# SBC Insurance Plan Profile - CARIN Digital Insurance Card v2.0.0-ballot

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **SBC Insurance Plan Profile**

## Resource Profile: SBC Insurance Plan Profile ( Experimental ) 

| | |
| :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan | *Version*:2.0.0-ballot |
| * Standards status: *[Informative](http://hl7.org/fhir/R4/versions.html#std-process) | *Computable Name*:SBCInsurancePlan |
| *Other Identifiers:*OID:2.16.840.1.113883.4.642.40.9.42.18 | |

 
Profile of InsurancePlan resource for representing Summary of Benefits and Coverage (SBC) documents as required under ACA Section 2715 and implementing regulations at 45 CFR 147.200, 29 CFR 2590.715-2715, and 26 CFR 54.9815-2715 

 
To represent Summary of Benefits and Coverage documents in structured FHIR format, enabling machine-readable representation of the 27 required benefit categories, cost-sharing information, network distinctions, and regulatory disclosures 

**Usages:**

* Refer to this Profile: [Additional Insurance Card Information](StructureDefinition-C4DIC-AdditionalCardInformation-extension.md)
* Examples for this Profile: [Sample Health HMO Gold Plan](InsurancePlan-SBCExampleHMO.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/resource/hl7.fhir.us.insurance-card|current/StructureDefinition/StructureDefinition-sbc-insurance-plan.json)

### Formal Views of Profile Content

 [Description of Profiles, Differentials, Snapshots and how the different presentations work](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](StructureDefinition-sbc-insurance-plan.csv), [Excel](StructureDefinition-sbc-insurance-plan.xlsx), [Schematron](StructureDefinition-sbc-insurance-plan.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "sbc-insurance-plan",
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "claims"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "informative",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/insurance-card/ImplementationGuide/hl7.fhir.us.insurance-card"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.40.9.42.18"
  }],
  "version" : "2.0.0-ballot",
  "name" : "SBCInsurancePlan",
  "title" : "SBC Insurance Plan Profile",
  "status" : "draft",
  "experimental" : true,
  "date" : "2026-08-13T02:29:19+10:00",
  "publisher" : "HL7 International / Payer/Provider Information Exchange Work Group",
  "contact" : [{
    "name" : "HL7 International / Payer/Provider Information Exchange Work Group",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/claims"
    },
    {
      "system" : "email",
      "value" : "pie@lists.HL7.org"
    }]
  }],
  "description" : "Profile of InsurancePlan resource for representing Summary of Benefits and Coverage (SBC) documents as required under ACA Section 2715 and implementing regulations at 45 CFR 147.200, 29 CFR 2590.715-2715, and 26 CFR 54.9815-2715",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US"
    }]
  }],
  "purpose" : "To represent Summary of Benefits and Coverage documents in structured FHIR format, enabling machine-readable representation of the 27 required benefit categories, cost-sharing information, network distinctions, and regulatory disclosures",
  "fhirVersion" : "4.0.1",
  "mapping" : [{
    "identity" : "w5",
    "uri" : "http://hl7.org/fhir/fivews",
    "name" : "FiveWs Pattern Mapping"
  },
  {
    "identity" : "rim",
    "uri" : "http://hl7.org/v3",
    "name" : "RIM Mapping"
  }],
  "kind" : "resource",
  "abstract" : false,
  "type" : "InsurancePlan",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/InsurancePlan",
  "derivation" : "constraint",
  "differential" : {
    "element" : [{
      "id" : "InsurancePlan",
      "path" : "InsurancePlan"
    },
    {
      "id" : "InsurancePlan.extension",
      "path" : "InsurancePlan.extension",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "url"
        }],
        "ordered" : false,
        "rules" : "open"
      }
    },
    {
      "id" : "InsurancePlan.extension:sbcMetadata",
      "path" : "InsurancePlan.extension",
      "sliceName" : "sbcMetadata",
      "short" : "SBC regulatory metadata",
      "definition" : "Contains minimum essential coverage indicator, minimum value indicator, abortion coverage disclosure, and SBC version date",
      "min" : 0,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.extension:excludedServices",
      "path" : "InsurancePlan.extension",
      "sliceName" : "excludedServices",
      "short" : "Excluded services list",
      "definition" : "Services that are NOT covered by this plan, as displayed in the 'Excluded Services & Other Covered Services' section of the SBC",
      "min" : 0,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.identifier",
      "path" : "InsurancePlan.identifier",
      "short" : "Business identifier for the insurance plan (e.g., HIOS ID)",
      "definition" : "Unique identifier for the plan, such as the 14-16 digit HIOS ID (5-digit HIOS ID + 2-digit State + 3-digit Product Iteration + 4-digit Plan Iteration + 2-digit Variant)",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.status",
      "path" : "InsurancePlan.status",
      "min" : 1,
      "fixedCode" : "active",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.name",
      "path" : "InsurancePlan.name",
      "short" : "Plan name as displayed on SBC",
      "definition" : "The official name of the health insurance plan as it appears in the SBC header",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.period",
      "path" : "InsurancePlan.period",
      "short" : "Coverage period",
      "definition" : "The time period during which this plan is or was available. Maps to the Coverage Period displayed in the SBC header",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.ownedBy",
      "path" : "InsurancePlan.ownedBy",
      "short" : "Plan issuer organization",
      "definition" : "The health insurance issuer or employer that owns/offers this plan",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.administeredBy",
      "path" : "InsurancePlan.administeredBy",
      "short" : "Plan administrator",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.contact",
      "path" : "InsurancePlan.contact",
      "short" : "Contact information for plan questions",
      "definition" : "Contact information including phone numbers, website addresses, and other contact methods required by SBC regulations for questions, provider lists, formulary, and uniform glossary access",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.coverage",
      "path" : "InsurancePlan.coverage",
      "short" : "Benefit coverage details",
      "definition" : "Details of benefit coverage for different categories of services. Each coverage entry should represent one or more of the 27 required SBC benefit categories",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.coverage.type",
      "path" : "InsurancePlan.coverage.type",
      "short" : "Type of coverage (e.g., medical, pharmacy)",
      "definition" : "High-level categorization of coverage type",
      "mustSupport" : true,
      "binding" : {
        "strength" : "extensible",
        "valueSet" : "http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category"
      }
    },
    {
      "id" : "InsurancePlan.coverage.network",
      "path" : "InsurancePlan.coverage.network",
      "short" : "Provider networks for this coverage",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.coverage.benefit",
      "path" : "InsurancePlan.coverage.benefit",
      "short" : "Specific benefits covered",
      "definition" : "Individual benefit types within this coverage category, corresponding to the 27 SBC benefit categories",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.coverage.benefit.extension",
      "path" : "InsurancePlan.coverage.benefit.extension",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "url"
        }],
        "ordered" : false,
        "rules" : "open"
      }
    },
    {
      "id" : "InsurancePlan.coverage.benefit.extension:limitation",
      "path" : "InsurancePlan.coverage.benefit.extension",
      "sliceName" : "limitation",
      "short" : "Limitations and exceptions",
      "definition" : "Specific limitations, exceptions, or additional context for this benefit as displayed in the SBC",
      "min" : 0,
      "max" : "*",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.coverage.benefit.type",
      "path" : "InsurancePlan.coverage.benefit.type",
      "short" : "Benefit category code",
      "definition" : "The specific benefit category from the SBC's 27 required categories",
      "mustSupport" : true,
      "binding" : {
        "strength" : "required",
        "valueSet" : "http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category"
      }
    },
    {
      "id" : "InsurancePlan.coverage.benefit.requirement",
      "path" : "InsurancePlan.coverage.benefit.requirement",
      "short" : "Requirements for accessing benefit",
      "definition" : "Text describing requirements such as prior authorization, referral requirements, or other access limitations",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan",
      "path" : "InsurancePlan.plan",
      "short" : "Health insurance plan details",
      "definition" : "Specific plan offerings with detailed cost-sharing information for each of the 27 SBC benefit categories",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.type",
      "path" : "InsurancePlan.plan.type",
      "short" : "Plan type (HMO, PPO, POS, EPO, etc.)",
      "definition" : "The type of health insurance plan as displayed in the SBC header (e.g., HMO, PPO, POS, EPO, HDHP, Indemnity)",
      "mustSupport" : true,
      "binding" : {
        "strength" : "extensible",
        "valueSet" : "http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-plan-type"
      }
    },
    {
      "id" : "InsurancePlan.plan.coverageArea",
      "path" : "InsurancePlan.plan.coverageArea",
      "short" : "Geographic coverage area",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.network",
      "path" : "InsurancePlan.plan.network",
      "short" : "Provider networks for this plan",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.generalCost",
      "path" : "InsurancePlan.plan.generalCost",
      "short" : "Overall plan costs",
      "definition" : "Plan-level costs such as overall deductibles and out-of-pocket maximums that apply across benefit categories",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.generalCost.type",
      "path" : "InsurancePlan.plan.generalCost.type",
      "short" : "Type of cost (deductible, out-of-pocket max)",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.generalCost.cost",
      "path" : "InsurancePlan.plan.generalCost.cost",
      "short" : "Cost amount",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.generalCost.comment",
      "path" : "InsurancePlan.plan.generalCost.comment",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost",
      "path" : "InsurancePlan.plan.specificCost",
      "short" : "Cost-sharing by benefit category",
      "definition" : "Cost-sharing information (copays, coinsurance, deductibles) for each of the 27 SBC benefit categories, with separate amounts for in-network and out-of-network services",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.category",
      "path" : "InsurancePlan.plan.specificCost.category",
      "short" : "Benefit category code",
      "definition" : "The specific SBC benefit category to which these costs apply",
      "mustSupport" : true,
      "binding" : {
        "strength" : "required",
        "valueSet" : "http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category"
      }
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit",
      "path" : "InsurancePlan.plan.specificCost.benefit",
      "short" : "Specific benefit with costs",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.extension",
      "path" : "InsurancePlan.plan.specificCost.benefit.extension",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "url"
        }],
        "ordered" : false,
        "rules" : "open"
      }
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.extension:limitation",
      "path" : "InsurancePlan.plan.specificCost.benefit.extension",
      "sliceName" : "limitation",
      "short" : "Benefit-specific limitations",
      "min" : 0,
      "max" : "*",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.type",
      "path" : "InsurancePlan.plan.specificCost.benefit.type",
      "short" : "Benefit type code",
      "mustSupport" : true,
      "binding" : {
        "strength" : "required",
        "valueSet" : "http://hl7.org/fhir/us/insurance-card/ValueSet/sbc-benefit-category"
      }
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost",
      "short" : "Cost-sharing amounts",
      "definition" : "Cost-sharing information including copays, coinsurance, and deductibles. Must include separate entries for in-network and out-of-network services where applicable",
      "min" : 2,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.extension",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.extension",
      "slicing" : {
        "discriminator" : [{
          "type" : "value",
          "path" : "url"
        }],
        "ordered" : false,
        "rules" : "open"
      }
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.extension:appliesToNetwork",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.extension",
      "sliceName" : "appliesToNetwork",
      "short" : "Network whose providers qualify for this cost tier",
      "definition" : "Identifies which of the plan's networks contains the providers that qualify for this designation-tier cost",
      "min" : 0,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.extension:deductibleApplies",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.extension",
      "sliceName" : "deductibleApplies",
      "short" : "Whether this cost accrues to the deductible",
      "definition" : "States whether this cost-sharing amount counts toward the plan deductible, as displayed in the SBC",
      "min" : 0,
      "max" : "1",
      "type" : [{
        "code" : "Extension",
        "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies"]
      }],
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.type",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.type",
      "short" : "Type of cost (copay, coinsurance, deductible)",
      "definition" : "The type of cost-sharing: copayment (fixed dollar amount), coinsurance (percentage), or deductible",
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.applicability",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.applicability",
      "short" : "Network applicability (in-network, out-of-network)",
      "definition" : "Whether this cost applies to in-network services, out-of-network services, or other scenarios",
      "min" : 1,
      "mustSupport" : true
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.qualifiers",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.qualifiers",
      "short" : "Cost tier (provider designation or modality)",
      "definition" : "Additional qualifying information for this cost, used to carry the provider-designation or modality tier (e.g., value-choice, standard, virtual) that distinguishes multiple cost entries for the same benefit and network applicability",
      "mustSupport" : true,
      "binding" : {
        "strength" : "extensible",
        "valueSet" : "http://hl7.org/fhir/us/insurance-card/ValueSet/cost-tier"
      }
    },
    {
      "id" : "InsurancePlan.plan.specificCost.benefit.cost.value",
      "path" : "InsurancePlan.plan.specificCost.benefit.cost.value",
      "short" : "Cost amount",
      "definition" : "The actual cost-sharing amount (dollar amount for copay, percentage for coinsurance)",
      "min" : 1,
      "mustSupport" : true
    }]
  }
}

```
