brand-name prescription medications not on the preferred drug list
specialty-drugs	Specialty Drugs	High-cost or specialty prescription medications
facility-fee	Facility Fee	Hospital or facility charges for services
physician-surgeon-fee	Physician/Surgeon Fees	Professional fees for physicians and surgeons
emergency-room-care	Emergency Room Care	Emergency department services
emergency-medical-transport	Emergency Medical Transportation	Ambulance and emergency medical transport services
urgent-care	Urgent Care	Urgent care facility services
hospital-outpatient	Hospital Outpatient Care	Outpatient hospital services and surgeries
hospital-inpatient	Hospital Inpatient Care	Inpatient hospital stays and services
mental-health-outpatient	Mental/Behavioral Health Outpatient Services	Outpatient mental health and substance abuse services
mental-health-inpatient	Mental/Behavioral Health Inpatient Services	Inpatient mental health and substance abuse services
pregnancy	Pregnancy Services	Prenatal and postnatal office visits
pregnancy-delivery	Childbirth/Delivery Professional Services	Professional services for childbirth and delivery
pregnancy-home-health	Pregnancy Home Health Care	Home health care services related to pregnancy
rehabilitation	Rehabilitation Services	Outpatient physical, occupational, and speech therapy
habilitation	Habilitation Services	Health care services that help develop or maintain daily living skills
skilled-nursing	Skilled Nursing Care	Skilled nursing facility services
durable-medical-equipment	Durable Medical Equipment	Medical equipment for home use such as wheelchairs, oxygen equipment
hospice	Hospice Services	End-of-life care services
children-eye-exam	Children's Eye Exam	Eye examinations for children
children-glasses	Children's Glasses	Eyeglasses for children
children-dental	Children's Dental Check-up	Routine dental care for children

Usage Notes

• These codes are derived from the SBC template's required benefit categories
• All 27 categories must be represented in a compliant SBC
• The pregnancy-related benefits are broken into three separate codes (office visits, delivery, home health) per SBC requirements
• These codes should be used in both InsurancePlan.coverage.benefit.type and InsurancePlan.plan.specificCost.category

SBC Plan Type Code System

URL: http://flexpa.com/fhir/sbc/CodeSystem/sbc-plan-type

Purpose: Defines codes for health insurance plan types displayed in Summary of Benefits and Coverage documents.

Status: Draft

Content: Complete

Codes

Code	Display	Definition
HMO	Health Maintenance Organization (HMO)	A type of health insurance plan that requires members to get health care services from doctors and hospitals in the plan's network, except in an emergency
PPO	Preferred Provider Organization (PPO)	A type of health insurance plan where members pay less if they use providers in the plan's network, but can use out-of-network providers at higher cost
POS	Point of Service (POS)	A type of health insurance plan where members pay less if they use doctors and hospitals in the plan's network and choose a primary care doctor to coordinate care
EPO	Exclusive Provider Organization (EPO)	A type of health insurance plan where services are covered only if members use doctors and providers in the plan's network, except in an emergency
HDHP	High Deductible Health Plan (HDHP)	A health insurance plan with a higher deductible than traditional plans, often paired with a Health Savings Account
INDEMNITY	Indemnity Plan	A type of health insurance that allows members to see any doctor or hospital and pays a portion of the bill

Usage Notes

• These plan types align with common categorizations used in health insurance
• Used in InsurancePlan.plan.type
• The definitions use consumer-friendly language consistent with SBC glossary terms
• Plans may also have product-level types that differ from plan-level types

Value Sets

SBC Benefit Category Value Set

URL: http://flexpa.com/fhir/sbc/ValueSet/sbc-benefit-category

Purpose: Contains all 27 benefit categories required in Summary of Benefits and Coverage documents.

Status: Draft

Compose: Includes all codes from the SBC Benefit Category Code System

Binding Strength: Required for InsurancePlan.coverage.benefit.type and InsurancePlan.plan.specificCost.category in the SBC InsurancePlan profile

SBC Plan Type Value Set

URL: http://flexpa.com/fhir/sbc/ValueSet/sbc-plan-type

Purpose: Contains health insurance plan types for Summary of Benefits and Coverage documents.

Status: Draft

Compose: Includes all codes from the SBC Plan Type Code System

Binding Strength: Extensible for InsurancePlan.plan.type in the SBC InsurancePlan profile

Relationships to Standard FHIR Terminology

FHIR Benefit Type Value Set

The standard FHIR benefit-type value set (http://hl7.org/fhir/ValueSet/benefit-type) contains only 12 codes:

• visit, room, vision-exam, vision-glasses, vision-contacts, medical-primarycare, pharmacy-dispense, etc.

This is insufficient for SBC requirements, which mandate 27 specific benefit categories. Therefore, this IG defines a custom code system with all required SBC categories.

Applicability Codes

For network applicability (InsurancePlan.plan.specificCost.benefit.cost.applicability), use the standard FHIR BenefitCostApplicability value set:

• in-network - Services provided by in-network providers
• out-of-network - Services provided by out-of-network providers
• other - Other applicability scenarios

Cost Type Codes

While this IG doesn't define a specific code system for cost types, implementations should use clear text values:

• "Copayment" - Fixed dollar amount per service
• "Coinsurance" - Percentage of cost
• "Deductible" - Amount to be met before coverage
• "Not covered" - Service is not covered under the plan

Extension Code Systems

Abortion Coverage Codes

For the SBCMetadata.abortionCoverage element (required for qualified health plans per 45 CFR 156.280):

Suggested codes (implementation-specific):

• covered - Abortion services are covered
• not-covered - Abortion services are not covered except excepted services
• excepted-only - Only excepted abortion services covered (life endangerment, rape, incest)

Note: This IG does not currently define a formal code system for abortion coverage; implementers may use local codes or text

Versioning and Maintenance

Code System Evolution

As SBC regulations evolve, this terminology may be updated to:

• Add new benefit categories if regulations change
• Refine definitions based on regulatory guidance
• Add translations for multi-language support
• Align with CMS terminology if formal codes are released

Relationship to Official CMS Terminology

Currently, CMS does not provide official code systems for SBC benefit categories. The codes in this IG are derived from the textual descriptions in the SBC template.

If CMS publishes official codes in the future, this IG should be updated to reference or align with those codes.

Extensibility

Adding Local Benefit Codes

The extensible binding on plan types allows implementations to add local codes for:

• Regional plan types
• State-specific variations
• Product-specific categorizations

Additional Benefit Categories

While the 27 SBC categories are required, plans may cover additional services. These can be represented using:

• The "Other Covered Services" section of the SBC (no specific code required)
• Local codes from institutional code systems
• Standard FHIR benefit-type codes where appropriate

Implementation Guidance

Coding Consistency

When representing an SBC document:

1. Use the same benefit category code in multiple places:
   • coverage.benefit.type - To indicate the benefit is covered
   • plan.specificCost.category - To group costs by benefit
   • plan.specificCost.benefit.type - To identify the specific benefit with costs
2. Example for Primary Care Visit: ``` coverage.benefit[x] .type = http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category#primary-care-visit

plan.specificCost[x] .category = http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category#primary-care-visit .benefit.type = http://flexpa.com/fhir/sbc/CodeSystem/sbc-benefit-category#primary-care-visit ```

Translation and Localization

SBC documents are required in multiple languages (English, Spanish, Chinese, Tagalog, Navajo, and others as of 2025).

Future versions of this IG may include:

• Translated display values for benefit category codes
• Language-specific value sets
• Translation metadata extensions

Currently, implementers should maintain translations separately and apply them when rendering SBC documents for consumers.