InsurancePlan Definitions
<a id="InsurancePlan"></a>
InsurancePlan
Plan details
Definition: 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.
Cardinality: 0..*
Mappings: w5=administrative.entity
<a id="InsurancePlan.identifier"></a>
InsurancePlan.identifier
Business Identifier for Plan
Definition: Identifiers, such as the plan ID and/or group ID associated with the insurance plan.
Comments: In some markets, the combination of a plan ID and a group ID are needed to uniquely identify an InsurancePlan. For example, if a single plan (Bronze) is offered to two employer groups (Boilermakers and Aviation), you would represent that using two InsurancePlan resources, as shown below:
InsurancePlan.identifier 0..* (Boilermakers) InsurancePlan/bm
[0].value = 1234 (bronze plan)
[0].type = Plan
[0].system = https://insurance-payer.com/plan-numbers
[1].value = Boilermakers
[1].type = Group
[1].system = https:// insurance-payer.com /group-numbers
InsurancePlan.identifier 0..* (Aviation) InsurancePlan/av
[0].value = 1234 (bronze plan)
[0].type = Plan
[0].system = https:// insurance-payer.com /plan-numbers
[1].value = Aviation
[1].type = Group
[1].system = https:// insurance-payer.com /group-numbers
Cardinality: 0..*
Type: Identifier
Summary: true
Mappings: w5=FiveWs.identifier; rim=.scopesRole
<a id="InsurancePlan.type"></a>
InsurancePlan.type
Classification of Plan
Definition: Type of plan. For example, "Platinum" or "High Deductable".
Cardinality: 0..1
Type: CodeableConcept
<a id="InsurancePlan.product"></a>
InsurancePlan.product
The product that this plan is available under
Definition: The product that this plan is available under.
Cardinality: 0..1
Type: Reference(InsuranceProduct)
Summary: true
Mappings: rim=N/A
<a id="InsurancePlan.coverageArea"></a>
InsurancePlan.coverageArea
Where product-plan applies
Definition: The geographic region in which a health insurance plan's benefits apply.
Cardinality: 0..*
Type: Reference(Location)
Summary: true
<a id="InsurancePlan.network"></a>
InsurancePlan.network
What networks provide coverage
Definition: Reference to the network that providing the type of coverage.
Comments: Networks are represented as a hierarchy of organization resources.
Cardinality: 0..*
Type: Reference(Organization)
<a id="InsurancePlan.generalCost"></a>
InsurancePlan.generalCost
Overall costs
Definition: Overall costs associated with the plan.
Cardinality: 0..*
Type: BackboneElement
<a id="InsurancePlan.generalCost.type"></a>
InsurancePlan.generalCost.type
Classification of specific cost
Definition: Type of cost.
Cardinality: 0..1
Type: CodeableConcept
<a id="InsurancePlan.generalCost.groupSize"></a>
InsurancePlan.generalCost.groupSize
Number of enrollees
Definition: Number of participants enrolled in the plan.
Cardinality: 0..1
Type: positiveInt
<a id="InsurancePlan.generalCost.cost"></a>
InsurancePlan.generalCost.cost
Cost value
Definition: Value of the cost.
Cardinality: 0..1
Type: Money
<a id="InsurancePlan.generalCost.comment"></a>
InsurancePlan.generalCost.comment
Additional cost information
Definition: Additional information about the general costs associated with this plan.
Cardinality: 0..1
Type: string
<a id="InsurancePlan.specificCost"></a>
InsurancePlan.specificCost
Individual cost elements
Definition: Costs associated with the coverage provided by the product-plan.
Cardinality: 0..*
Type: BackboneElement
<a id="InsurancePlan.specificCost.category"></a>
InsurancePlan.specificCost.category
General category of benefit
Definition: General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).
Cardinality: 1..1
Type: CodeableConcept
<a id="InsurancePlan.specificCost.benefit"></a>
InsurancePlan.specificCost.benefit
Benefits list
Definition: List of the specific benefits under this category of benefit.
Cardinality: 0..*
Type: BackboneElement
<a id="InsurancePlan.specificCost.benefit.type"></a>
InsurancePlan.specificCost.benefit.type
Classification of benefit provided
Definition: Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).
Cardinality: 1..1
Type: CodeableConcept
<a id="InsurancePlan.specificCost.benefit.cost"></a>
InsurancePlan.specificCost.benefit.cost
List of the costs
Definition: List of the costs associated with a specific benefit.
Cardinality: 0..*
Type: BackboneElement
<a id="InsurancePlan.specificCost.benefit.cost.type"></a>
InsurancePlan.specificCost.benefit.cost.type
Classification of specific cost
Definition: Type of cost (copay; individual cap; family cap; coinsurance; deductible).
Cardinality: 1..1
Type: CodeableConcept
<a id="InsurancePlan.specificCost.benefit.cost.applicability"></a>
InsurancePlan.specificCost.benefit.cost.applicability
in-network | out-of-network | other
Definition: Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).
Cardinality: 0..1
Type: CodeableConcept
Binding: required:insuranceplan-applicability
<a id="InsurancePlan.specificCost.benefit.cost.qualifier"></a>
InsurancePlan.specificCost.benefit.cost.qualifier
Additional information about the cost
Definition: Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).
Cardinality: 0..*
Type: CodeableConcept
<a id="InsurancePlan.specificCost.benefit.cost.value"></a>
InsurancePlan.specificCost.benefit.cost.value
The actual cost value
Definition: The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).
Cardinality: 0..1
Type: Quantity