InsurancePlan

Introduction

Scope and Usage

Insurance offerings will be fully described by the combination of both InsurancePlan (the costs) and InsuranceProduct (the benefits). However, some systems may only need to represent the InsurancePlan, so that Coverage resources can describe which plan is associated with a given beneficiary. In that case, there will be some other system that is responsible for tracking the benefits associated with the plan.

An InsurancePlan pairs the health insurance coverage benefits under an InsuranceProduct with the particular cost sharing structure offered to a consumer. A given InsuranceProduct may comprise multiple InsurancePlans.

Note to Balloters:

This resource is likely to be removed from the specification and moved to being an Additional Resource after this ballot due to concerns around it's readiness, and the thin implementation experience. Ballot comments on this subject are welcome.

Boundaries and Relationships

InsuranceProduct describes a list of covered benefits and networks as well as details about who administers the product and applicable coverage areas.

InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct referenced in InsurancePlan.product.

A Coverage resource establishes the link between an InsurancePlan and a beneficiary and optionally a subscriber.

Notes

Notes:

StructureDefinition

Elements (Simplified)

• InsurancePlan [0..*]: - Plan details
• InsurancePlan.identifier [0..*]: Identifier Business Identifier for Plan
• InsurancePlan.type [0..1]: CodeableConcept Classification of Plan
• InsurancePlan.product [0..1]: Reference(InsuranceProduct) The product that this plan is available under
• InsurancePlan.coverageArea [0..*]: Reference(Location) Where product-plan applies
• InsurancePlan.network [0..*]: Reference(Organization) What networks provide coverage
• InsurancePlan.generalCost [0..*]: BackboneElement Overall costs
• InsurancePlan.generalCost.type [0..1]: CodeableConcept Classification of specific cost
• InsurancePlan.generalCost.groupSize [0..1]: positiveInt Number of enrollees
• InsurancePlan.generalCost.cost [0..1]: Money Cost value
• InsurancePlan.generalCost.comment [0..1]: string Additional cost information
• InsurancePlan.specificCost [0..*]: BackboneElement Individual cost elements
• InsurancePlan.specificCost.category [1..1]: CodeableConcept General category of benefit
• InsurancePlan.specificCost.benefit [0..*]: BackboneElement Benefits list
• InsurancePlan.specificCost.benefit.type [1..1]: CodeableConcept Classification of benefit provided
• InsurancePlan.specificCost.benefit.cost [0..*]: BackboneElement List of the costs
• InsurancePlan.specificCost.benefit.cost.type [1..1]: CodeableConcept Classification of specific cost
• InsurancePlan.specificCost.benefit.cost.applicability [0..1]: CodeableConcept required:insuranceplan-applicability in-network | out-of-network | other
• InsurancePlan.specificCost.benefit.cost.qualifier [0..*]: CodeableConcept Additional information about the cost
• InsurancePlan.specificCost.benefit.cost.value [0..1]: Quantity The actual cost value

Mappings

• InsurancePlan Mappings — 4 mapping entries

Resource Packs

list-InsurancePlan-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir">
  <id value="InsurancePlan-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

• identifier — token — External identifiers for this item — InsurancePlan.identifier
• type — token — A code for the type of insurance plan — InsurancePlan.type
• product — reference — The product this plan is available to — InsurancePlan.product
• coverage-area — reference — Location(s) insurance product is intended for/available to — InsurancePlan.coverageArea
• network — reference — The product this plan is available to — InsurancePlan.network

Full Search Parameters

Examples

• example — insuranceplan-example — A general insurance plan example
• insuranceplan-example — insuranceplan-example
• insuranceplan-example-onc — insuranceplan-example-onc
• insuranceplan-example1 — insuranceplan-example1
• insuranceplan-examples-header — insuranceplan-examples-header

Full Examples

Mapping Exceptions

insuranceplan-fivews-mapping-exceptions.xml

Unmapped Elements

• FiveWs.what — Unknown
• FiveWs.recorded — Unknown
• FiveWs.author — Unknown
• FiveWs.actor — Unknown
• FiveWs.cause — Unknown
• FiveWs.version — Unknown
• FiveWs.witness — Unknown
• FiveWs.class — Unknown
• FiveWs.where — Unknown
• FiveWs.context — Unknown
• FiveWs.init — Unknown
• FiveWs.why — Unknown
• FiveWs.source — Unknown
• FiveWs.who — Unknown
• FiveWs.grade — Unknown
• FiveWs.status — Unknown
• FiveWs.planned — Unknown
• FiveWs.done — Unknown
• FiveWs.subject — Unknown