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8.35 Resource InsurancePlan - Content

Patient Administration icon Work GroupMaturity Level: 1 Trial UseSecurity Category: Business Compartments: No defined compartments

InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct referenced in InsurancePlan.product.

Insurance offerings will be fully described by the combination of both InsurancePlan (the costs) and InsuranceProduct (the benefits). However, some systems may only need to represent the InsurancePlan, so that Coverage resources can describe which plan is associated with a given beneficiary. In that case, there will be some other system that is responsible for tracking the benefits associated with the plan.

An InsurancePlan pairs the health insurance coverage benefits under an InsuranceProduct with the particular cost sharing structure offered to a consumer. A given InsuranceProduct may comprise multiple InsurancePlans.

InsuranceProduct describes a list of covered benefits and networks as well as details about who administers the product and applicable coverage areas.

InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct referenced in InsurancePlan.product.

A Coverage resource establishes the link between an InsurancePlan and a beneficiary and optionally a subscriber.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan TU DomainResource Plan details

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier Business Identifier for Plan

... type 0..1 CodeableConcept Classification of Plan
... product Σ 0..1 Reference(InsuranceProduct) The product that this plan is available under
... network 0..* Reference(Organization) What networks provide coverage

... generalCost 0..* BackboneElement Overall costs

.... type 0..1 CodeableConcept Classification of specific cost
.... groupSize 0..1 positiveInt Number of enrollees
.... cost 0..1 Money Cost value
.... comment 0..1 string Additional cost information
... specificCost 0..* BackboneElement Individual cost elements

.... category 1..1 CodeableConcept General category of benefit
.... benefit 0..* BackboneElement Benefits list

..... type 1..1 CodeableConcept Classification of benefit provided
..... cost 0..* BackboneElement List of the costs

...... type 1..1 CodeableConcept Classification of specific cost
...... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: Benefit Cost Applicability (Required)
...... qualifier 0..* CodeableConcept Additional information about the cost

...... value 0..1 Quantity The actual cost value

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

Path ValueSet Type Documentation
InsurancePlan.specificCost.benefit.cost.applicability BenefitCostApplicability Required

Whether the cost applies to in-network or out-of-network providers.

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
coverage-area reference Location(s) insurance product is intended for/available to InsurancePlan.coverageArea
(Location)
identifier token External identifiers for this item InsurancePlan.identifier
network reference The product this plan is available to InsurancePlan.network
(Organization)
product reference The product this plan is available to InsurancePlan.product
(InsuranceProduct)
type token A code for the type of insurance plan InsurancePlan.type