@prefix fhir: . @prefix owl: . @prefix rdfs: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:InsurancePlan ; fhir:nodeRole fhir:treeRoot ; fhir:Resource.id [ fhir:value "19898FL0340001-01"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan" ; fhir:index 0 ; fhir:link ], [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot" ; fhir:index 1 ; fhir:link ] ] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "extensions" ] ; fhir:Narrative.div "

Generated Narrative: InsurancePlan 19898FL0340001-01

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

Plan Benefits Source Release

url

release

value: aca-2026-2026-08-10

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

lastModified: 2026-08-10

sha256: 954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2

url

file

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

lastModified: 2026-08-10

sha256: aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682

url

file

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

lastModified: 2026-08-10

sha256: 3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3

url

file

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

lastModified: 2026-08-10

sha256: eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f

url

file

Plan Benefits Plan Facts

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

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

status: Active

type: Qualified Health Plan

name: AvMed Entrust Gold 125 (2026)

period: 2026 --> 2026

ownedBy: AvMed

coverageArea: Unnamed Location

contact

Data Absent Reason: unknown

purpose: General Questions

contact

purpose: Provider directory

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

contact

purpose: Summary of Benefits and Coverage

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

contact

purpose: Plan brochure

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

contact

purpose: Drug list

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

network: AvMed HIX Network

coverage

type: health insurance plan policy

benefit

type: Primary Care Visit

benefit

type: Specialist Visit

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

benefit

type: Urgent Care

benefit

type: Emergency Room Care

benefit

type: Hospital Inpatient Care

benefit

type: Facility Fee

benefit

type: Physician/Surgeon Fees

benefit

type: Imaging (CT/PET/MRI)

benefit

type: Rehabilitation Services

benefit

type: Mental/Behavioral Health Outpatient Services

benefit

type: Emergency Medical Transportation

benefit

type: Skilled Nursing Care

plan

Plan Benefits Additional Benefit

url

category

value: Laboratory Outpatient and Professional Services

Plan Benefits Source Text: $10.00

type: Copayment

applicability: In Network

qualifier: In network, tier 1

qualifier: Counts toward the out-of-pocket maximum

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

url

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifier: In network, tier 2

qualifier: Counts toward the out-of-pocket maximum

amount:

url

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

url

cost

Plan Benefits Additional Benefit

url

category

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

Plan Benefits Source Text: $35.00

type: Copayment

applicability: In Network

qualifier: In network, tier 1

qualifier: Counts toward the out-of-pocket maximum

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

url

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifier: In network, tier 2

qualifier: Counts toward the out-of-pocket maximum

amount:

url

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

url

cost

Plan Benefits Additional Benefit

url

category

value: Home Health Care Services

Plan Benefits Source Text: $70.00 Copay after deductible

type: Copayment

applicability: In Network

qualifier: In network, tier 1

qualifier: After deductible

qualifier: Counts toward the out-of-pocket maximum

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

deductibleApplies: true

url

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

qualifier: In network, tier 2

qualifier: Counts toward the out-of-pocket maximum

amount:

url

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

url

cost

type: HMO

coverageArea: Unnamed Location

generalCost

type: Monthly premium

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2,000

type: Individual Deductible

Costs

-ValueCurrency
*2000United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2000 per person

type: Family Deductible (per person)

Costs

-ValueCurrency
*2000United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $4000 per group

type: Family Deductible

Costs

-ValueCurrency
*4000United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2,000

type: Individual Deductible

Costs

-ValueCurrency
*2000United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $2000 per person

type: Family Deductible (per person)

Costs

-ValueCurrency
*2000United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $4000 per group

type: Family Deductible

Costs

-ValueCurrency
*4000United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Deductible

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

type: Family Deductible (per person)

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Deductible

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Deductible

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

type: Family Deductible (per person)

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Deductible

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5,850

type: Individual Out-of-Pocket Maximum

Costs

-ValueCurrency
*5850United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5850 per person

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

Costs

-ValueCurrency
*5850United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $11700 per group

type: Family Out-of-Pocket Maximum

Costs

-ValueCurrency
*11700United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5,850

type: Individual Out-of-Pocket Maximum

Costs

-ValueCurrency
*5850United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $5850 per person

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

Costs

-ValueCurrency
*5850United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: $11700 per group

type: Family Out-of-Pocket Maximum

Costs

-ValueCurrency
*11700United States dollar

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Out-of-Pocket Maximum

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

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

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Out-of-Pocket Maximum

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: Not Applicable

type: Individual Out-of-Pocket Maximum

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per person not applicable

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

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

generalCost

Plan Benefits Cost Scope

Plan Benefits Source Text: per group not applicable

type: Family Out-of-Pocket Maximum

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

specificCost

category: Primary Care Visit

benefit

type: Primary Care Visit

cost

Plan Benefits Source Text: $35.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Specialist Visit

benefit

type: Specialist Visit

cost

Plan Benefits Source Text: $70.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Urgent Care

benefit

type: Urgent Care

cost

Plan Benefits Source Text: $125.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: $250.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: $250.00

type: Copayment

applicability: Out of Network

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

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

specificCost

category: Emergency Room Care

benefit

type: Emergency Room Care

cost

Plan Benefits Source Text: $500.00 Copay after deductible

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: $500.00 Copay after deductible

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

type: Copayment

applicability: Out of Network

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

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

specificCost

category: Hospital Inpatient Care

benefit

type: Hospital Inpatient Care

cost

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

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Facility Fee

benefit

type: Facility Fee

cost

Plan Benefits Source Text: $650.00 Copay after deductible

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: $650.00 Copay after deductible

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Physician/Surgeon Fees

benefit

type: Physician/Surgeon Fees

cost

Plan Benefits Source Text: No Charge after deductible

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Imaging (CT/PET/MRI)

benefit

type: Imaging (CT/PET/MRI)

cost

Plan Benefits Source Text: $250.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: $500.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Rehabilitation Services

benefit

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

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

type: Rehabilitation Services

cost

Plan Benefits Source Text: $70.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: $70.00 Copay after deductible

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Mental/Behavioral Health Outpatient Services

benefit

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

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

type: Mental/Behavioral Health Outpatient Services

cost

Plan Benefits Source Text: $35.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

specificCost

category: Emergency Medical Transportation

benefit

type: Emergency Medical Transportation

cost

Plan Benefits Source Text: $200.00

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: $200.00

type: Copayment

applicability: Out of Network

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

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

specificCost

category: Skilled Nursing Care

benefit

type: Skilled Nursing Care

cost

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

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

type: Copayment

applicability: In Network

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

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

cost

Plan Benefits Source Text: Not Applicable

type: Not stated

applicability: In Network

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

value:

cost

Plan Benefits Source Text: 100.00%

type: Coinsurance

applicability: Out of Network

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

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

Generated Narrative: Organization #issuer

AvMed (Health Insurance Oversight System: HIOSIssuerId#19898)

Generated Narrative: Organization #network

AvMed HIX Network

Generated Narrative: Location #state-FL

Unnamed Location

Form:Jurisdiction
Address:FL
" ] ; fhir:DomainResource.contained [ a fhir:Organization ; fhir:index 0 ; fhir:Resource.id [ fhir:value "issuer" ] ; fhir:Organization.identifier [ fhir:index 0 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/payor-identifier-types-cs" ] ; fhir:Coding.code [ fhir:value "hios-id" ] ; fhir:Coding.display [ fhir:value "Health Insurance Oversight System" ] ] ] ; fhir:Identifier.system [ fhir:value "https://haau3.com/fhir/NamingSystem/hios-issuer-id" ] ; fhir:Identifier.value [ fhir:value "19898" ] ] ; fhir:Organization.name [ fhir:value "AvMed" ] ], [ a fhir:Organization ; fhir:index 1 ; fhir:Resource.id [ fhir:value "network" ] ; fhir:Organization.name [ fhir:value "AvMed HIX Network" ] ], [ a fhir:Location ; fhir:index 2 ; fhir:Resource.id [ fhir:value "state-FL" ] ; fhir:Location.address [ fhir:Address.state [ fhir:value "FL" ] ] ; fhir:Location.physicalType [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/location-physical-type" ] ; fhir:Coding.code [ fhir:value "jdn" ] ; fhir:Coding.display [ fhir:value "Jurisdiction" ] ] ] ] ; fhir:DomainResource.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "release" ] ; fhir:Extension.valueString [ fhir:value "aca-2026-2026-08-10" ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "downloadUrl" ] ; fhir:Extension.valueUri [ fhir:value "https://download.cms.gov/marketplace-puf/2026/plan-attributes-puf.zip" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "lastModified" ] ; fhir:Extension.valueDate [ fhir:value "2026-08-10"^^xsd:date ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "sha256" ] ; fhir:Extension.valueString [ fhir:value "954e697885efcb709aed0be1de14075afe11704bf3447372960d08c879950af2" ] ] ; fhir:Extension.url [ fhir:value "file" ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "downloadUrl" ] ; fhir:Extension.valueUri [ fhir:value "https://download.cms.gov/marketplace-puf/2026/benefits-and-cost-sharing-puf.zip" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "lastModified" ] ; fhir:Extension.valueDate [ fhir:value "2026-08-10"^^xsd:date ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "sha256" ] ; fhir:Extension.valueString [ fhir:value "aa2d6874704bc951ed28792af3e65a4bd5b48eb3dbc086325f5ce053f08d8682" ] ] ; fhir:Extension.url [ fhir:value "file" ] ], [ fhir:index 3 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "downloadUrl" ] ; fhir:Extension.valueUri [ fhir:value "https://download.cms.gov/marketplace-puf/2026/network-puf.zip" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "lastModified" ] ; fhir:Extension.valueDate [ fhir:value "2026-08-10"^^xsd:date ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "sha256" ] ; fhir:Extension.valueString [ fhir:value "3d06ea11631c49efa7f7ae687a163d4a8d4b80ffc81dee8199cdf1d73f13a9f3" ] ] ; fhir:Extension.url [ fhir:value "file" ] ], [ fhir:index 4 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "downloadUrl" ] ; fhir:Extension.valueUri [ fhir:value "https://download.cms.gov/marketplace-puf/2026/service-area-puf.zip" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "lastModified" ] ; fhir:Extension.valueDate [ fhir:value "2026-08-10"^^xsd:date ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "sha256" ] ; fhir:Extension.valueString [ fhir:value "eb2d7d18b6c4b9a6124e7841862c5f51384511840791ac30a72f98a248b7817f" ] ] ; fhir:Extension.url [ fhir:value "file" ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release" ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "metalLevel" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/insuranceplan-plan-type" ] ; fhir:Coding.code [ fhir:value "gold" ] ; fhir:Coding.display [ fhir:value "Gold-QHP" ] ] ; fhir:CodeableConcept.text [ fhir:value "Gold" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "csrVariation" ] ; fhir:Extension.valueString [ fhir:value "Standard Gold On Exchange Plan" ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "market" ] ; fhir:Extension.valueString [ fhir:value "Individual" ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "hsaEligible" ] ; fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "effectiveDate" ] ; fhir:Extension.valueDate [ fhir:value "2026-01-01"^^xsd:date ] ], [ fhir:index 5 ; fhir:Extension.url [ fhir:value "enrollmentEnd" ] ; fhir:Extension.valueDate [ fhir:value "2026-12-31"^^xsd:date ] ], [ fhir:index 6 ; fhir:Extension.url [ fhir:value "outOfServiceAreaCoverage" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index 7 ; fhir:Extension.url [ fhir:value "outOfServiceAreaDescription" ] ; fhir:Extension.valueString [ fhir:value "Emergency Only" ] ], [ fhir:index 8 ; fhir:Extension.url [ fhir:value "outOfCountryCoverage" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index 9 ; fhir:Extension.url [ fhir:value "outOfCountryDescription" ] ; fhir:Extension.valueString [ fhir:value "Emergency Only" ] ], [ fhir:index 10 ; fhir:Extension.url [ fhir:value "multipleInNetworkTiers" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index 11 ; fhir:Extension.url [ fhir:value "deductiblesIntegrated" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index 12 ; fhir:Extension.url [ fhir:value "maximumIntegrated" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ], [ fhir:index 13 ; fhir:Extension.url [ fhir:value "primaryCareVisitsBeforeCostSharing" ] ; fhir:Extension.valueUnsignedInt [ fhir:value "0"^^xsd:nonNegativeInteger ] ], [ fhir:index 14 ; fhir:Extension.url [ fhir:value "primaryCareCopaysBeforeDeductible" ] ; fhir:Extension.valueUnsignedInt [ fhir:value "0"^^xsd:nonNegativeInteger ] ], [ fhir:index 15 ; fhir:Extension.url [ fhir:value "inpatientCopayMaxDays" ] ; fhir:Extension.valueUnsignedInt [ fhir:value "0"^^xsd:nonNegativeInteger ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts" ] ] ; fhir:InsurancePlan.identifier [ fhir:index 0 ; fhir:Identifier.system [ fhir:value "https://haau3.com/fhir/NamingSystem/hios-plan-id" ] ; fhir:Identifier.value [ fhir:value "19898FL0340001-01" ] ], [ fhir:index 1 ; fhir:Identifier.system [ fhir:value "https://haau3.com/fhir/NamingSystem/hios-standard-component-id" ] ; fhir:Identifier.value [ fhir:value "19898FL0340001" ] ] ; fhir:InsurancePlan.status [ fhir:value "active"] ; fhir:InsurancePlan.type [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/insurance-product-type" ] ; fhir:Coding.code [ fhir:value "qhp" ] ; fhir:Coding.display [ fhir:value "Qualified Health Plan" ] ] ] ; fhir:InsurancePlan.name [ fhir:value "AvMed Entrust Gold 125 (2026)"] ; fhir:InsurancePlan.period [ fhir:Period.start [ fhir:value "2026"^^xsd:gYear ] ; fhir:Period.end [ fhir:value "2026"^^xsd:gYear ] ] ; fhir:InsurancePlan.ownedBy [ fhir:Reference.reference [ fhir:value "#issuer" ] ; fhir:Reference.display [ fhir:value "AvMed" ] ] ; fhir:InsurancePlan.coverageArea [ fhir:index 0 ; fhir:Reference.reference [ fhir:value "#state-FL" ] ] ; fhir:InsurancePlan.contact [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.text [ fhir:value "General Questions" ] ] ], [ fhir:index 1 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.text [ fhir:value "Provider directory" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index 0 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "https://avmed.healthsparq.com/healthsparq/public/#/one/insurerCode=AVMED_I&brandCode=AVMED" ] ] ], [ fhir:index 2 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.text [ fhir:value "Summary of Benefits and Coverage" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index 0 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "https://apps.avmed.com/Public/OHBRFileManager/DownloadFile.aspx?filePath=%2Fpresales%2FAvMed%2F2026%2FSBC%2FIFP%2FAVINHG16510101260625.pdf" ] ] ], [ fhir:index 3 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.text [ fhir:value "Plan brochure" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index 0 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Avmed-Buyers-Guide-pdf" ] ] ], [ fhir:index 4 ; fhir:InsurancePlan.contact.purpose [ fhir:CodeableConcept.text [ fhir:value "Drug list" ] ] ; fhir:InsurancePlan.contact.telecom [ fhir:index 0 ; fhir:ContactPoint.system [ fhir:value "url" ] ; fhir:ContactPoint.value [ fhir:value "https://shc-p-001.sitecorecontenthub.cloud/api/public/content/2026-Individual-and-Family-Plan-Formulary-Non-Standard-pdf" ] ] ] ; fhir:InsurancePlan.network [ fhir:index 0 ; fhir:Reference.reference [ fhir:value "#network" ] ; fhir:Reference.display [ fhir:value "AvMed HIX Network" ] ] ; fhir:InsurancePlan.coverage [ fhir:index 0 ; fhir:InsurancePlan.coverage.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ] ; fhir:Coding.code [ fhir:value "HIP" ] ; fhir:Coding.display [ fhir:value "health insurance plan policy" ] ] ] ; fhir:InsurancePlan.coverage.benefit [ fhir:index 0 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "primary-care-visit" ] ; fhir:Coding.display [ fhir:value "Primary Care Visit" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Primary Care Visit to Treat an Injury or Illness" ] ; fhir:Coding.display [ fhir:value "Primary Care Visit to Treat an Injury or Illness" ] ] ] ], [ fhir:index 1 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "specialist-visit" ] ; fhir:Coding.display [ fhir:value "Specialist Visit" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Specialist Visit" ] ; fhir:Coding.display [ fhir:value "Specialist Visit" ] ] ] ; fhir:InsurancePlan.coverage.benefit.requirement [ fhir:value "Referral required: All except OB/Gyn, Chiropractor, and Podiatrist for diabetic foot care." ] ], [ fhir:index 2 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "urgent-care" ] ; fhir:Coding.display [ fhir:value "Urgent Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Urgent Care Centers or Facilities" ] ; fhir:Coding.display [ fhir:value "Urgent Care Centers or Facilities" ] ] ] ], [ fhir:index 3 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "emergency-room-care" ] ; fhir:Coding.display [ fhir:value "Emergency Room Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Emergency Room Services" ] ; fhir:Coding.display [ fhir:value "Emergency Room Services" ] ] ] ], [ fhir:index 4 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "hospital-inpatient" ] ; fhir:Coding.display [ fhir:value "Hospital Inpatient Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Inpatient Hospital Services (e.g., Hospital Stay)" ] ; fhir:Coding.display [ fhir:value "Inpatient Hospital Services (e.g., Hospital Stay)" ] ] ] ], [ fhir:index 5 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "facility-fee" ] ; fhir:Coding.display [ fhir:value "Facility Fee" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)" ] ; fhir:Coding.display [ fhir:value "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)" ] ] ] ], [ fhir:index 6 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "physician-surgeon-fee" ] ; fhir:Coding.display [ fhir:value "Physician/Surgeon Fees" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Outpatient Surgery Physician/Surgical Services" ] ; fhir:Coding.display [ fhir:value "Outpatient Surgery Physician/Surgical Services" ] ] ] ], [ fhir:index 7 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "imaging" ] ; fhir:Coding.display [ fhir:value "Imaging (CT/PET/MRI)" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Imaging (CT/PET Scans, MRIs)" ] ; fhir:Coding.display [ fhir:value "Imaging (CT/PET Scans, MRIs)" ] ] ] ], [ fhir:index 8 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "rehabilitation" ] ; fhir:Coding.display [ fhir:value "Rehabilitation Services" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Rehabilitative Occupational and Rehabilitative Physical Therapy" ] ; fhir:Coding.display [ fhir:value "Rehabilitative Occupational and Rehabilitative Physical Therapy" ] ] ] ], [ fhir:index 9 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "mental-health-outpatient" ] ; fhir:Coding.display [ fhir:value "Mental/Behavioral Health Outpatient Services" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Mental/Behavioral Health Outpatient Services" ] ; fhir:Coding.display [ fhir:value "Mental/Behavioral Health Outpatient Services" ] ] ] ], [ fhir:index 10 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "emergency-medical-transport" ] ; fhir:Coding.display [ fhir:value "Emergency Medical Transportation" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Emergency Transportation/Ambulance" ] ; fhir:Coding.display [ fhir:value "Emergency Transportation/Ambulance" ] ] ] ], [ fhir:index 11 ; fhir:InsurancePlan.coverage.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "skilled-nursing" ] ; fhir:Coding.display [ fhir:value "Skilled Nursing Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Skilled Nursing Facility" ] ; fhir:Coding.display [ fhir:value "Skilled Nursing Facility" ] ] ] ] ] ; fhir:InsurancePlan.plan [ fhir:index 0 ; 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fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; 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fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ; fhir:Extension.url [ fhir:value "cost" ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit" ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "category" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Other Practitioner Office Visit (Nurse, Physician Assistant)" ] ; fhir:Coding.display [ fhir:value "Other Practitioner Office Visit (Nurse, Physician Assistant)" ] ] ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$35.00" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 5 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Quantity.value [ fhir:value "35"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ] ; fhir:Extension.url [ fhir:value "cost" ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "Not Applicable" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type" ] ; fhir:Coding.code [ fhir:value "not-stated" ] ; fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 5 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ] ; fhir:Extension.url [ fhir:value "cost" ] ], [ fhir:index 3 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ; fhir:Extension.url [ fhir:value "cost" ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit" ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "category" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Home Health Care Services" ] ; fhir:Coding.display [ fhir:value "Home Health Care Services" ] ] ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$70.00 Copay after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ] ], [ fhir:index 5 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 6 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 7 ; fhir:Extension.url [ fhir:value "deductibleApplies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:Extension.url [ fhir:value "cost" ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "Not Applicable" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type" ] ; fhir:Coding.code [ fhir:value "not-stated" ] ; fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 5 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ] ; fhir:Extension.url [ fhir:value "cost" ] ], [ fhir:index 3 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "type" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "applicability" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ], [ fhir:index 3 ; fhir:Extension.url [ fhir:value "qualifier" ] ; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ], [ fhir:index 4 ; fhir:Extension.url [ fhir:value "amount" ] ; fhir:Extension.valueQuantity [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ; fhir:Extension.url [ fhir:value "cost" ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit" ] ] ; fhir:InsurancePlan.plan.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type" ] ; fhir:Coding.code [ fhir:value "HMO" ] ; fhir:Coding.display [ fhir:value "Health Maintenance Organization (HMO)" ] ] ; fhir:CodeableConcept.text [ fhir:value "HMO" ] ] ; fhir:InsurancePlan.plan.coverageArea [ fhir:index 0 ; fhir:Reference.reference [ fhir:value "#state-FL" ] ] ; fhir:InsurancePlan.plan.generalCost [ fhir:index 0 ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type" ] ; fhir:Coding.code [ fhir:value "monthly-premium" ] ; fhir:Coding.display [ fhir:value "Monthly premium" ] ] ; fhir:CodeableConcept.text [ fhir:value "Monthly premium" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "Depends on age and where you live; not in these files." ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; fhir:Coding.code [ fhir:value "in" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "individual" ] ; fhir:Coding.display [ fhir:value "Individual" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "medical-and-drug" ] ; fhir:Coding.display [ fhir:value "Medical and drugs" ] ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$2,000" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "deductible" ] ; fhir:Coding.display [ fhir:value "Deductible" ] ] ; fhir:CodeableConcept.text [ fhir:value "Individual Deductible" ] ] ; fhir:InsurancePlan.plan.generalCost.cost [ fhir:Money.value [ fhir:value "2000"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In network tier 1, for medical care and drugs" ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; fhir:Coding.code [ fhir:value "in" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "family-per-person" ] ; fhir:Coding.display [ fhir:value "Family, per person" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "medical-and-drug" ] ; fhir:Coding.display [ fhir:value "Medical and drugs" ] ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$2000 per person" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "deductible" ] ; fhir:Coding.display [ fhir:value "Deductible" ] ] ; fhir:CodeableConcept.text [ fhir:value "Family Deductible (per person)" ] ] ; fhir:InsurancePlan.plan.generalCost.cost [ fhir:Money.value [ fhir:value "2000"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In network tier 1, for medical care and drugs" ] ], [ fhir:index 3 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; fhir:Coding.code [ fhir:value "in" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "family" ] ; fhir:Coding.display [ fhir:value "Family" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "medical-and-drug" ] ; fhir:Coding.display [ fhir:value "Medical and drugs" ] ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$4000 per group" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "deductible" ] ; fhir:Coding.display [ fhir:value "Deductible" ] ] ; fhir:CodeableConcept.text [ fhir:value "Family Deductible" ] ] ; fhir:InsurancePlan.plan.generalCost.cost [ fhir:Money.value [ fhir:value "4000"^^xsd:decimal ] ; fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In network tier 1, for medical care and drugs" ] ], [ fhir:index 4 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "individual" ] ; fhir:Coding.display [ fhir:value "Individual" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; 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fhir:Coding.display [ fhir:value "Medical and drugs" ] ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "per person not applicable" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "deductible" ] ; fhir:Coding.display [ fhir:value "Deductible" ] ] ; fhir:CodeableConcept.text [ fhir:value "Family Deductible (per person)" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "Out of network, for medical care and drugs: not stated" ] ], [ fhir:index 9 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; 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fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "per person not applicable" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "deductible" ] ; fhir:Coding.display [ fhir:value "Deductible" ] ] ; fhir:CodeableConcept.text [ fhir:value "Family Deductible (per person)" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In and out of network combined, for medical care and drugs: not stated" ] ], [ fhir:index 12 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "combined" ] ; fhir:Coding.display [ fhir:value "In and out of network combined" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "family" ] ; fhir:Coding.display [ fhir:value "Family" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "medical-and-drug" ] ; fhir:Coding.display [ fhir:value "Medical and drugs" ] ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "per group not applicable" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "deductible" ] ; fhir:Coding.display [ fhir:value "Deductible" ] ] ; fhir:CodeableConcept.text [ fhir:value "Family Deductible" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In and out of network combined, for medical care and drugs: not stated" ] ], [ fhir:index 13 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; fhir:Coding.code [ fhir:value "in" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-unit" ] ; fhir:Coding.code [ fhir:value "individual" ] ; fhir:Coding.display [ fhir:value "Individual" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; 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fhir:Money.currency [ fhir:value "USD" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In network tier 1, for medical care and drugs" ] ], [ fhir:index 14 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; fhir:Coding.code [ fhir:value "in" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "member" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; fhir:Coding.code [ fhir:value "family-per-person" ] ; fhir:Coding.display [ fhir:value "Family, per person" ] ] ], [ fhir:index 2 ; fhir:Extension.url [ fhir:value "appliesTo" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope" ] ; 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fhir:Coding.display [ fhir:value "Medical and drugs" ] ] ] ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "Not Applicable" ] ] ; fhir:InsurancePlan.plan.generalCost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/coverage-copay-type" ] ; fhir:Coding.code [ fhir:value "maxoutofpocket" ] ; fhir:Coding.display [ fhir:value "Maximum out of pocket" ] ] ; fhir:CodeableConcept.text [ fhir:value "Individual Out-of-Pocket Maximum" ] ] ; fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "Out of network, for medical care and drugs: not stated" ] ], [ fhir:index 20 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "network" ] ; fhir:Extension.valueCoding [ fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-network" ] ; 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fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; 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fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "Not Applicable" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type" ] ; fhir:Coding.code [ fhir:value "not-stated" ] ; fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$500.00 Copay after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "500"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ] ] ], [ fhir:index 4 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "hospital-inpatient" ] ; fhir:Coding.display [ fhir:value "Hospital Inpatient Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Inpatient Hospital Services (e.g., Hospital Stay)" ] ; fhir:Coding.display [ fhir:value "Inpatient Hospital Services (e.g., Hospital Stay)" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index 0 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "hospital-inpatient" ] ; fhir:Coding.display [ fhir:value "Hospital Inpatient Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Inpatient Hospital Services (e.g., Hospital Stay)" ] ; fhir:Coding.display [ fhir:value "Inpatient Hospital Services (e.g., Hospital Stay)" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$850.00 Copay per Stay after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "per-stay" ] ; fhir:Coding.display [ fhir:value "Per stay" ] ] ], [ fhir:index 2 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 3 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "850"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "Not Applicable" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type" ] ; fhir:Coding.code [ fhir:value "not-stated" ] ; fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index 5 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "facility-fee" ] ; fhir:Coding.display [ fhir:value "Facility Fee" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)" ] ; fhir:Coding.display [ fhir:value "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index 0 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "facility-fee" ] ; fhir:Coding.display [ fhir:value "Facility Fee" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)" ] ; fhir:Coding.display [ fhir:value "Outpatient Facility Fee (e.g., Ambulatory Surgery Center)" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$650.00 Copay after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 2 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "650"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$650.00 Copay after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 2 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "650"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index 6 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "physician-surgeon-fee" ] ; fhir:Coding.display [ fhir:value "Physician/Surgeon Fees" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Outpatient Surgery Physician/Surgical Services" ] ; fhir:Coding.display [ fhir:value "Outpatient Surgery Physician/Surgical Services" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index 0 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "physician-surgeon-fee" ] ; fhir:Coding.display [ fhir:value "Physician/Surgeon Fees" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Outpatient Surgery Physician/Surgical Services" ] ; fhir:Coding.display [ fhir:value "Outpatient Surgery Physician/Surgical Services" ] ] ] ; 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fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 2 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; 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fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "500"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; 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fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index 8 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "rehabilitation" ] ; fhir:Coding.display [ fhir:value "Rehabilitation Services" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Rehabilitative Occupational and Rehabilitative Physical Therapy" ] ; fhir:Coding.display [ fhir:value "Rehabilitative Occupational and Rehabilitative Physical Therapy" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "limitText" ] ; fhir:Extension.valueString [ fhir:value "Combined limit for all outpatient therapy plus chiropractic." ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "rehabilitation" ] ; fhir:Coding.display [ fhir:value "Rehabilitation Services" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Rehabilitative Occupational and Rehabilitative Physical Therapy" ] ; fhir:Coding.display [ fhir:value "Rehabilitative Occupational and Rehabilitative Physical Therapy" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$70.00" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$70.00 Copay after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 2 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "70"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; 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All other outpatient services [e.g., Detox, Neuropsychology, Psychological Testing] may be subject to additional cost sharing." ] ] ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "mental-health-outpatient" ] ; fhir:Coding.display [ fhir:value "Mental/Behavioral Health Outpatient Services" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Mental/Behavioral Health Outpatient Services" ] ; fhir:Coding.display [ fhir:value "Mental/Behavioral Health Outpatient Services" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$35.00" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; 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fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ], [ fhir:index 10 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "emergency-medical-transport" ] ; fhir:Coding.display [ fhir:value "Emergency Medical Transportation" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Emergency Transportation/Ambulance" ] ; fhir:Coding.display [ fhir:value "Emergency Transportation/Ambulance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index 0 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "emergency-medical-transport" ] ; fhir:Coding.display [ fhir:value "Emergency Medical Transportation" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Emergency Transportation/Ambulance" ] ; fhir:Coding.display [ fhir:value "Emergency Transportation/Ambulance" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$200.00" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ], [ fhir:index 1 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "Not Applicable" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type" ] ; fhir:Coding.code [ fhir:value "not-stated" ] ; fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$200.00" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "200"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "USD" ] ; fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ; fhir:Quantity.code [ fhir:value "USD" ] ] ] ] ], [ fhir:index 11 ; fhir:InsurancePlan.plan.specificCost.category [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "skilled-nursing" ] ; fhir:Coding.display [ fhir:value "Skilled Nursing Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Skilled Nursing Facility" ] ; fhir:Coding.display [ fhir:value "Skilled Nursing Facility" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit [ fhir:index 0 ; fhir:InsurancePlan.plan.specificCost.benefit.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category" ] ; fhir:Coding.code [ fhir:value "skilled-nursing" ] ; fhir:Coding.display [ fhir:value "Skilled Nursing Care" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-marketplace-benefit-name" ] ; fhir:Coding.code [ fhir:value "Skilled Nursing Facility" ] ; fhir:Coding.display [ fhir:value "Skilled Nursing Facility" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost [ fhir:index 0 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "$250.00 Copay per Day after deductible" ] ], [ fhir:index 1 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies" ] ; fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay" ] ; fhir:Coding.display [ fhir:value "Copayment per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Copayment" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-1" ] ; fhir:Coding.display [ fhir:value "In network, tier 1" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "per-day" ] ; fhir:Coding.display [ fhir:value "Per day" ] ] ], [ fhir:index 2 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "after-deductible" ] ; fhir:Coding.display [ fhir:value "After deductible" ] ] ], [ fhir:index 3 ; 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fhir:Coding.display [ fhir:value "Not stated" ] ] ; fhir:CodeableConcept.text [ fhir:value "Not stated" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "in-network" ] ; fhir:Coding.display [ fhir:value "In Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "tier-2" ] ; fhir:Coding.display [ fhir:value "In network, tier 2" ] ] ], [ fhir:index 1 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "counts-toward-maximum" ] ; fhir:Coding.display [ fhir:value "Counts toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/data-absent-reason" ] ; fhir:Extension.valueCode [ fhir:value "unknown" ] ] ] ], [ fhir:index 2 ; fhir:Element.extension [ fhir:index 0 ; fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text" ] ; fhir:Extension.valueString [ fhir:value "100.00%" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/benefit-type" ] ; fhir:Coding.code [ fhir:value "copay-percent" ] ; fhir:Coding.display [ fhir:value "Copayment Percent per service" ] ] ; fhir:CodeableConcept.text [ fhir:value "Coinsurance" ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/applicability" ] ; fhir:Coding.code [ fhir:value "out-of-network" ] ; fhir:Coding.display [ fhir:value "Out of Network" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier" ] ; fhir:Coding.code [ fhir:value "excluded-from-maximum" ] ; fhir:Coding.display [ fhir:value "Does not count toward the out-of-pocket maximum" ] ] ] ; fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ; fhir:Quantity.unit [ fhir:value "%" ] ; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ; fhir:Quantity.code [ fhir:value "%" ] ] ] ] ] ] . # - ontology header ------------------------------------------------------------ a owl:Ontology ; owl:imports fhir:fhir.ttl . # -------------------------------------------------------------------------------------