Resource type: insuranceplan

Description

Details of a Health Insurance product/plan provided by an organization.

Elements

PathShortDefinitionComments
Details of a Health Insurance product/plan provided by an organizationDetails of a Health Insurance product/plan provided by an organization.
identifierBusiness Identifier for ProductBusiness identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.
statusdraft | active | retired | unknownThe current state of the health insurance product.
typeKind of productThe kind of health insurance product.
nameOfficial nameOfficial name of the health insurance product as designated by the owner.If the name of the product/plan changes, consider putting the old name in the alias column so that it can still be located through searches.
aliasAlternate namesA list of alternate names that the product is known as, or was known as in the past.There are no dates associated with the alias/historic names, as this is not intended to track when names were used, but to assist in searching so that older names can still result in identifying the product/plan.
periodWhen the product is availableThe period of time that the health insurance product is available.
ownedByPlan issuerThe entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers'.
administeredByProduct administratorAn organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.
coverageAreaWhere product appliesThe geographic region in which a health insurance product's benefits apply.
contactContact for the productThe contact for the health insurance product for a certain purpose.Where multiple contacts for the same purpose are provided there is a standard extension that can be used to determine which one is the preferred contact to use.
contact.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
contact.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
contact.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
contact.purposeThe type of contactIndicates a purpose for which the contact can be reached.
contact.nameA name associated with the contactA name associated with the contact.
contact.telecomContact details (telephone, email, etc.) for a contactA contact detail (e.g. a telephone number or an email address) by which the party may be contacted.
contact.addressVisiting or postal addresses for the contactVisiting or postal addresses for the contact.
endpointTechnical endpointThe technical endpoints providing access to services operated for the health insurance product.
networkWhat networks are IncludedReference to the network included in the health insurance product.Networks are represented as a hierarchy of organization resources.
coverageCoverage detailsDetails about the coverage offered by the insurance product.
coverage.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
coverage.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
coverage.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
coverage.typeType of coverageType of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).
coverage.networkWhat networks provide coverageReference to the network that providing the type of coverage.Networks are represented as a hierarchy of organization resources.
coverage.benefitList of benefitsSpecific benefits under this type of coverage.
coverage.benefit.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
coverage.benefit.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
coverage.benefit.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
coverage.benefit.typeType of benefitType of benefit (primary care; speciality care; inpatient; outpatient).
coverage.benefit.requirementReferral requirementsThe referral requirements to have access/coverage for this benefit.
coverage.benefit.limitBenefit limitsThe specific limits on the benefit.
coverage.benefit.limit.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
coverage.benefit.limit.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
coverage.benefit.limit.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
coverage.benefit.limit.valueMaximum value allowedThe maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses.May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”.
coverage.benefit.limit.codeBenefit limit detailsThe specific limit on the benefit.Use `CodeableConcept.text` element if the data is free (uncoded) text.
planPlan detailsDetails about an insurance plan.
plan.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.identifierBusiness Identifier for ProductBusiness identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.
plan.typeType of planType of plan. For example, "Platinum" or "High Deductable".
plan.coverageAreaWhere product appliesThe geographic region in which a health insurance plan's benefits apply.
plan.networkWhat networks provide coverageReference to the network that providing the type of coverage.Networks are represented as a hierarchy of organization resources.
plan.generalCostOverall costsOverall costs associated with the plan.
plan.generalCost.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.generalCost.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.generalCost.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.generalCost.typeType of costType of cost.
plan.generalCost.groupSizeNumber of enrolleesNumber of participants enrolled in the plan.
plan.generalCost.costCost valueValue of the cost.
plan.generalCost.commentAdditional cost informationAdditional information about the general costs associated with this plan.
plan.specificCostSpecific costsCosts associated with the coverage provided by the product.
plan.specificCost.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.specificCost.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.specificCost.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.specificCost.categoryGeneral category of benefitGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).
plan.specificCost.benefitBenefits listList of the specific benefits under this category of benefit.
plan.specificCost.benefit.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.specificCost.benefit.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.specificCost.benefit.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.specificCost.benefit.typeType of specific benefitType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).
plan.specificCost.benefit.costList of the costsList of the costs associated with a specific benefit.
plan.specificCost.benefit.cost.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.specificCost.benefit.cost.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.specificCost.benefit.cost.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
plan.specificCost.benefit.cost.typeType of costType of cost (copay; individual cap; family cap; coinsurance; deductible).
plan.specificCost.benefit.cost.applicabilityin-network | out-of-network | otherWhether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).
plan.specificCost.benefit.cost.qualifiersAdditional information about the costAdditional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).
plan.specificCost.benefit.cost.valueThe actual cost valueThe actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).

Scope and Usage

A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. A given payer’s products typically differ by network type and/or coverage benefits. A plan pairs the health insurance coverage benefits under a product with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans.

InsurancePlan describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.

Boundaries and Relationships

TBD.

Notes:

Search Parameters

addressA server defined search that may match any of the string fields in the Address, including line, city, district, state, country, postalCode, and/or textInsurancePlan.contact.address
address-cityA city specified in an addressInsurancePlan.contact.address.city
address-countryA country specified in an addressInsurancePlan.contact.address.country
address-postalcodeA postal code specified in an addressInsurancePlan.contact.address.postalCode
address-stateA state specified in an addressInsurancePlan.contact.address.state
address-useA use code specified in an addressInsurancePlan.contact.address.use
administered-byProduct administratorInsurancePlan.administeredBy
endpointTechnical endpointInsurancePlan.endpoint
identifierAny identifier for the organization (not the accreditation issuer's identifier)InsurancePlan.identifier
nameA portion of the organization's name or aliasname | alias
owned-byAn organization of which this organization forms a partInsurancePlan.ownedBy
phoneticA portion of the organization's name using some kind of phonetic matching algorithmInsurancePlan.name
statusIs the Organization record activeInsurancePlan.status
typeA code for the type of organizationInsurancePlan.type

Extension Definitions

These are extension definitions for this resource defined by the spec