# Example SBC - Sample HMO Health Plan - CARIN Digital Insurance Card v2.0.0-ballot

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Example SBC - Sample HMO Health Plan**

## Example InsurancePlan: Example SBC - Sample HMO Health Plan

| |
| :--- |
| *Page standards status:*[Informative](http://hl7.org/fhir/R4/versions.html#std-process) |

Profile: [SBC Insurance Plan Profile](StructureDefinition-sbc-insurance-plan.md)

> **SBC Metadata Extension**
* sbcVersionDate: 2021-01-01
* minimumEssentialCoverage: true
* minimumValue: true

> **Excluded Services Extension****serviceType**: Cosmetic surgery**description**: Services for cosmetic purposes are not covered
> **url**service
**serviceType**: Weight loss programs**description**: Weight loss programs except when medically necessary
> **url**service

**identifier**: `https://www.cms.gov/CCIIO/Resources/Data-Resources/hios`/12345CA0010001-01

**status**: Active

**name**: Sample Health HMO Gold Plan

**period**: 2025-01-01 --> 2025-12-31

**ownedBy**: [Sample Health Insurance Company](Organization-ExampleIssuerOrg.md)

**administeredBy**: [Organization Sample Health Insurance Company](Organization-ExampleIssuerOrg.md)

> **contact****purpose**: General Questions**telecom**: ph: 1-800-123-4567, [https://www.samplehealth.com](https://www.samplehealth.com)

> **contact****purpose**: Uniform Glossary**telecom**: [https://www.healthcare.gov/sbc-glossary/](https://www.healthcare.gov/sbc-glossary/)

> **coverage****type**: health insurance plan policy
> **benefit****type**: Preventive Care/Screening/Immunization**requirement**: No prior authorization required for in-network preventive services

> **benefit****type**: Primary Care Visit**requirement**: No referral required

> **benefit**
> **Benefit Limitation Extension**
* limitText: Limited to network specialists only; out-of-network not covered except in emergencies

> **Benefit Limitation Extension**
* limitText: Limited to 35 visits per plan year
* limitType: Visits
* limitValue: 35 visits
* limitPeriod: Plan Year

**type**: Specialist Visit**requirement**: Referral required from primary care physician

> **benefit**
> **Benefit Limitation Extension**
* limitText: Copay waived if admitted to hospital

**type**: Emergency Room Care

> **benefit****type**: Hospital Inpatient Care**requirement**: Prior authorization required for non-emergency admissions

> **plan****type**: Health Maintenance Organization (HMO)**network**: [Sample Health Value Choice Network](Organization-ExampleValueChoiceNetwork.md)
> **generalCost****type**: Individual Deductible

### Costs

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 1500 | United States dollar |

**comment**: Individual in-network deductible

> **generalCost****type**: Family Deductible

### Costs

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 3000 | United States dollar |


> **generalCost****type**: Individual Out-of-Pocket Maximum

### Costs

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 6000 | United States dollar |


> **generalCost****type**: Family Out-of-Pocket Maximum

### Costs

| | | |
| :--- | :--- | :--- |
| - | **Value** | **Currency** |
| * | 12000 | United States dollar |


> **specificCost****category**: Preventive Care/Screening/Immunization
> **benefit****type**: Preventive Care/Screening/Immunization
> **cost****type**: No charge**applicability**: In Network**value**: 0 USD

> **cost****type**: Not covered**applicability**: Out of Network**value**: 0 USD


> **specificCost****category**: Primary Care Visit
> **benefit****type**: Primary Care Visit
> **cost****Deductible Applies Extension**: false**type**: Copayment**applicability**: In Network**value**: 25 USD

> **cost****type**: Not covered**applicability**: Out of Network**value**: 0 USD


> **specificCost****category**: Specialist Visit
> **benefit****type**: Specialist Visit
> **cost****Cost Applies To Network Extension**: [Organization Sample Health Value Choice Network](Organization-ExampleValueChoiceNetwork.md)**type**: Copayment**applicability**: In Network**qualifiers**: Value Choice Provider**value**: 0 USD

> **cost****type**: Copayment**applicability**: In Network**qualifiers**: Standard Provider**value**: 50 USD

> **cost****type**: Copayment**applicability**: In Network**qualifiers**: Virtual Visit**value**: 10 USD

> **cost****type**: Not covered**applicability**: Out of Network**value**: 0 USD


> **specificCost****category**: Emergency Room Care
> **benefit**
> **Benefit Limitation Extension**
* limitText: Copay waived if admitted

**type**: Emergency Room Care
> **cost****type**: Copayment**applicability**: In Network**value**: 350 USD

> **cost****type**: Copayment**applicability**: Out of Network**value**: 350 USD


> **specificCost****category**: Generic Drugs
> **benefit****type**: Generic Drugs
> **cost****type**: Copayment**applicability**: In Network**value**: 10 USD

> **cost****type**: Not covered**applicability**: Out of Network**value**: 0 USD


> **specificCost****category**: Hospital Inpatient Care
> **benefit**
> **Benefit Limitation Extension**
* limitText: Prior authorization required

**type**: Hospital Inpatient Care
> **cost****Deductible Applies Extension**: true**type**: Coinsurance**applicability**: In Network**value**: 20 %

> **cost****type**: Not covered**applicability**: Out of Network**value**: 0 %





## Resource Content

```json
{
  "resourceType" : "InsurancePlan",
  "id" : "SBCExampleHMO",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan"]
  },
  "extension" : [{
    "extension" : [{
      "url" : "sbcVersionDate",
      "valueDate" : "2021-01-01"
    },
    {
      "url" : "minimumEssentialCoverage",
      "valueBoolean" : true
    },
    {
      "url" : "minimumValue",
      "valueBoolean" : true
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-metadata"
  },
  {
    "extension" : [{
      "extension" : [{
        "url" : "serviceType",
        "valueCodeableConcept" : {
          "text" : "Cosmetic surgery"
        }
      },
      {
        "url" : "description",
        "valueString" : "Services for cosmetic purposes are not covered"
      }],
      "url" : "service"
    },
    {
      "extension" : [{
        "url" : "serviceType",
        "valueCodeableConcept" : {
          "text" : "Weight loss programs"
        }
      },
      {
        "url" : "description",
        "valueString" : "Weight loss programs except when medically necessary"
      }],
      "url" : "service"
    }],
    "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/excluded-services"
  }],
  "identifier" : [{
    "system" : "https://www.cms.gov/CCIIO/Resources/Data-Resources/hios",
    "value" : "12345CA0010001-01"
  }],
  "status" : "active",
  "name" : "Sample Health HMO Gold Plan",
  "period" : {
    "start" : "2025-01-01",
    "end" : "2025-12-31"
  },
  "ownedBy" : {
    "reference" : "Organization/ExampleIssuerOrg",
    "display" : "Sample Health Insurance Company"
  },
  "administeredBy" : {
    "reference" : "Organization/ExampleIssuerOrg"
  },
  "contact" : [{
    "purpose" : {
      "text" : "General Questions"
    },
    "telecom" : [{
      "system" : "phone",
      "value" : "1-800-123-4567"
    },
    {
      "system" : "url",
      "value" : "https://www.samplehealth.com"
    }]
  },
  {
    "purpose" : {
      "text" : "Uniform Glossary"
    },
    "telecom" : [{
      "system" : "url",
      "value" : "https://www.healthcare.gov/sbc-glossary/"
    }]
  }],
  "coverage" : [{
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code" : "HIP",
        "display" : "health insurance plan policy"
      }]
    },
    "benefit" : [{
      "type" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "preventive-care"
        }]
      },
      "requirement" : "No prior authorization required for in-network preventive services"
    },
    {
      "type" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "primary-care-visit"
        }]
      },
      "requirement" : "No referral required"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "limitText",
          "valueString" : "Limited to network specialists only; out-of-network not covered except in emergencies"
        }],
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
      },
      {
        "extension" : [{
          "url" : "limitText",
          "valueString" : "Limited to 35 visits per plan year"
        },
        {
          "url" : "limitType",
          "valueCodeableConcept" : {
            "coding" : [{
              "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type",
              "code" : "visits",
              "display" : "Visits"
            }]
          }
        },
        {
          "url" : "limitValue",
          "valueQuantity" : {
            "value" : 35,
            "unit" : "visits"
          }
        },
        {
          "url" : "limitPeriod",
          "valueCodeableConcept" : {
            "coding" : [{
              "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period",
              "code" : "plan-year",
              "display" : "Plan Year"
            }]
          }
        }],
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "specialist-visit"
        }]
      },
      "requirement" : "Referral required from primary care physician"
    },
    {
      "extension" : [{
        "extension" : [{
          "url" : "limitText",
          "valueString" : "Copay waived if admitted to hospital"
        }],
        "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
      }],
      "type" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "emergency-room-care"
        }]
      }
    },
    {
      "type" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "hospital-inpatient"
        }]
      },
      "requirement" : "Prior authorization required for non-emergency admissions"
    }]
  }],
  "plan" : [{
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type",
        "code" : "HMO"
      }]
    },
    "network" : [{
      "reference" : "Organization/ExampleValueChoiceNetwork",
      "display" : "Sample Health Value Choice Network"
    }],
    "generalCost" : [{
      "type" : {
        "text" : "Individual Deductible"
      },
      "cost" : {
        "value" : 1500,
        "currency" : "USD"
      },
      "comment" : "Individual in-network deductible"
    },
    {
      "type" : {
        "text" : "Family Deductible"
      },
      "cost" : {
        "value" : 3000,
        "currency" : "USD"
      }
    },
    {
      "type" : {
        "text" : "Individual Out-of-Pocket Maximum"
      },
      "cost" : {
        "value" : 6000,
        "currency" : "USD"
      }
    },
    {
      "type" : {
        "text" : "Family Out-of-Pocket Maximum"
      },
      "cost" : {
        "value" : 12000,
        "currency" : "USD"
      }
    }],
    "specificCost" : [{
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "preventive-care"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "preventive-care"
          }]
        },
        "cost" : [{
          "type" : {
            "text" : "No charge"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "value" : {
            "value" : 0,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Not covered"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "value" : {
            "value" : 0,
            "unit" : "USD"
          }
        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "primary-care-visit"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "primary-care-visit"
          }]
        },
        "cost" : [{
          "extension" : [{
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : false
          }],
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "value" : {
            "value" : 25,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Not covered"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "value" : {
            "value" : 0,
            "unit" : "USD"
          }
        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "specialist-visit"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "specialist-visit"
          }]
        },
        "cost" : [{
          "extension" : [{
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/cost-applies-to-network",
            "valueReference" : {
              "reference" : "Organization/ExampleValueChoiceNetwork"
            }
          }],
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier",
              "code" : "value-choice",
              "display" : "Value Choice Provider"
            }]
          }],
          "value" : {
            "value" : 0,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier",
              "code" : "standard",
              "display" : "Standard Provider"
            }]
          }],
          "value" : {
            "value" : 50,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "qualifiers" : [{
            "coding" : [{
              "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier",
              "code" : "virtual",
              "display" : "Virtual Visit"
            }]
          }],
          "value" : {
            "value" : 10,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Not covered"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "value" : {
            "value" : 0,
            "unit" : "USD"
          }
        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "emergency-room-care"
        }]
      },
      "benefit" : [{
        "extension" : [{
          "extension" : [{
            "url" : "limitText",
            "valueString" : "Copay waived if admitted"
          }],
          "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
        }],
        "type" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "emergency-room-care"
          }]
        },
        "cost" : [{
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "value" : {
            "value" : 350,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "value" : {
            "value" : 350,
            "unit" : "USD"
          }
        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "generic-drugs"
        }]
      },
      "benefit" : [{
        "type" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "generic-drugs"
          }]
        },
        "cost" : [{
          "type" : {
            "text" : "Copayment"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "value" : {
            "value" : 10,
            "unit" : "USD"
          }
        },
        {
          "type" : {
            "text" : "Not covered"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "value" : {
            "value" : 0,
            "unit" : "USD"
          }
        }]
      }]
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
          "code" : "hospital-inpatient"
        }]
      },
      "benefit" : [{
        "extension" : [{
          "extension" : [{
            "url" : "limitText",
            "valueString" : "Prior authorization required"
          }],
          "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
        }],
        "type" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
            "code" : "hospital-inpatient"
          }]
        },
        "cost" : [{
          "extension" : [{
            "url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
            "valueBoolean" : true
          }],
          "type" : {
            "text" : "Coinsurance"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "in-network",
              "display" : "In Network"
            }]
          },
          "value" : {
            "value" : 20,
            "unit" : "%"
          }
        },
        {
          "type" : {
            "text" : "Not covered"
          },
          "applicability" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/applicability",
              "code" : "out-of-network",
              "display" : "Out of Network"
            }]
          },
          "value" : {
            "value" : 0,
            "unit" : "%"
          }
        }]
      }]
    }]
  }]
}

```
