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8.35 Resource InsurancePlan - Content

Patient Administration icon

Work Group

Maturity Level: 1

Trial Use

Security Category: Business

Compartments: No defined compartments

Details about an insurance plan.

8.35.1 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.

8.35.2 Boundaries and Relationships

TBD.

8.35.3 References to this Resource

Resource References: Coverage and UsageContext

Structure

Name	Flags	Card.	Type	Description & Constraints
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
coverageArea	Σ	0..*	Reference(Location)	Where product-plan applies
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
Documentation for this format

See the Extensions for this resource

UML Diagram (Legend)

XML Template

<InsurancePlan xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier>
 <type><!-- 0..1 CodeableConcept Classification of Plan --></type>
 <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product>
 <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea>
 <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
 <generalCost>  <!-- 0..* Overall costs -->
  <type><!-- 0..1 CodeableConcept Classification of specific cost --></type>
  <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
  <cost><!-- 0..1 Money Cost value --></cost>
  <comment value="[string]"/><!-- 0..1 Additional cost information -->
 </generalCost>
 <specificCost>  <!-- 0..* Individual cost elements -->
  <category><!-- 1..1 CodeableConcept General category of benefit --></category>
  <benefit>  <!-- 0..* Benefits list -->
   <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type>
   <cost>  <!-- 0..* List of the costs -->
    <type><!-- 1..1 CodeableConcept Classification of specific cost --></type>
    <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
    <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier>
    <value><!-- 0..1 Quantity The actual cost value --></value>
   </cost>
  </benefit>
 </specificCost>
</InsurancePlan>

JSON Template

{
  "resourceType" : "InsurancePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for Plan
  "type" : { CodeableConcept }, // Classification of Plan
  "product" : { Reference(InsuranceProduct) }, // The product that this plan is available under
  "coverageArea" : [{ Reference(Location) }], // Where product-plan applies
  "network" : [{ Reference(Organization) }], // What networks provide coverage
  "generalCost" : [{ // Overall costs
    "type" : { CodeableConcept }, // Classification of specific cost
    "groupSize" : "<positiveInt>", // Number of enrollees
    "cost" : { Money }, // Cost value
    "comment" : "<string>" // Additional cost information
  }],
  "specificCost" : [{ // Individual cost elements
    "category" : { CodeableConcept }, // R!  General category of benefit
    "benefit" : [{ // Benefits list
      "type" : { CodeableConcept }, // R!  Classification of benefit provided
      "cost" : [{ // List of the costs
        "type" : { CodeableConcept }, // R!  Classification of specific cost
        "applicability" : { CodeableConcept }, // in-network | out-of-network | other
        "qualifier" : [{ CodeableConcept }], // Additional information about the cost
        "value" : { Quantity } // The actual cost value
      }]
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan
  fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan
  fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
  fhir:generalCost ( [ # 0..* Overall costs
    fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost
    fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees
    fhir:cost [ Money ] ; # 0..1 Cost value
    fhir:comment [ string ] ; # 0..1 Additional cost information
  ] ... ) ;
  fhir:specificCost ( [ # 0..* Individual cost elements
    fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit
    fhir:benefit ( [ # 0..* Benefits list
      fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided
      fhir:cost ( [ # 0..* List of the costs
        fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost
        fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other
        fhir:qualifier  ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost
        fhir:value [ Quantity ] ; # 0..1 The actual cost value
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
]

Changes from both R4 and R4B

InsurancePlan

InsurancePlan.type

Max Cardinality changed from * to 1

InsurancePlan.product

Added Element

InsurancePlan.generalCost

Added Element

InsurancePlan.generalCost.type

Added Element

InsurancePlan.generalCost.groupSize

Added Element

InsurancePlan.generalCost.cost

Added Element

InsurancePlan.generalCost.comment

Added Element

InsurancePlan.specificCost

Added Element

InsurancePlan.specificCost.category

Added Mandatory Element

InsurancePlan.specificCost.benefit

Added Element

InsurancePlan.specificCost.benefit.type

Added Mandatory Element

InsurancePlan.specificCost.benefit.cost

Added Element

InsurancePlan.specificCost.benefit.cost.type

Added Mandatory Element

InsurancePlan.specificCost.benefit.cost.applicability

Added Element

InsurancePlan.specificCost.benefit.cost.qualifier

Added Element

InsurancePlan.specificCost.benefit.cost.value

Added Element

InsurancePlan.status

Deleted

InsurancePlan.name

Deleted

InsurancePlan.alias

Deleted

InsurancePlan.period

Deleted

InsurancePlan.ownedBy

Deleted

InsurancePlan.administeredBy

Deleted

InsurancePlan.contact

Deleted

InsurancePlan.endpoint

Deleted

InsurancePlan.coverage

Deleted

InsurancePlan.plan

Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

Structure

Name	Flags	Card.	Type	Description & Constraints
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
coverageArea	Σ	0..*	Reference(Location)	Where product-plan applies
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
Documentation for this format

See the Extensions for this resource

UML Diagram (Legend)

XML Template

<InsurancePlan xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier>
 <type><!-- 0..1 CodeableConcept Classification of Plan --></type>
 <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product>
 <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea>
 <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
 <generalCost>  <!-- 0..* Overall costs -->
  <type><!-- 0..1 CodeableConcept Classification of specific cost --></type>
  <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
  <cost><!-- 0..1 Money Cost value --></cost>
  <comment value="[string]"/><!-- 0..1 Additional cost information -->
 </generalCost>
 <specificCost>  <!-- 0..* Individual cost elements -->
  <category><!-- 1..1 CodeableConcept General category of benefit --></category>
  <benefit>  <!-- 0..* Benefits list -->
   <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type>
   <cost>  <!-- 0..* List of the costs -->
    <type><!-- 1..1 CodeableConcept Classification of specific cost --></type>
    <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
    <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier>
    <value><!-- 0..1 Quantity The actual cost value --></value>
   </cost>
  </benefit>
 </specificCost>
</InsurancePlan>

JSON Template

{
  "resourceType" : "InsurancePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for Plan
  "type" : { CodeableConcept }, // Classification of Plan
  "product" : { Reference(InsuranceProduct) }, // The product that this plan is available under
  "coverageArea" : [{ Reference(Location) }], // Where product-plan applies
  "network" : [{ Reference(Organization) }], // What networks provide coverage
  "generalCost" : [{ // Overall costs
    "type" : { CodeableConcept }, // Classification of specific cost
    "groupSize" : "<positiveInt>", // Number of enrollees
    "cost" : { Money }, // Cost value
    "comment" : "<string>" // Additional cost information
  }],
  "specificCost" : [{ // Individual cost elements
    "category" : { CodeableConcept }, // R!  General category of benefit
    "benefit" : [{ // Benefits list
      "type" : { CodeableConcept }, // R!  Classification of benefit provided
      "cost" : [{ // List of the costs
        "type" : { CodeableConcept }, // R!  Classification of specific cost
        "applicability" : { CodeableConcept }, // in-network | out-of-network | other
        "qualifier" : [{ CodeableConcept }], // Additional information about the cost
        "value" : { Quantity } // The actual cost value
      }]
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan
  fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan
  fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
  fhir:generalCost ( [ # 0..* Overall costs
    fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost
    fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees
    fhir:cost [ Money ] ; # 0..1 Cost value
    fhir:comment [ string ] ; # 0..1 Additional cost information
  ] ... ) ;
  fhir:specificCost ( [ # 0..* Individual cost elements
    fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit
    fhir:benefit ( [ # 0..* Benefits list
      fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided
      fhir:cost ( [ # 0..* List of the costs
        fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost
        fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other
        fhir:qualifier  ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost
        fhir:value [ Quantity ] ; # 0..1 The actual cost value
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
]

Changes from both R4 and R4B

InsurancePlan

InsurancePlan.type

Max Cardinality changed from * to 1

InsurancePlan.product

Added Element

InsurancePlan.generalCost

Added Element

InsurancePlan.generalCost.type

Added Element

InsurancePlan.generalCost.groupSize

Added Element

InsurancePlan.generalCost.cost

Added Element

InsurancePlan.generalCost.comment

Added Element

InsurancePlan.specificCost

Added Element

InsurancePlan.specificCost.category

Added Mandatory Element

InsurancePlan.specificCost.benefit

Added Element

InsurancePlan.specificCost.benefit.type

Added Mandatory Element

InsurancePlan.specificCost.benefit.cost

Added Element

InsurancePlan.specificCost.benefit.cost.type

Added Mandatory Element

InsurancePlan.specificCost.benefit.cost.applicability

Added Element

InsurancePlan.specificCost.benefit.cost.qualifier

Added Element

InsurancePlan.specificCost.benefit.cost.value

Added Element

InsurancePlan.status

Deleted

InsurancePlan.name

Deleted

InsurancePlan.alias

Deleted

InsurancePlan.period

Deleted

InsurancePlan.ownedBy

Deleted

InsurancePlan.administeredBy

Deleted

InsurancePlan.contact

Deleted

InsurancePlan.endpoint

Deleted

InsurancePlan.coverage

Deleted

InsurancePlan.plan

Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

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

8.35.4.1 Terminology Bindings

Path	ValueSet	Type	Documentation
InsurancePlan.specificCost.benefit.cost.applicability	BenefitCostApplicability	Required	Whether the cost applies to in-network or out-of-network providers.

Path

ValueSet

Type

Documentation

InsurancePlan.specificCost.benefit.cost.applicability

BenefitCostApplicability

Required

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

8.35.5 Notes:

8.35.6 Search Parameters

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