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>