haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
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
{
"resourceType" : "InsurancePlan",
"id" : "19898FL0340001-01",
"meta" : {
"profile" : [
🔗 "https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan",
"http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan 19898FL0340001-01</b></p><a name=\"19898FL0340001-01\"> </a><a name=\"hc19898FL0340001-01\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profiles: <a href=\"StructureDefinition-haau3-insurance-plan.html\">haau3 Insurance Plan (Plan Benefits)</a>, <code>http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot</code></p></div><blockquote><p><b>Plan Benefits Source Release</b></p><blockquote><p><b>url</b></p>release</blockquote><p><b>value</b>: aca-2026-2026-08-10</p><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip\">https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: 954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2</p><blockquote><p><b>url</b></p>file</blockquote><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip\">https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682</p><blockquote><p><b>url</b></p>file</blockquote><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/network-puf.zip\">https://download.cms.gov/marketplace-puf/2026/network-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: 3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3</p><blockquote><p><b>url</b></p>file</blockquote><p><b>downloadUrl</b>: <a href=\"https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip\">https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip</a></p><p><b>lastModified</b>: 2026-08-10</p><p><b>sha256</b>: eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f</p><blockquote><p><b>url</b></p>file</blockquote></blockquote><blockquote><p><b>Plan Benefits Plan Facts</b></p><ul><li>metalLevel: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insuranceplan-plan-type gold}\">Gold</span></li><li>csrVariation: Standard Gold On Exchange Plan</li><li>market: Individual</li><li>hsaEligible: false</li><li>effectiveDate: 2026-01-01</li><li>enrollmentEnd: 2026-12-31</li><li>outOfServiceAreaCoverage: true</li><li>outOfServiceAreaDescription: Emergency Only</li><li>outOfCountryCoverage: true</li><li>outOfCountryDescription: Emergency Only</li><li>multipleInNetworkTiers: true</li><li>deductiblesIntegrated: true</li><li>maximumIntegrated: true</li><li>primaryCareVisitsBeforeCostSharing: 0</li><li>primaryCareCopaysBeforeDeductible: 0</li><li>inpatientCopayMaxDays: 0</li></ul></blockquote><p><b>identifier</b>: <a href=\"NamingSystem-hios-plan-id.html\" title=\"A Marketplace plan's 17-character plan ID in CMS's Health Insurance Oversight System (HIOS): the 14-character standard component ID, a hyphen and a two-digit cost-sharing reduction variant (19898FL0340001-01), as CMS's Plan Attributes public use file writes it (PlanId). haau3 publishes this until CMS or HL7 publishes an identifier system for it.\">HIOSPlanId</a>/19898FL0340001-01, <a href=\"NamingSystem-hios-standard-component-id.html\" title=\"A Marketplace plan's 14-character standard component ID in CMS's Health Insurance Oversight System (HIOS), shared by every cost-sharing reduction variant of the plan (19898FL0340001), as CMS's Plan Attributes public use file writes it (StandardComponentId). haau3 publishes this until CMS or HL7 publishes an identifier system for it.\">HIOSStandardComponentId</a>/19898FL0340001</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insurance-product-type qhp}\">Qualified Health Plan</span></p><p><b>name</b>: AvMed Entrust Gold 125 (2026)</p><p><b>period</b>: 2026 --> 2026</p><p><b>ownedBy</b>: <a href=\"#hc19898FL0340001-01/issuer\">AvMed</a></p><p><b>coverageArea</b>: <a href=\"#hc19898FL0340001-01/state-FL\">Unnamed Location</a></p><blockquote><p><b>contact</b></p><p><b>Data Absent Reason</b>: unknown</p><p><b>purpose</b>: <span title=\"Codes:\">General Questions</span></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Provider directory</span></p><p><b>telecom</b>: <a href=\"https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&brandCode=AVMED\">https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&brandCode=AVMED</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Summary of Benefits and Coverage</span></p><p><b>telecom</b>: <a href=\"https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf\">https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Plan brochure</span></p><p><b>telecom</b>: <a href=\"https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf\">https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf</a></p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Drug list</span></p><p><b>telecom</b>: <a href=\"https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf\">https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf</a></p></blockquote><p><b>network</b>: <a href=\"#hc19898FL0340001-01/network\">AvMed HIX Network</a></p><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Primary Care Visit to Treat an Injury or Illness}\">Primary Care Visit</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Specialist Visit}\">Specialist Visit</span></p><p><b>requirement</b>: Referral required: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care.</p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Urgent Care Centers or Facilities}\">Urgent Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Room Services}\">Emergency Room Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Inpatient Hospital Services (e.g., Hospital Stay)}\">Hospital Inpatient Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Facility Fee (e.g., Ambulatory Surgery Center)}\">Facility Fee</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category physician-surgeon-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Surgery Physician/Surgical Services}\">Physician/Surgeon Fees</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category imaging}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Imaging (CT/PET Scans, MRIs)}\">Imaging (CT/PET/MRI)</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Rehabilitative Occupational and Rehabilitative Physical Therapy}\">Rehabilitation Services</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Mental/Behavioral Health Outpatient Services}\">Mental/Behavioral Health Outpatient Services</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Transportation/Ambulance}\">Emergency Medical Transportation</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Skilled Nursing Facility}\">Skilled Nursing Care</span></p></blockquote></blockquote><blockquote><p><b>plan</b></p><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Laboratory Outpatient and Professional Services}\">Laboratory Outpatient and Professional Services</span></p><p><b>Plan Benefits Source Text</b>: $10.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: 10 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: </p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>amount</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Other Practitioner Office Visit (Nurse, Physician Assistant)}\">Other Practitioner Office Visit (Nurse, Physician Assistant)</span></p><p><b>Plan Benefits Source Text</b>: $35.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: 35 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: </p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>amount</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Home Health Care Services}\">Home Health Care Services</span></p><p><b>Plan Benefits Source Text</b>: $70.00 Copay after deductible</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p><p><b>deductibleApplies</b>: true</p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>amount</b>: </p><blockquote><p><b>url</b></p>cost</blockquote><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>amount</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type HMO}\">HMO</span></p><p><b>coverageArea</b>: <a href=\"#hc19898FL0340001-01/state-FL\">Unnamed Location</a></p><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type monthly-premium}\">Monthly premium</span></p><p><b>comment</b>: Depends on age and where you live; not in these files.</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2,000</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2000 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $4000 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>4000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2,000</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $2000 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>2000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $4000 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>4000</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible (per person)</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Family Deductible</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5,850</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5850 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $11700 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>11700</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 1, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5,850</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $5850 per person</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>5850</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-tier-2\">Plan Benefits Cost Scope: tier-2</a> (In network, tier 2)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: $11700 per group</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>11700</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network tier 2, for medical care and drugs</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum</span></p><p><b>comment</b>: Out of network, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-family-per-person\">Plan Benefits Cost Scope: family-per-person</a> (Family, per person)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per person not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum (per person)</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-family\">Unit Type Codes: family</a> (Family)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical-and-drug\">Plan Benefits Cost Scope: medical-and-drug</a> (Medical and drugs)</li></ul></blockquote><p><b>Plan Benefits Source Text</b>: per group not applicable</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Family Out-of-Pocket Maximum</span></p><p><b>comment</b>: In and out of network combined, for medical care and drugs: not stated</p></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Primary Care Visit to Treat an Injury or Illness}\">Primary Care Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Primary Care Visit to Treat an Injury or Illness}\">Primary Care Visit</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $35.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 35 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Specialist Visit}\">Specialist Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Specialist Visit}\">Specialist Visit</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $70.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Urgent Care Centers or Facilities}\">Urgent Care</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Urgent Care Centers or Facilities}\">Urgent Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $125.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 125 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Room Services}\">Emergency Room Care</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Room Services}\">Emergency Room Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $500.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $500.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Inpatient Hospital Services (e.g., Hospital Stay)}\">Hospital Inpatient Care</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Inpatient Hospital Services (e.g., Hospital Stay)}\">Hospital Inpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $850.00 Copay per Stay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-stay}\">Per stay</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 850 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Facility Fee (e.g., Ambulatory Surgery Center)}\">Facility Fee</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Facility Fee (e.g., Ambulatory Surgery Center)}\">Facility Fee</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $650.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 650 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $650.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 650 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category physician-surgeon-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Surgery Physician/Surgical Services}\">Physician/Surgeon Fees</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category physician-surgeon-fee}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Outpatient Surgery Physician/Surgical Services}\">Physician/Surgeon Fees</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: No Charge after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category imaging}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Imaging (CT/PET Scans, MRIs)}\">Imaging (CT/PET/MRI)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category imaging}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Imaging (CT/PET Scans, MRIs)}\">Imaging (CT/PET/MRI)</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $500.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Rehabilitative Occupational and Rehabilitative Physical Therapy}\">Rehabilitation Services</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>limitText: Combined limit for all outpatient therapy plus chiropractic.</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Rehabilitative Occupational and Rehabilitative Physical Therapy}\">Rehabilitation Services</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $70.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $70.00 Copay after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 70 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Mental/Behavioral Health Outpatient Services}\">Mental/Behavioral Health Outpatient Services</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>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.</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Mental/Behavioral Health Outpatient Services}\">Mental/Behavioral Health Outpatient Services</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $35.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 35 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Transportation/Ambulance}\">Emergency Medical Transportation</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Emergency Transportation/Ambulance}\">Emergency Medical Transportation</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $200.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 200 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $200.00</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 200 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Skilled Nursing Facility}\">Skilled Nursing Care</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name Skilled Nursing Facility}\">Skilled Nursing Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: $250.00 Copay per Day after deductible</p><p><b>org/fhir/us/insurance-card/StructureDefinition/deductible-applies</b>: true</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-1}\">In network, tier 1</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier after-deductible}\">After deductible</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: Not Applicable</p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type not-stated}\">Not stated</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier tier-2}\">In network, tier 2</span>, <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier counts-toward-maximum}\">Counts toward the out-of-pocket maximum</span></p><p><b>value</b>: </p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Source Text</b>: 100.00%</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier excluded-from-maximum}\">Does not count toward the out-of-pocket maximum</span></p><p><b>value</b>: 100 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></blockquote></blockquote></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Organization #issuer</b></p><a name=\"19898FL0340001-01/issuer\"> </a><a name=\"hc19898FL0340001-01/issuer\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">AvMed (Health Insurance Oversight System: HIOSIssuerId#19898)</p><hr/></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Organization #network</b></p><a name=\"19898FL0340001-01/network\"> </a><a name=\"hc19898FL0340001-01/network\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">AvMed HIX Network</p><hr/></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Location #state-FL</b></p><a name=\"19898FL0340001-01/state-FL\"> </a><a name=\"hc19898FL0340001-01/state-FL\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Unnamed Location</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"The physical form of the location (e.g. building, room, vehicle, road)\">Form:</td><td colspan=\"3\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/location-physical-type jdn}\">Jurisdiction</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Physical location\">Address:</td><td colspan=\"3\">FL </td></tr></table></blockquote></div>"
},
"contained" : [
{
"resourceType" : "Organization",
"id" : "issuer",
"identifier" : [
{
"type" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/payor-identifier-types-cs",
"code" : "hios-id",
"display" : "Health Insurance Oversight System"
}
]
},
"system" : "https://haau3.com/fhir/NamingSystem/hios-issuer-id",
"value" : "19898"
}
],
"name" : "AvMed"
},
{
"resourceType" : "Organization",
"id" : "network",
"name" : "AvMed HIX Network"
},
{
"resourceType" : "Location",
"id" : "state-FL",
"address" : {
"state" : "FL"
},
"physicalType" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/location-physical-type",
"code" : "jdn",
"display" : "Jurisdiction"
}
]
}
}
],
"extension" : [
{
"extension" : [
{
"url" : "release",
"valueString" : "aca-2026-2026-08-10"
},
{
"extension" : [
{
"url" : "downloadUrl",
"valueUri" : "https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip"
},
{
"url" : "lastModified",
"valueDate" : "2026-08-10"
},
{
"url" : "sha256",
"valueString" : "954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2"
}
],
"url" : "file"
},
{
"extension" : [
{
"url" : "downloadUrl",
"valueUri" : "https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip"
},
{
"url" : "lastModified",
"valueDate" : "2026-08-10"
},
{
"url" : "sha256",
"valueString" : "aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682"
}
],
"url" : "file"
},
{
"extension" : [
{
"url" : "downloadUrl",
"valueUri" : "https://download.cms.gov/marketplace-puf/2026/network-puf.zip"
},
{
"url" : "lastModified",
"valueDate" : "2026-08-10"
},
{
"url" : "sha256",
"valueString" : "3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3"
}
],
"url" : "file"
},
{
"extension" : [
{
"url" : "downloadUrl",
"valueUri" : "https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip"
},
{
"url" : "lastModified",
"valueDate" : "2026-08-10"
},
{
"url" : "sha256",
"valueString" : "eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f"
}
],
"url" : "file"
}
],
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release"
},
{
"extension" : [
{
"url" : "metalLevel",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/insuranceplan-plan-type",
"code" : "gold",
"display" : "Gold-QHP"
}
],
"text" : "Gold"
}
},
{
"url" : "csrVariation",
"valueString" : "Standard Gold On Exchange Plan"
},
{
"url" : "market",
"valueString" : "Individual"
},
{
"url" : "hsaEligible",
"valueBoolean" : false
},
{
"url" : "effectiveDate",
"valueDate" : "2026-01-01"
},
{
"url" : "enrollmentEnd",
"valueDate" : "2026-12-31"
},
{
"url" : "outOfServiceAreaCoverage",
"valueBoolean" : true
},
{
"url" : "outOfServiceAreaDescription",
"valueString" : "Emergency Only"
},
{
"url" : "outOfCountryCoverage",
"valueBoolean" : true
},
{
"url" : "outOfCountryDescription",
"valueString" : "Emergency Only"
},
{
"url" : "multipleInNetworkTiers",
"valueBoolean" : true
},
{
"url" : "deductiblesIntegrated",
"valueBoolean" : true
},
{
"url" : "maximumIntegrated",
"valueBoolean" : true
},
{
"url" : "primaryCareVisitsBeforeCostSharing",
"valueUnsignedInt" : 0
},
{
"url" : "primaryCareCopaysBeforeDeductible",
"valueUnsignedInt" : 0
},
{
"url" : "inpatientCopayMaxDays",
"valueUnsignedInt" : 0
}
],
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts"
}
],
"identifier" : [
{
"system" : "https://haau3.com/fhir/NamingSystem/hios-plan-id",
"value" : "19898FL0340001-01"
},
{
"system" : "https://haau3.com/fhir/NamingSystem/hios-standard-component-id",
"value" : "19898FL0340001"
}
],
"status" : "active",
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/insurance-product-type",
"code" : "qhp",
"display" : "Qualified Health Plan"
}
]
}
],
"name" : "AvMed Entrust Gold 125 (2026)",
"period" : {
"start" : "2026",
"end" : "2026"
},
"ownedBy" : {
"reference" : "#issuer",
"display" : "AvMed"
},
"coverageArea" : [
{
"reference" : "#state-FL"
}
],
"contact" : [
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode" : "unknown"
}
],
"purpose" : {
"text" : "General Questions"
}
},
{
"purpose" : {
"text" : "Provider directory"
},
"telecom" : [
{
"system" : "url",
"value" : "https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&brandCode=AVMED"
}
]
},
{
"purpose" : {
"text" : "Summary of Benefits and Coverage"
},
"telecom" : [
{
"system" : "url",
"value" : "https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf"
}
]
},
{
"purpose" : {
"text" : "Plan brochure"
},
"telecom" : [
{
"system" : "url",
"value" : "https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf"
}
]
},
{
"purpose" : {
"text" : "Drug list"
},
"telecom" : [
{
"system" : "url",
"value" : "https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf"
}
]
}
],
"network" : [
{
"reference" : "#network",
"display" : "AvMed HIX Network"
}
],
"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" : "primary-care-visit",
"display" : "Primary Care Visit"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Primary Care Visit to Treat an Injury or Illness",
"display" : "Primary Care Visit to Treat an Injury or Illness"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "specialist-visit",
"display" : "Specialist Visit"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Specialist Visit",
"display" : "Specialist Visit"
}
]
},
"requirement" : "Referral required: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care."
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "urgent-care",
"display" : "Urgent Care"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Urgent Care Centers or Facilities",
"display" : "Urgent Care Centers or Facilities"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "emergency-room-care",
"display" : "Emergency Room Care"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Emergency Room Services",
"display" : "Emergency Room Services"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "hospital-inpatient",
"display" : "Hospital Inpatient Care"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Inpatient Hospital Services (e.g., Hospital Stay)",
"display" : "Inpatient Hospital Services (e.g., Hospital Stay)"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "facility-fee",
"display" : "Facility Fee"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)",
"display" : "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "physician-surgeon-fee",
"display" : "Physician/Surgeon Fees"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Outpatient Surgery Physician/Surgical Services",
"display" : "Outpatient Surgery Physician/Surgical Services"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "imaging",
"display" : "Imaging (CT/PET/MRI)"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Imaging (CT/PET Scans, MRIs)",
"display" : "Imaging (CT/PET Scans, MRIs)"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "rehabilitation",
"display" : "Rehabilitation Services"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Rehabilitative Occupational and Rehabilitative Physical Therapy",
"display" : "Rehabilitative Occupational and Rehabilitative Physical Therapy"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "mental-health-outpatient",
"display" : "Mental/Behavioral Health Outpatient Services"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Mental/Behavioral Health Outpatient Services",
"display" : "Mental/Behavioral Health Outpatient Services"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "emergency-medical-transport",
"display" : "Emergency Medical Transportation"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Emergency Transportation/Ambulance",
"display" : "Emergency Transportation/Ambulance"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
"code" : "skilled-nursing",
"display" : "Skilled Nursing Care"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Skilled Nursing Facility",
"display" : "Skilled Nursing Facility"
}
]
}
}
]
}
],
"plan" : [
{
"extension" : [
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Laboratory Outpatient and Professional Services",
"display" : "Laboratory Outpatient and Professional Services"
}
]
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$10.00"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
}
],
"text" : "Copayment"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "in-network",
"display" : "In Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-1",
"display" : "In network, tier 1"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"value" : 10,
"unit" : "USD",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
}
],
"url" : "cost"
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
"code" : "not-stated",
"display" : "Not stated"
}
],
"text" : "Not stated"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "in-network",
"display" : "In Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-2",
"display" : "In network, tier 2"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode" : "unknown"
}
]
}
}
],
"url" : "cost"
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay-percent",
"display" : "Copayment Percent per service"
}
],
"text" : "Coinsurance"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "out-of-network",
"display" : "Out of Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "excluded-from-maximum",
"display" : "Does not count toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"value" : 100,
"unit" : "%",
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
],
"url" : "cost"
}
],
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit"
},
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Other Practitioner Office Visit (Nurse, Physician Assistant)",
"display" : "Other Practitioner Office Visit (Nurse, Physician Assistant)"
}
]
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$35.00"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
}
],
"text" : "Copayment"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "in-network",
"display" : "In Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-1",
"display" : "In network, tier 1"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"value" : 35,
"unit" : "USD",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
}
],
"url" : "cost"
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
"code" : "not-stated",
"display" : "Not stated"
}
],
"text" : "Not stated"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "in-network",
"display" : "In Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-2",
"display" : "In network, tier 2"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode" : "unknown"
}
]
}
}
],
"url" : "cost"
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay-percent",
"display" : "Copayment Percent per service"
}
],
"text" : "Coinsurance"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "out-of-network",
"display" : "Out of Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "excluded-from-maximum",
"display" : "Does not count toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"value" : 100,
"unit" : "%",
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
],
"url" : "cost"
}
],
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit"
},
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Home Health Care Services",
"display" : "Home Health Care Services"
}
]
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$70.00 Copay after deductible"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
}
],
"text" : "Copayment"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "in-network",
"display" : "In Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-1",
"display" : "In network, tier 1"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "after-deductible",
"display" : "After deductible"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"value" : 70,
"unit" : "USD",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"url" : "deductibleApplies",
"valueBoolean" : true
}
],
"url" : "cost"
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
"code" : "not-stated",
"display" : "Not stated"
}
],
"text" : "Not stated"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "in-network",
"display" : "In Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-2",
"display" : "In network, tier 2"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
"valueCode" : "unknown"
}
]
}
}
],
"url" : "cost"
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
},
{
"url" : "type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay-percent",
"display" : "Copayment Percent per service"
}
],
"text" : "Coinsurance"
}
},
{
"url" : "applicability",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
"code" : "out-of-network",
"display" : "Out of Network"
}
]
}
},
{
"url" : "qualifier",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "excluded-from-maximum",
"display" : "Does not count toward the out-of-pocket maximum"
}
]
}
},
{
"url" : "amount",
"valueQuantity" : {
"value" : 100,
"unit" : "%",
"system" : "http://unitsofmeasure.org",
"code" : "%"
}
}
],
"url" : "cost"
}
],
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit"
}
],
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type",
"code" : "HMO",
"display" : "Health Maintenance Organization (HMO)"
}
],
"text" : "HMO"
},
"coverageArea" : [
{
"reference" : "#state-FL"
}
],
"generalCost" : [
{
"type" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type",
"code" : "monthly-premium",
"display" : "Monthly premium"
}
],
"text" : "Monthly premium"
},
"comment" : "Depends on age and where you live; not in these files."
},
{
"extension" : [
{
"extension" : [
{
"url" : "network",
"valueCoding" : {
"system" : "http://terminology.hl7.org/CodeSystem/benefit-network",
"code" : "in",
"display" : "In Network"
}
},
{
"url" : "member",
"valueCoding" : {
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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{
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{
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
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],
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"comment" : "Out of network, for medical care and drugs: not stated"
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{
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{
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{
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"code" : "medical-and-drug",
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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{
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{
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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"comment" : "Out of network, for medical care and drugs: not stated"
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{
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{
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{
"url" : "network",
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{
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
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{
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{
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{
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{
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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{
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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{
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{
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{
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{
"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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}
],
"value" : {
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}
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{
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{
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"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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],
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"display" : "Not stated"
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"coding" : [
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{
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]
}
],
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}
},
{
"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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}
],
"value" : {
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}
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}
]
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{
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{
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{
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]
},
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"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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"coding" : [
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},
{
"coding" : [
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}
],
"value" : {
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}
]
}
]
},
{
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{
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]
},
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{
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},
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
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}
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{
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
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{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
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"display" : "Not stated"
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"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
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}
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{
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{
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"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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{
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]
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{
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]
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "No Charge after deductible"
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"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
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]
}
],
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{
"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
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"coding" : [
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"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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]
}
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{
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]
},
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{
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]
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"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$250.00"
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],
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"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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"coding" : [
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"extension" : [
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"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
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"coding" : [
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{
"coding" : [
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"code" : "counts-toward-maximum",
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]
}
],
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}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
}
],
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay-percent",
"display" : "Copayment Percent per service"
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"coding" : [
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"display" : "Does not count toward the out-of-pocket maximum"
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]
}
],
"value" : {
"value" : 100,
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"system" : "http://unitsofmeasure.org",
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}
]
}
]
},
{
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{
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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]
},
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{
"extension" : [
{
"extension" : [
{
"url" : "limitText",
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],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
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"coding" : [
{
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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]
},
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{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$70.00"
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
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],
"text" : "Copayment"
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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"display" : "In Network"
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},
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-1",
"display" : "In network, tier 1"
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},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
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]
}
],
"value" : {
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"system" : "urn:iso:std:iso:4217",
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}
},
{
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{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$70.00 Copay after deductible"
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{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
"valueBoolean" : true
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
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"text" : "Copayment"
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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},
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "tier-2",
"display" : "In network, tier 2"
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]
},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "after-deductible",
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},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
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]
}
],
"value" : {
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"unit" : "USD",
"system" : "urn:iso:std:iso:4217",
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}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
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],
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay-percent",
"display" : "Copayment Percent per service"
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],
"text" : "Coinsurance"
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"coding" : [
{
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "excluded-from-maximum",
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]
}
],
"value" : {
"value" : 100,
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"system" : "http://unitsofmeasure.org",
"code" : "%"
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}
]
}
]
},
{
"category" : {
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{
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Mental/Behavioral Health Outpatient Services",
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]
},
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{
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{
"extension" : [
{
"url" : "limitText",
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],
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation"
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],
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{
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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]
},
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{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$35.00"
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],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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"display" : "Copayment per service"
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"coding" : [
{
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},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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]
}
],
"value" : {
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"system" : "urn:iso:std:iso:4217",
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}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
}
],
"type" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
"code" : "not-stated",
"display" : "Not stated"
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],
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"coding" : [
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"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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},
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
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]
}
],
"value" : {
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{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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]
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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"display" : "Copayment Percent per service"
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],
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},
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{
"coding" : [
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"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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]
}
],
"value" : {
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"system" : "http://unitsofmeasure.org",
"code" : "%"
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}
]
}
]
},
{
"category" : {
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{
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Emergency Transportation/Ambulance",
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]
},
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{
"type" : {
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{
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"display" : "Emergency Medical Transportation"
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
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]
},
"cost" : [
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$200.00"
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
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"display" : "Copayment per service"
}
],
"text" : "Copayment"
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{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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]
},
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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]
},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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]
}
],
"value" : {
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"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
}
],
"type" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
"code" : "not-stated",
"display" : "Not stated"
}
],
"text" : "Not stated"
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"coding" : [
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"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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"display" : "In Network"
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]
},
"qualifiers" : [
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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"display" : "In network, tier 2"
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]
},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
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]
}
],
"value" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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]
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$200.00"
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
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],
"text" : "Copayment"
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "excluded-from-maximum",
"display" : "Does not count toward the out-of-pocket maximum"
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]
}
],
"value" : {
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"unit" : "USD",
"system" : "urn:iso:std:iso:4217",
"code" : "USD"
}
}
]
}
]
},
{
"category" : {
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{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Skilled Nursing Facility",
"display" : "Skilled Nursing Facility"
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]
},
"benefit" : [
{
"type" : {
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{
"system" : "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category",
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"display" : "Skilled Nursing Care"
},
{
"system" : "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name",
"code" : "Skilled Nursing Facility",
"display" : "Skilled Nursing Facility"
}
]
},
"cost" : [
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "$250.00 Copay per Day after deductible"
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{
"url" : "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies",
"valueBoolean" : true
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay",
"display" : "Copayment per service"
}
],
"text" : "Copayment"
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"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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]
},
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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"display" : "In network, tier 1"
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]
},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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]
},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
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]
}
],
"value" : {
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"unit" : "USD",
"system" : "urn:iso:std:iso:4217",
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}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "Not Applicable"
}
],
"type" : {
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type",
"code" : "not-stated",
"display" : "Not stated"
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"text" : "Not stated"
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"applicability" : {
"coding" : [
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"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
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"display" : "In network, tier 2"
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},
{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "counts-toward-maximum",
"display" : "Counts toward the out-of-pocket maximum"
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]
}
],
"value" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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]
}
},
{
"extension" : [
{
"url" : "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text",
"valueString" : "100.00%"
}
],
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/benefit-type",
"code" : "copay-percent",
"display" : "Copayment Percent per service"
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],
"text" : "Coinsurance"
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"applicability" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/applicability",
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]
},
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{
"coding" : [
{
"system" : "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier",
"code" : "excluded-from-maximum",
"display" : "Does not count toward the out-of-pocket maximum"
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]
}
],
"value" : {
"value" : 100,
"unit" : "%",
"system" : "http://unitsofmeasure.org",
"code" : "%"
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}
]
}
]
}
]
}
]
}