CARIN Digital Insurance Card
2.0.0-ballot - STU 2 Ballot

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

Page standards status: Informative

Profile: SBC Insurance Plan Profile

> 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

administeredBy: Organization Sample Health Insurance Company

> contact

> purpose: General Questions

> telecom: ph: 1-800-123-4567, https://www.samplehealth.com

> contact

> purpose: Uniform Glossary

> telecom: 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

> > 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

> > > > 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 %