Health Insurance Policy (id = "INS-101")

<?xml version="1.0" encoding="UTF-8"?>

<Contract xmlns="http://hl7.org/fhir">
   <id value="INS-101"/> 

   <text> 
      <status value="generated"/> 
      <div xmlns="http://www.w3.org/1999/xhtml">
         <p> Plan: Your Choice Split Copay (Non-Grandfathered)</p> 
         <p> Certificate Form Number: YCSCWLN (01-2017)</p> 
      </div> 
   </text> 

   <identifier> 
      <system value="http://xyz-insurance.com/forms"/> 
      <value value="YCSCWLN(01-2017)"/> 
   </identifier> 
   
   <applies> 
      <start value="2017-01-01"/> 
   </applies> 
   
   <subject> 
      <reference value="Patient/1"/> 
   </subject> 
   
   <type> 
      <coding> 
         <system value="http://terminology.hl7.org/CodeSystem/contract-type"/> 
         <code value="healthinsurance"/> 
         <display value="Health Insurance"/> 
      </coding> 
   </type> 
   
   <term> 
      <offer> 
         <text value="The benefits, limitations, exclusions and other coverage provisions in this booklet are
       subject to the terms of our contract with the Group. This booklet is a part of that contract,
       which is on file in the Group's office."/> 
      </offer> 
      <asset> 
         <type> 
            <coding> 
            <system value="urn:ietf:rfc:3986"/> 
            <code value="urn:uuid:3a48c68c-318d-4c68-8471-4a3c10fcb41b"/> 
            <display value="RicardianContract"/> 
         </coding> 
         </type> 
         <subtype> 
            <text value="sample"/> 
         </subtype> 
         <period> 
            <start value="2017-06-01"/> 
         </period> 
         <valuedItem> 
            <entityCodeableConcept> 
               <text value="Ford Bobcat"/> 
            </entityCodeableConcept> 
            <identifier> 
               <system value="http://somewhere.motor-vehicle.com/vin"/> 
               <value value="XXSVT34-7665t952236"/> 
            </identifier> 
            <effectiveTime value="1995"/> 
            <quantity> 
               <value value="1"/> 
            </quantity> 
            <unitPrice> 
               <value value="200.00"/> 
               <currency value="CAD"/> 
            </unitPrice> 
            <factor value="1.0"/> 
            <points value="1.0"/> 
            <net> 
               <value value="200.00"/> 
               <currency value="CAD"/> 
            </net> 
         </valuedItem> 
      </asset> 
      <group> 
         <offer> 
            <text value="Eligible Providers"/> 
         </offer> 
      </group> 
      <group> 
         <offer> 
            <text value="Responsibility for Payment"/> 
         </offer> 
      </group> 
      <group> 
         <offer> 
            <text value="List of Benefits"/> 
         </offer> 
         <group> 
            <offer> 
               <text value="Copays"/> 
            </offer> 
            <group> 
               <offer> 
                  <text value="Emergency Room Copay"/> 
               </offer> 
            </group> 
            <group> 
               <offer> 
                  <text value="Professional Visit Copay"/> 
               </offer> 
            </group> 
         </group> 
         <group> 
            <offer> 
               <text value="Calendar Year Deductible"/> 
            </offer> 
         </group> 
         <group> 
            <offer> 
               <text value="Out-Of-Pocket Maximum"/> 
            </offer> 
         </group> 
         <group> 
            <offer> 
               <text value="Medical Services"/> 
            </offer> 
            <group> 
               <offer> 
                  <text value="Ambulance Services"/> 
               </offer> 
            </group> 
            <group> 
               <offer> 
                  <text value="Dental Services"/> 
               </offer> 
            </group> 
            <group> 
               <offer> 
                  <text value="Diagnostic Services"/> 
               </offer> 
            </group> 
            <group> 
               <offer> 
                  <text value="Emergency Room Services"/> 
               </offer> 
            </group> 
            <group> 
               <offer> 
                  <text value="Hospital Inpatient Care"/> 
               </offer> 
            </group> 
         </group> 
      </group> 
   </term> 
</Contract>