Plan Benefits: Medicare Advantage plan H2406-013-000 - haau3 FHIR Implementation Guide (HFIG) v1.0.0

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

Example InsurancePlan: Plan Benefits: Medicare Advantage plan H2406-013-000

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: ma-2027-2026-10-01
downloadUrl: https://www.cms.gov/files/zip/pbp-benefits-2027.zip
lastModified: 2026-10-01
sha256: 6d8430e2ecb51acf3cc8547f12dd73506aa73f0dccf034cc3c3393868576ff47
url
file

Plan Benefits Plan Facts
specialNeeds: false
employerOnly: false
partBOnly: false
filesCostData: true
outOfNetworkBenefit: true
pointOfService: false

identifier: CMSMAPlanId/H2406-013-000, CMSMABidId/H2406_013_0

status: Active

type: Medicare Advantage

name: AARP Medicare Advantage from UHC FL-0021 (PPO)

period: 2027 --> 2027

ownedBy: UnitedHealthcare

coverageArea: Unnamed Location

contact
purpose: General Questions
telecom: ph: (866)627-7806, AARPMedicarePlans.com

contact
purpose: Provider directory
telecom: AARPMedicarePlans.com

coverage
type: health insurance plan policy
benefit
type: Primary Care Visit
benefit
type: Specialist Visit
benefit
type: Urgent Care
benefit
type: Emergency Room Care
benefit
type: Hospital Inpatient Care
benefit
type: Hospital Outpatient Care
benefit
type: Facility Fee
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: Lab Services
type: Copayment
applicability: In Network
amount: 0 USD (Details: unknown codeUSD = 'United States dollar')
url
cost
type: Copayment
applicability: Out of Network
amount: 0 USD (Details: unknown codeUSD = 'United States dollar')
url
cost
Plan Benefits Additional Benefit
url
category
value: Observation Services
type: Copayment
applicability: In Network
qualifier: Per day
amount: 550 USD (Details: unknown codeUSD = 'United States dollar')
url
cost
type: Coinsurance
applicability: Out of Network
amount: 40 % (Details: UCUM code% = '%')
url
cost
Plan Benefits Additional Benefit
url
category
value: Home Health Services
type: Copayment
applicability: In Network
amount: 0 USD (Details: unknown codeUSD = 'United States dollar')
url
cost
type: Coinsurance
applicability: Out of Network
amount: 50 % (Details: UCUM code% = '%')
url
cost
type: Local PPO
coverageArea: Unnamed Location
generalCost
type: Monthly premium
Costs
- Value Currency
* 0 United States dollar
generalCost
type: Part B premium reduction
comment: None
generalCost
Plan Benefits Cost Scope
network: Network Type Codes: out (Out of Network)
member: Unit Type Codes: individual (Individual)
appliesTo: Plan Benefits Cost Scope: medical (Medical)
type: Individual Deductible
Costs
- Value Currency
* 1000 United States dollar
comment: Out of network, for medical care
generalCost
Plan Benefits Cost Scope
network: Network Type Codes: in (In Network)
member: Unit Type Codes: individual (Individual)
appliesTo: Plan Benefits Cost Scope: medical (Medical)
type: Individual Out-of-Pocket Maximum
Costs
- Value Currency
* 7150 United States dollar
comment: In network, for medical care
generalCost
Plan Benefits Cost Scope
network: Network Type Codes: out (Out of Network)
member: Unit Type Codes: individual (Individual)
appliesTo: Plan Benefits Cost Scope: medical (Medical)
type: Individual Out-of-Pocket Maximum
comment: Out of network, for medical care: none
generalCost
Plan Benefits Cost Scope
network: Plan Benefits Cost Scope: combined (In and out of network combined)
member: Unit Type Codes: individual (Individual)
appliesTo: Plan Benefits Cost Scope: medical (Medical)
type: Individual Out-of-Pocket Maximum
Costs
- Value Currency
* 10750 United States dollar
comment: In and out of network combined, for medical care
specificCost
category: Primary Care Visit
benefit
type: Primary Care Visit
cost
type: Copayment
applicability: In Network
value: 0 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
value: 45 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Specialist Visit
benefit
type: Specialist Visit
cost
Plan Benefits Cost Range: 0-65 USD
type: Copayment
applicability: In Network
value: <=65 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
value: 100 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Urgent Care
benefit
type: Urgent Care
cost
Plan Benefits Cost Range: 0-50 USD
type: Copayment
applicability: In Network
qualifiers: One price in and out of network
value: <=50 USD (Details: unknown codeUSD = 'United States dollar')
cost
Plan Benefits Cost Range: 0-50 USD
type: Copayment
applicability: Out of Network
qualifiers: One price in and out of network
value: <=50 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Emergency Room Care
benefit
org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
limitText: Copay waived if admitted to the hospital within 24 hours
type: Emergency Room Care
cost
type: Copayment
applicability: In Network
qualifiers: One price in and out of network
value: 130 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
qualifiers: One price in and out of network
value: 130 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Hospital Inpatient Care
benefit
org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
limitText: Benefit period (in network): Per Admission or Per Stay
type: Hospital Inpatient Care
cost
Plan Benefits Day Range: 1-5 d
type: Copayment
applicability: In Network
qualifiers: Per day
value: 550 USD (Details: unknown codeUSD = 'United States dollar')
cost
Plan Benefits Day Range: 6-90 d
type: Copayment
applicability: In Network
qualifiers: Per day
value: 0 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: In Network
qualifiers: Per stay
value: 0 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
applicability: Out of Network
qualifiers: Per stay
value: 40 % (Details: UCUM code% = '%')
specificCost
category: Hospital Outpatient Care
benefit
type: Hospital Outpatient Care
cost
Plan Benefits Cost Range: 0-550 USD
type: Copayment
applicability: In Network
value: <=550 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
applicability: Out of Network
value: 40 % (Details: UCUM code% = '%')
specificCost
category: Facility Fee
benefit
type: Facility Fee
cost
Plan Benefits Cost Range: 0-500 USD
type: Copayment
applicability: In Network
value: <=500 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
applicability: Out of Network
value: 40 % (Details: UCUM code% = '%')
specificCost
category: Imaging (CT/PET/MRI)
benefit
type: Imaging (CT/PET/MRI)
cost
Plan Benefits Cost Range: 0-320 USD
type: Copayment
applicability: In Network
value: <=320 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Coinsurance
applicability: Out of Network
value: 40 % (Details: UCUM code% = '%')
specificCost
category: Rehabilitation Services
benefit
type: Rehabilitation Services
cost
type: Copayment
applicability: In Network
value: 65 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
value: 100 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Mental/Behavioral Health Outpatient Services
benefit
type: Mental/Behavioral Health Outpatient Services
cost
Plan Benefits Cost Range: 0-25 USD
type: Copayment
applicability: In Network
value: <=25 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
value: 40 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Emergency Medical Transportation
benefit
type: Emergency Medical Transportation
cost
type: Copayment
applicability: In Network
value: 380 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
value: 380 USD (Details: unknown codeUSD = 'United States dollar')
specificCost
category: Skilled Nursing Care
benefit
org/fhir/us/insurance-card/StructureDefinition/benefit-limitation
limitText: Benefit period (in network): Original Medicare
type: Skilled Nursing Care
cost
Plan Benefits Day Range: 1-20 d
type: Copayment
applicability: In Network
qualifiers: Per day
value: 0 USD (Details: unknown codeUSD = 'United States dollar')
cost
Plan Benefits Day Range: 21-100 d
type: Copayment
applicability: In Network
qualifiers: Per day
value: 221 USD (Details: unknown codeUSD = 'United States dollar')
cost
Plan Benefits Day Range: 1-100 d
type: Copayment
applicability: Out of Network
qualifiers: Per day
value: 250 USD (Details: unknown codeUSD = 'United States dollar')
cost
type: Copayment
applicability: Out of Network
qualifiers: Per stay
value: 0 USD (Details: unknown codeUSD = 'United States dollar')

Generated Narrative: Organization #issuer

UnitedHealthcare (CMS Contract ID: CMSMAContractId#H2406)
Alias: CARE IMPROVEMENT PLUS SOUTH CENTRAL INSURANCE CO.

Generated Narrative: Location #state-FL

Unnamed Location
Form: Jurisdiction
Address: FL