haau3 FHIR Implementation Guide (HFIG)
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haau3 FHIR Implementation Guide (HFIG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example InsurancePlan: Plan Benefits: ACA Marketplace plan 19898FL0340001-01

Profiles: haau3 Insurance Plan (Plan Benefits), http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot

Plan Benefits Source Release

url

release

value: aca-2026-2026-08-10

downloadUrl: https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip

lastModified: 2026-08-10

sha256: 954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2

url

file

downloadUrl: https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip

lastModified: 2026-08-10

sha256: aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682

url

file

downloadUrl: https://download.cms.gov/marketplace-puf/2026/network-puf.zip

lastModified: 2026-08-10

sha256: 3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3

url

file

downloadUrl: https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip

lastModified: 2026-08-10

sha256: eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f

url

file

Plan Benefits Plan Facts

  • metalLevel: Gold
  • csrVariation: Standard Gold On Exchange Plan
  • market: Individual
  • hsaEligible: false
  • effectiveDate: 2026-01-01
  • enrollmentEnd: 2026-12-31
  • outOfServiceAreaCoverage: true
  • outOfServiceAreaDescription: Emergency Only
  • outOfCountryCoverage: true
  • outOfCountryDescription: Emergency Only
  • multipleInNetworkTiers: true
  • deductiblesIntegrated: true
  • maximumIntegrated: true
  • primaryCareVisitsBeforeCostSharing: 0
  • primaryCareCopaysBeforeDeductible: 0
  • inpatientCopayMaxDays: 0

identifier: HIOSPlanId/19898FL0340001-01, HIOSStandardComponentId/19898FL0340001

status: Active

type: Qualified Health Plan

name: AvMed Entrust Gold 125 (2026)

period: 2026 --> 2026

ownedBy: AvMed

coverageArea: Unnamed Location

contact

Data Absent Reason: unknown

purpose: General Questions

contact

purpose: Provider directory

telecom: https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&brandCode=AVMED

contact

purpose: Summary of Benefits and Coverage

telecom: https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf

contact

purpose: Plan brochure

telecom: https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf

contact

purpose: Drug list

telecom: https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf

network: AvMed HIX Network

coverage

type: health insurance plan policy

benefit

type: Primary Care Visit

benefit

type: Specialist Visit

requirement: Referral required: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care.

benefit

type: Urgent Care

benefit

type: Emergency Room Care

benefit

type: Hospital Inpatient Care

benefit

type: Facility Fee

benefit

type: Physician/Surgeon Fees

benefit

type: Imaging (CT/PET/MRI)

benefit

type: Rehabilitation Services

benefit

type: Mental/Behavioral Health Outpatient Services

benefit

type: Emergency Medical Transportation

benefit

type: Skilled Nursing Care

plan

Plan Benefits Additional Benefit

url

category

value: Laboratory Outpatient and Professional Services

Plan Benefits Source Text: $10.00

type: Copayment

applicability: In Network

qualifier: In network, tier 1

qualifier: Counts toward the out-of-pocket maximum

amount: 10 USD (Details: unknown codeUSD = 'United States dollar')

url

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifier: In network, tier 2

qualifier: Counts toward the out-of-pocket maximum

amount:

url

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifier: Does not count toward the out-of-pocket maximum

amount: 100 % (Details: UCUM code% = '%')

url

cost

Plan Benefits Additional Benefit

url

category

value: Other Practitioner Office Visit (Nurse, Physician Assistant)

Plan Benefits Source Text: $35.00

type: Copayment

applicability: In Network

qualifier: In network, tier 1

qualifier: Counts toward the out-of-pocket maximum

amount: 35 USD (Details: unknown codeUSD = 'United States dollar')

url

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifier: In network, tier 2

qualifier: Counts toward the out-of-pocket maximum

amount:

url

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifier: Does not count toward the out-of-pocket maximum

amount: 100 % (Details: UCUM code% = '%')

url

cost

Plan Benefits Additional Benefit

url

category

value: Home Health Care Services

Plan Benefits Source Text: $70.00 Copay after deductible

type: Copayment

applicability: In Network

qualifier: In network, tier 1

qualifier: After deductible

qualifier: Counts toward the out-of-pocket maximum

amount: 70 USD (Details: unknown codeUSD = 'United States dollar')

deductibleApplies: true

url

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifier: In network, tier 2

qualifier: Counts toward the out-of-pocket maximum

amount:

url

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifier: Does not count toward the out-of-pocket maximum

amount: 100 % (Details: UCUM code% = '%')

url

cost

type: HMO

coverageArea: Unnamed Location

generalCost

type: Monthly premium

comment: Depends on age and where you live; not in these files.

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2,000

type: Individual Deductible

Costs

-ValueCurrency
*2000United States dollar

comment: In network tier 1, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2000 per person

type: Family Deductible (per person)

Costs

-ValueCurrency
*2000United States dollar

comment: In network tier 1, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $4000 per group

type: Family Deductible

Costs

-ValueCurrency
*4000United States dollar

comment: In network tier 1, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2,000

type: Individual Deductible

Costs

-ValueCurrency
*2000United States dollar

comment: In network tier 2, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2000 per person

type: Family Deductible (per person)

Costs

-ValueCurrency
*2000United States dollar

comment: In network tier 2, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $4000 per group

type: Family Deductible

Costs

-ValueCurrency
*4000United States dollar

comment: In network tier 2, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Deductible

comment: Out of network, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

type: Family Deductible (per person)

comment: Out of network, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Deductible

comment: Out of network, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Deductible

comment: In and out of network combined, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

type: Family Deductible (per person)

comment: In and out of network combined, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Deductible

comment: In and out of network combined, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5,850

type: Individual Out-of-Pocket Maximum

Costs

-ValueCurrency
*5850United States dollar

comment: In network tier 1, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5850 per person

type: Family Out-of-Pocket Maximum (per person)

Costs

-ValueCurrency
*5850United States dollar

comment: In network tier 1, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $11700 per group

type: Family Out-of-Pocket Maximum

Costs

-ValueCurrency
*11700United States dollar

comment: In network tier 1, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5,850

type: Individual Out-of-Pocket Maximum

Costs

-ValueCurrency
*5850United States dollar

comment: In network tier 2, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5850 per person

type: Family Out-of-Pocket Maximum (per person)

Costs

-ValueCurrency
*5850United States dollar

comment: In network tier 2, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $11700 per group

type: Family Out-of-Pocket Maximum

Costs

-ValueCurrency
*11700United States dollar

comment: In network tier 2, for medical care and drugs

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Out-of-Pocket Maximum

comment: Out of network, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

type: Family Out-of-Pocket Maximum (per person)

comment: Out of network, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Out-of-Pocket Maximum

comment: Out of network, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Out-of-Pocket Maximum

comment: In and out of network combined, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

type: Family Out-of-Pocket Maximum (per person)

comment: In and out of network combined, for medical care and drugs: not stated

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Out-of-Pocket Maximum

comment: In and out of network combined, for medical care and drugs: not stated

specificCost

category: Primary Care Visit

benefit

type: Primary Care Visit

cost

Plan Benefits Source Text: $35.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 35 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Specialist Visit

benefit

type: Specialist Visit

cost

Plan Benefits Source Text: $70.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 70 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Urgent Care

benefit

type: Urgent Care

cost

Plan Benefits Source Text: $125.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 125 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: $250.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value: 250 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: $250.00

type: Copayment

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 250 USD (Details: unknown codeUSD = 'United States dollar')

specificCost

category: Emergency Room Care

benefit

type: Emergency Room Care

cost

Plan Benefits Source Text: $500.00 Copay after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, After deductible, Counts toward the out-of-pocket maximum

value: 500 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: $500.00 Copay after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: Out of Network

qualifiers: After deductible, Does not count toward the out-of-pocket maximum

value: 500 USD (Details: unknown codeUSD = 'United States dollar')

specificCost

category: Hospital Inpatient Care

benefit

type: Hospital Inpatient Care

cost

Plan Benefits Source Text: $850.00 Copay per Stay after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Per stay, After deductible, Counts toward the out-of-pocket maximum

value: 850 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Facility Fee

benefit

type: Facility Fee

cost

Plan Benefits Source Text: $650.00 Copay after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, After deductible, Counts toward the out-of-pocket maximum

value: 650 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: $650.00 Copay after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 2, After deductible, Counts toward the out-of-pocket maximum

value: 650 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Physician/Surgeon Fees

benefit

type: Physician/Surgeon Fees

cost

Plan Benefits Source Text: No Charge after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, After deductible, Counts toward the out-of-pocket maximum

value: 0 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Imaging (CT/PET/MRI)

benefit

type: Imaging (CT/PET/MRI)

cost

Plan Benefits Source Text: $250.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 250 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: $500.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value: 500 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Rehabilitation Services

benefit

org/fhir/us/insurance-card/StructureDefinition/benefit-limitation

  • limitText: Combined limit for all outpatient therapy plus chiropractic.

type: Rehabilitation Services

cost

Plan Benefits Source Text: $70.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 70 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: $70.00 Copay after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 2, After deductible, Counts toward the out-of-pocket maximum

value: 70 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Mental/Behavioral Health Outpatient Services

benefit

org/fhir/us/insurance-card/StructureDefinition/benefit-limitation

  • limitText: The cost sharing applies to outpatient office visits only. All other outpatient services [e.g., Detox, Neuropsychology, Psychological Testing] may be subject to additional cost sharing.

type: Mental/Behavioral Health Outpatient Services

cost

Plan Benefits Source Text: $35.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 35 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

specificCost

category: Emergency Medical Transportation

benefit

type: Emergency Medical Transportation

cost

Plan Benefits Source Text: $200.00

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Counts toward the out-of-pocket maximum

value: 200 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: $200.00

type: Copayment

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 200 USD (Details: unknown codeUSD = 'United States dollar')

specificCost

category: Skilled Nursing Care

benefit

type: Skilled Nursing Care

cost

Plan Benefits Source Text: $250.00 Copay per Day after deductible

org/fhir/us/insurance-card/StructureDefinition/deductible-applies: true

type: Copayment

applicability: In Network

qualifiers: In network, tier 1, Per day, After deductible, Counts toward the out-of-pocket maximum

value: 250 USD (Details: unknown codeUSD = 'United States dollar')

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifiers: In network, tier 2, Counts toward the out-of-pocket maximum

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

qualifiers: Does not count toward the out-of-pocket maximum

value: 100 % (Details: UCUM code% = '%')

Generated Narrative: Organization #issuer

AvMed (Health Insurance Oversight System: HIOSIssuerId#19898)

Generated Narrative: Organization #network

AvMed HIX Network

Generated Narrative: Location #state-FL

Unnamed Location

Form:Jurisdiction
Address:FL