haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build United States of America flag

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

: Plan Benefits: Medicare Advantage plan H2406-013-000 - TTL Representation

Raw ttl | Download

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/InsurancePlan/H2406-013-000> a fhir:InsurancePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "H2406-013-000"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan" ;
       fhir:index 0 ;
       fhir:link <https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan>
     ], [
       fhir:value "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot" ;
       fhir:index 1 ;
       fhir:link <http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot>
     ]
  ] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan H2406-013-000</b></p><a name=\"H2406-013-000\"> </a><a name=\"hcH2406-013-000\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profiles: <a href=\"StructureDefinition-haau3-insurance-plan.html\">haau3 Insurance Plan (Plan Benefits)</a>, <code>http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot</code></p></div><blockquote><p><b>Plan Benefits Source Release</b></p><blockquote><p><b>url</b></p>release</blockquote><p><b>value</b>: ma-2027-2026-10-01</p><p><b>downloadUrl</b>: <a href=\"https://www.cms.gov/files/zip/pbp-benefits-2027.zip\">https://www.cms.gov/files/zip/pbp-benefits-2027.zip</a></p><p><b>lastModified</b>: 2026-10-01</p><p><b>sha256</b>: 6d8430e2ecb51acf3cc8547f12dd73506aa73f0dccf034cc3c3393868576ff47</p><blockquote><p><b>url</b></p>file</blockquote></blockquote><blockquote><p><b>Plan Benefits Plan Facts</b></p><ul><li>specialNeeds: false</li><li>employerOnly: false</li><li>partBOnly: false</li><li>filesCostData: true</li><li>outOfNetworkBenefit: true</li><li>pointOfService: false</li></ul></blockquote><p><b>identifier</b>: <a href=\"NamingSystem-cms-ma-plan-id.html\" title=\"CMS's identifier for a Medicare Advantage plan: the contract number, the plan ID and the segment ID joined with hyphens, with 000 for a plan that is not segmented (H2406-013-000). CMS defines this system in its technical implementation guide for Medicare Advantage provider directory data and confirmed the format in its office hours Q&amp;A of 2026-09-16. CMS publishes no NamingSystem resource for it, so haau3 publishes this one, which only describes CMS's system, so that a validator can resolve it. It gives way to one CMS or HL7 publishes.\">CMSMAPlanId</a>/H2406-013-000, <a href=\"NamingSystem-cms-ma-bid-id.html\" title=\"The bid_id that keys a Medicare Advantage plan in CMS's Plan Benefit Package (PBP) Benefits files, exactly as the files write it: the contract number, the plan ID and the segment ID joined with underscores, the segment unpadded (H2406_013_0). Carried beside CMS's ma-plan-id so that the key matches the files byte for byte. haau3 publishes this until CMS or HL7 publishes an identifier system for it.\">CMSMABidId</a>/H2406_013_0</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/insurance-product-type mediadv}\">Medicare Advantage</span></p><p><b>name</b>: AARP Medicare Advantage from UHC FL-0021 (PPO)</p><p><b>period</b>: 2027 --&gt; 2027</p><p><b>ownedBy</b>: <a href=\"#hcH2406-013-000/issuer\">UnitedHealthcare</a></p><p><b>coverageArea</b>: <a href=\"#hcH2406-013-000/state-FL\">Unnamed Location</a></p><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">General Questions</span></p><p><b>telecom</b>: ph: (866)627-7806, AARPMedicarePlans.com</p></blockquote><blockquote><p><b>contact</b></p><p><b>purpose</b>: <span title=\"Codes:\">Provider directory</span></p><p><b>telecom</b>: AARPMedicarePlans.com</p></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode HIP}\">health insurance plan policy</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7a}\">Primary Care Visit</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7d}\">Specialist Visit</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 4b}\">Urgent Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 4a}\">Emergency Room Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 1a}\">Hospital Inpatient Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9a1}\">Hospital Outpatient Care</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9b}\">Facility Fee</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category imaging}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 8b1}\">Imaging (CT/PET/MRI)</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7i}\">Rehabilitation Services</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7e1}\">Mental/Behavioral Health Outpatient Services</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 10a1}\">Emergency Medical Transportation</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 2}\">Skilled Nursing Care</span></p></blockquote></blockquote><blockquote><p><b>plan</b></p><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 8a2}\">Lab Services</span></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>amount</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>amount</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9a2}\">Observation Services</span></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifier</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span></p><p><b>amount</b>: 550 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>amount</b>: 40 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><blockquote><p><b>Plan Benefits Additional Benefit</b></p><blockquote><p><b>url</b></p>category</blockquote><p><b>value</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 6}\">Home Health Services</span></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>amount</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p><blockquote><p><b>url</b></p>cost</blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>amount</b>: 50 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p><blockquote><p><b>url</b></p>cost</blockquote></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type PPO}\">Local PPO</span></p><p><b>coverageArea</b>: <a href=\"#hcH2406-013-000/state-FL\">Unnamed Location</a></p><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type monthly-premium}\">Monthly premium</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>United States dollar</td></tr></table></blockquote><blockquote><p><b>generalCost</b></p><p><b>type</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type part-b-premium-reduction}\">Part B premium reduction</span></p><p><b>comment</b>: None</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical\">Plan Benefits Cost Scope: medical</a> (Medical)</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type deductible}\">Individual Deductible</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1000</td><td>United States dollar</td></tr></table><p><b>comment</b>: Out of network, for medical care</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-in\">Network Type Codes: in</a> (In Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical\">Plan Benefits Cost Scope: medical</a> (Medical)</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>7150</td><td>United States dollar</td></tr></table><p><b>comment</b>: In network, for medical care</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-network.html#benefit-network-out\">Network Type Codes: out</a> (Out of Network)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical\">Plan Benefits Cost Scope: medical</a> (Medical)</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><p><b>comment</b>: Out of network, for medical care: none</p></blockquote><blockquote><p><b>generalCost</b></p><blockquote><p><b>Plan Benefits Cost Scope</b></p><ul><li>network: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-combined\">Plan Benefits Cost Scope: combined</a> (In and out of network combined)</li><li>member: <a href=\"http://terminology.hl7.org/7.4.0/CodeSystem-benefit-unit.html#benefit-unit-individual\">Unit Type Codes: individual</a> (Individual)</li><li>appliesTo: <a href=\"CodeSystem-plan-benefits-cost-scope.html#plan-benefits-cost-scope-medical\">Plan Benefits Cost Scope: medical</a> (Medical)</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/coverage-copay-type maxoutofpocket}\">Individual Out-of-Pocket Maximum</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>10750</td><td>United States dollar</td></tr></table><p><b>comment</b>: In and out of network combined, for medical care</p></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7a}\">Primary Care Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category primary-care-visit}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7a}\">Primary Care Visit</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 45 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7d}\">Specialist Visit</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category specialist-visit}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7d}\">Specialist Visit</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-65 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: &lt;=65 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 100 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 4b}\">Urgent Care</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category urgent-care}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 4b}\">Urgent Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-50 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier one-price-both-networks}\">One price in and out of network</span></p><p><b>value</b>: &lt;=50 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-50 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier one-price-both-networks}\">One price in and out of network</span></p><p><b>value</b>: &lt;=50 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 4a}\">Emergency Room Care</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>limitText: Copay waived if admitted to the hospital within 24 hours</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-room-care}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 4a}\">Emergency Room Care</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier one-price-both-networks}\">One price in and out of network</span></p><p><b>value</b>: 130 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier one-price-both-networks}\">One price in and out of network</span></p><p><b>value</b>: 130 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 1a}\">Hospital Inpatient Care</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>limitText: Benefit period (in network): Per Admission or Per Stay</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-inpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 1a}\">Hospital Inpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Day Range</b>: 1-5 d</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span></p><p><b>value</b>: 550 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Day Range</b>: 6-90 d</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-stay}\">Per stay</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-stay}\">Per stay</span></p><p><b>value</b>: 40 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9a1}\">Hospital Outpatient Care</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category hospital-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9a1}\">Hospital Outpatient Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-550 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: &lt;=550 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 40 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9b}\">Facility Fee</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category facility-fee}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 9b}\">Facility Fee</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-500 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: &lt;=500 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 40 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category imaging}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 8b1}\">Imaging (CT/PET/MRI)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category imaging}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 8b1}\">Imaging (CT/PET/MRI)</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-320 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: &lt;=320 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay-percent}\">Coinsurance</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 40 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code% = '%')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7i}\">Rehabilitation Services</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category rehabilitation}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7i}\">Rehabilitation Services</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 65 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 100 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7e1}\">Mental/Behavioral Health Outpatient Services</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category mental-health-outpatient}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 7e1}\">Mental/Behavioral Health Outpatient Services</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Cost Range</b>: 0-25 USD</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: &lt;=25 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 40 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 10a1}\">Emergency Medical Transportation</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category emergency-medical-transport}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 10a1}\">Emergency Medical Transportation</span></p><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>value</b>: 380 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>value</b>: 380 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 2}\">Skilled Nursing Care</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>org/fhir/us/insurance-card/StructureDefinition/benefit-limitation</b></p><ul><li>limitText: Benefit period (in network): Original Medicare</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category skilled-nursing}, {https://haau3.com/fhir/CodeSystem/cms-pbp-service-category 2}\">Skilled Nursing Care</span></p><blockquote><p><b>cost</b></p><p><b>Plan Benefits Day Range</b>: 1-20 d</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Day Range</b>: 21-100 d</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability in-network}\">In Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span></p><p><b>value</b>: 221 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>Plan Benefits Day Range</b>: 1-100 d</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-day}\">Per day</span></p><p><b>value</b>: 250 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote><blockquote><p><b>cost</b></p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/benefit-type copay}\">Copayment</span></p><p><b>applicability</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/applicability out-of-network}\">Out of Network</span></p><p><b>qualifiers</b>: <span title=\"Codes:{https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier per-stay}\">Per stay</span></p><p><b>value</b>: 0 USD<span style=\"background: LightGoldenRodYellow\"> (Details: unknown  codeUSD = 'United States dollar')</span></p></blockquote></blockquote></blockquote></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Organization #issuer</b></p><a name=\"H2406-013-000/issuer\"> </a><a name=\"hcH2406-013-000/issuer\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">UnitedHealthcare (CMS Contract ID: CMSMAContractId#H2406)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Other names this is known by\">Alias:</td><td colspan=\"3\">CARE IMPROVEMENT PLUS SOUTH CENTRAL INSURANCE CO.</td></tr></table></blockquote><hr/><blockquote><p class=\"res-header-id\"><b>Generated Narrative: Location #state-FL</b></p><a name=\"H2406-013-000/state-FL\"> </a><a name=\"hcH2406-013-000/state-FL\"> </a><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">Unnamed Location</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"The physical form of the location (e.g. building, room, vehicle, road)\">Form:</td><td colspan=\"3\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/location-physical-type jdn}\">Jurisdiction</span></td></tr><tr><td style=\"background-color: #f3f5da\" title=\"Physical location\">Address:</td><td colspan=\"3\">FL </td></tr></table></blockquote></div>"
  ] ;
  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 "cms-contract-id" ] ;
           fhir:Coding.display [ fhir:value "CMS Contract ID" ]
         ]
       ] ;
       fhir:Identifier.system [ fhir:value "https://haau3.com/fhir/NamingSystem/cms-ma-contract-id" ] ;
       fhir:Identifier.value [ fhir:value "H2406" ]
     ] ;
     fhir:Organization.name [ fhir:value "UnitedHealthcare" ] ;
     fhir:Organization.alias [
       fhir:value "CARE IMPROVEMENT PLUS SOUTH CENTRAL INSURANCE CO." ;
       fhir:index 0
     ]
  ], [
     a fhir:Location ;
     fhir:index 1 ;
     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 "ma-2027-2026-10-01" ]
     ], [
       fhir:index 1 ;
       fhir:Element.extension [
         fhir:index 0 ;
         fhir:Extension.url [ fhir:value "downloadUrl" ] ;
         fhir:Extension.valueUri [ fhir:value "https://www.cms.gov/files/zip/pbp-benefits-2027.zip" ]
       ], [
         fhir:index 1 ;
         fhir:Extension.url [ fhir:value "lastModified" ] ;
         fhir:Extension.valueDate [ fhir:value "2026-10-01"^^xsd:date ]
       ], [
         fhir:index 2 ;
         fhir:Extension.url [ fhir:value "sha256" ] ;
         fhir:Extension.valueString [ fhir:value "6d8430e2ecb51acf3cc8547f12dd73506aa73f0dccf034cc3c3393868576ff47" ]
       ] ;
       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 "specialNeeds" ] ;
       fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ]
     ], [
       fhir:index 1 ;
       fhir:Extension.url [ fhir:value "employerOnly" ] ;
       fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ]
     ], [
       fhir:index 2 ;
       fhir:Extension.url [ fhir:value "partBOnly" ] ;
       fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ]
     ], [
       fhir:index 3 ;
       fhir:Extension.url [ fhir:value "filesCostData" ] ;
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]
     ], [
       fhir:index 4 ;
       fhir:Extension.url [ fhir:value "outOfNetworkBenefit" ] ;
       fhir:Extension.valueBoolean [ fhir:value "true"^^xsd:boolean ]
     ], [
       fhir:index 5 ;
       fhir:Extension.url [ fhir:value "pointOfService" ] ;
       fhir:Extension.valueBoolean [ fhir:value "false"^^xsd:boolean ]
     ] ;
     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 "http://cms.gov/medicare/ma-plan-id" ] ;
     fhir:Identifier.value [ fhir:value "H2406-013-000" ]
  ], [
     fhir:index 1 ;
     fhir:Identifier.system [ fhir:value "https://haau3.com/fhir/NamingSystem/cms-ma-bid-id" ] ;
     fhir:Identifier.value [ fhir:value "H2406_013_0" ]
  ] ;
  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 "mediadv" ] ;
       fhir:Coding.display [ fhir:value "Medicare Advantage" ]
     ]
  ] ;
  fhir:InsurancePlan.name [ fhir:value "AARP Medicare Advantage from UHC FL-0021 (PPO)"] ;
  fhir:InsurancePlan.period [
     fhir:Period.start [ fhir:value "2027"^^xsd:gYear ] ;
     fhir:Period.end [ fhir:value "2027"^^xsd:gYear ]
  ] ;
  fhir:InsurancePlan.ownedBy [
     fhir:Reference.reference [ fhir:value "#issuer" ] ;
     fhir:Reference.display [ fhir:value "UnitedHealthcare" ]
  ] ;
  fhir:InsurancePlan.coverageArea [
     fhir:index 0 ;
     fhir:Reference.reference [ fhir:value "#state-FL" ]
  ] ;
  fhir:InsurancePlan.contact [
     fhir:index 0 ;
     fhir:InsurancePlan.contact.purpose [
       fhir:CodeableConcept.text [ fhir:value "General Questions" ]
     ] ;
     fhir:InsurancePlan.contact.telecom [
       fhir:index 0 ;
       fhir:ContactPoint.system [ fhir:value "phone" ] ;
       fhir:ContactPoint.value [ fhir:value "(866)627-7806" ]
     ], [
       fhir:index 1 ;
       fhir:ContactPoint.system [ fhir:value "url" ] ;
       fhir:ContactPoint.value [ fhir:value "AARPMedicarePlans.com" ]
     ]
  ], [
     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 "AARPMedicarePlans.com" ]
     ]
  ] ;
  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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7a" ] ;
           fhir:Coding.display [ fhir:value "Primary Care Physician Services" ]
         ]
       ]
     ], [
       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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7d" ] ;
           fhir:Coding.display [ fhir:value "Physician Specialist Services" ]
         ]
       ]
     ], [
       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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "4b" ] ;
           fhir:Coding.display [ fhir:value "Urgently Needed Services" ]
         ]
       ]
     ], [
       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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "4a" ] ;
           fhir:Coding.display [ fhir:value "Emergency 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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "1a" ] ;
           fhir:Coding.display [ fhir:value "Inpatient Hospital-Acute" ]
         ]
       ]
     ], [
       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 "hospital-outpatient" ] ;
           fhir:Coding.display [ fhir:value "Hospital Outpatient Care" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "9a1" ] ;
           fhir:Coding.display [ fhir:value "Outpatient Hospital Services" ]
         ]
       ]
     ], [
       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 "facility-fee" ] ;
           fhir:Coding.display [ fhir:value "Facility Fee" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "9b" ] ;
           fhir:Coding.display [ fhir:value "Ambulatory Surgical Center (ASC) 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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "8b1" ] ;
           fhir:Coding.display [ fhir:value "Diagnostic Radiological Services" ]
         ]
       ]
     ], [
       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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7i" ] ;
           fhir:Coding.display [ fhir:value "Physical Therapy and Speech-Language Pathology Services" ]
         ]
       ]
     ], [
       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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7e1" ] ;
           fhir:Coding.display [ fhir:value "Individual Sessions for Mental Health Specialty 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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "10a1" ] ;
           fhir:Coding.display [ fhir:value "Ground Ambulance Services" ]
         ]
       ]
     ], [
       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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "2" ] ;
           fhir:Coding.display [ fhir:value "Skilled Nursing Facility (SNF)" ]
         ]
       ]
     ]
  ] ;
  fhir:InsurancePlan.plan [
     fhir:index 0 ;
     fhir:Element.extension [
       fhir:index 0 ;
       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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "8a2" ] ;
             fhir:Coding.display [ fhir:value "Lab Services" ]
           ]
         ]
       ], [
         fhir:index 1 ;
         fhir:Element.extension [
           fhir:index 0 ;
           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 1 ;
           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 2 ;
           fhir:Extension.url [ fhir:value "amount" ] ;
           fhir:Extension.valueQuantity [
             fhir:Quantity.value [ fhir:value "0"^^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 "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 1 ;
           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 2 ;
           fhir:Extension.url [ fhir:value "amount" ] ;
           fhir:Extension.valueQuantity [
             fhir:Quantity.value [ fhir:value "0"^^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: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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "9a2" ] ;
             fhir:Coding.display [ fhir:value "Observation Services" ]
           ]
         ]
       ], [
         fhir:index 1 ;
         fhir:Element.extension [
           fhir:index 0 ;
           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 1 ;
           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 2 ;
           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 "per-day" ] ;
               fhir:Coding.display [ fhir:value "Per day" ]
             ]
           ]
         ], [
           fhir:index 3 ;
           fhir:Extension.url [ fhir:value "amount" ] ;
           fhir:Extension.valueQuantity [
             fhir:Quantity.value [ fhir:value "550"^^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 "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 1 ;
           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 2 ;
           fhir:Extension.url [ fhir:value "amount" ] ;
           fhir:Extension.valueQuantity [
             fhir:Quantity.value [ fhir:value "40"^^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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "6" ] ;
             fhir:Coding.display [ fhir:value "Home Health Services" ]
           ]
         ]
       ], [
         fhir:index 1 ;
         fhir:Element.extension [
           fhir:index 0 ;
           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 1 ;
           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 2 ;
           fhir:Extension.url [ fhir:value "amount" ] ;
           fhir:Extension.valueQuantity [
             fhir:Quantity.value [ fhir:value "0"^^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 "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 1 ;
           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 2 ;
           fhir:Extension.url [ fhir:value "amount" ] ;
           fhir:Extension.valueQuantity [
             fhir:Quantity.value [ fhir:value "50"^^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 "PPO" ] ;
         fhir:Coding.display [ fhir:value "Preferred Provider Organization (PPO)" ]
       ] ;
       fhir:CodeableConcept.text [ fhir:value "Local PPO" ]
     ] ;
     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.cost [
         fhir:Money.value [ fhir:value "0"^^xsd:decimal ] ;
         fhir:Money.currency [ fhir:value "USD" ]
       ]
     ], [
       fhir:index 1 ;
       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 "part-b-premium-reduction" ] ;
           fhir:Coding.display [ fhir:value "Part B premium reduction" ]
         ] ;
         fhir:CodeableConcept.text [ fhir:value "Part B premium reduction" ]
       ] ;
       fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "None" ]
     ], [
       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 "out" ] ;
             fhir:Coding.display [ fhir:value "Out of 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" ] ;
             fhir:Coding.display [ fhir:value "Medical" ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ]
       ] ;
       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 "1000"^^xsd:decimal ] ;
         fhir:Money.currency [ fhir:value "USD" ]
       ] ;
       fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "Out of network, for medical care" ]
     ], [
       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 "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" ] ;
             fhir:Coding.display [ fhir:value "Medical" ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ]
       ] ;
       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.cost [
         fhir:Money.value [ fhir:value "7150"^^xsd:decimal ] ;
         fhir:Money.currency [ fhir:value "USD" ]
       ] ;
       fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In network, for medical care" ]
     ], [
       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 "http://terminology.hl7.org/CodeSystem/benefit-network" ] ;
             fhir:Coding.code [ fhir:value "out" ] ;
             fhir:Coding.display [ fhir:value "Out of 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" ] ;
             fhir:Coding.display [ fhir:value "Medical" ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ]
       ] ;
       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: none" ]
     ], [
       fhir:index 5 ;
       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 "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" ] ;
             fhir:Coding.display [ fhir:value "Medical" ]
           ]
         ] ;
         fhir:Extension.url [ fhir:value "https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope" ]
       ] ;
       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.cost [
         fhir:Money.value [ fhir:value "10750"^^xsd:decimal ] ;
         fhir:Money.currency [ fhir:value "USD" ]
       ] ;
       fhir:InsurancePlan.plan.generalCost.comment [ fhir:value "In and out of network combined, for medical care" ]
     ] ;
     fhir:InsurancePlan.plan.specificCost [
       fhir:index 0 ;
       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 "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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7a" ] ;
           fhir:Coding.display [ fhir:value "Primary Care Physician 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 "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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "7a" ] ;
             fhir:Coding.display [ fhir:value "Primary Care Physician Services" ]
           ]
         ] ;
         fhir:InsurancePlan.plan.specificCost.benefit.cost [
           fhir:index 0 ;
           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.value [
             fhir:Quantity.value [ fhir:value "0"^^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: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.value [
             fhir:Quantity.value [ fhir:value "45"^^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: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 "specialist-visit" ] ;
           fhir:Coding.display [ fhir:value "Specialist Visit" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7d" ] ;
           fhir:Coding.display [ fhir:value "Physician Specialist 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 "specialist-visit" ] ;
             fhir:Coding.display [ fhir:value "Specialist Visit" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "7d" ] ;
             fhir:Coding.display [ fhir:value "Physician Specialist 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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 fhir:Quantity.value [ fhir:value "65"^^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: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.value [
             fhir:Quantity.value [ fhir:value "65"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             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: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.value [
             fhir:Quantity.value [ fhir:value "100"^^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: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 "urgent-care" ] ;
           fhir:Coding.display [ fhir:value "Urgent Care" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "4b" ] ;
           fhir:Coding.display [ fhir:value "Urgently Needed 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 "urgent-care" ] ;
             fhir:Coding.display [ fhir:value "Urgent Care" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "4b" ] ;
             fhir:Coding.display [ fhir:value "Urgently Needed 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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 fhir:Quantity.value [ fhir:value "50"^^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: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 "one-price-both-networks" ] ;
               fhir:Coding.display [ fhir:value "One price in and out of network" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 fhir:Quantity.value [ fhir:value "50"^^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: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 "one-price-both-networks" ] ;
               fhir:Coding.display [ fhir:value "One price in and out of network" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "50"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             fhir:Quantity.unit [ fhir:value "USD" ] ;
             fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ;
             fhir:Quantity.code [ fhir:value "USD" ]
           ]
         ]
       ]
     ], [
       fhir:index 3 ;
       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-room-care" ] ;
           fhir:Coding.display [ fhir:value "Emergency Room Care" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "4a" ] ;
           fhir:Coding.display [ fhir:value "Emergency Services" ]
         ]
       ] ;
       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 "Copay waived if admitted to the hospital within 24 hours" ]
           ] ;
           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 "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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "4a" ] ;
             fhir:Coding.display [ fhir:value "Emergency Services" ]
           ]
         ] ;
         fhir:InsurancePlan.plan.specificCost.benefit.cost [
           fhir:index 0 ;
           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 "one-price-both-networks" ] ;
               fhir:Coding.display [ fhir:value "One price in and out of network" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "130"^^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: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 "one-price-both-networks" ] ;
               fhir:Coding.display [ fhir:value "One price in and out of network" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "130"^^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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "1a" ] ;
           fhir:Coding.display [ fhir:value "Inpatient Hospital-Acute" ]
         ]
       ] ;
       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 "Benefit period (in network): Per Admission or Per Stay" ]
           ] ;
           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 "hospital-inpatient" ] ;
             fhir:Coding.display [ fhir:value "Hospital Inpatient Care" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "1a" ] ;
             fhir:Coding.display [ fhir:value "Inpatient Hospital-Acute" ]
           ]
         ] ;
         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-day-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "1"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ] ;
               fhir:Range.high [
                 fhir:Quantity.value [ fhir:value "5"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ]
             ]
           ] ;
           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 "per-day" ] ;
               fhir:Coding.display [ fhir:value "Per day" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "550"^^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-day-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "6"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ] ;
               fhir:Range.high [
                 fhir:Quantity.value [ fhir:value "90"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ]
             ]
           ] ;
           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 "per-day" ] ;
               fhir:Coding.display [ fhir:value "Per day" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "0"^^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: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 "per-stay" ] ;
               fhir:Coding.display [ fhir:value "Per stay" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "0"^^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 3 ;
           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 "per-stay" ] ;
               fhir:Coding.display [ fhir:value "Per stay" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "40"^^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 "hospital-outpatient" ] ;
           fhir:Coding.display [ fhir:value "Hospital Outpatient Care" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "9a1" ] ;
           fhir:Coding.display [ fhir:value "Outpatient Hospital 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 "hospital-outpatient" ] ;
             fhir:Coding.display [ fhir:value "Hospital Outpatient Care" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "9a1" ] ;
             fhir:Coding.display [ fhir:value "Outpatient Hospital 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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 fhir:Quantity.value [ fhir:value "550"^^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: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.value [
             fhir:Quantity.value [ fhir:value "550"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             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: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.value [
             fhir:Quantity.value [ fhir:value "40"^^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 "facility-fee" ] ;
           fhir:Coding.display [ fhir:value "Facility Fee" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "9b" ] ;
           fhir:Coding.display [ fhir:value "Ambulatory Surgical Center (ASC) 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 "facility-fee" ] ;
             fhir:Coding.display [ fhir:value "Facility Fee" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "9b" ] ;
             fhir:Coding.display [ fhir:value "Ambulatory Surgical Center (ASC) 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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 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: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.value [
             fhir:Quantity.value [ fhir:value "500"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             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: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.value [
             fhir:Quantity.value [ fhir:value "40"^^xsd:decimal ] ;
             fhir:Quantity.unit [ fhir:value "%" ] ;
             fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
             fhir:Quantity.code [ fhir:value "%" ]
           ]
         ]
       ]
     ], [
       fhir:index 7 ;
       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 "imaging" ] ;
           fhir:Coding.display [ fhir:value "Imaging (CT/PET/MRI)" ]
         ], [
           fhir:index 1 ;
           fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "8b1" ] ;
           fhir:Coding.display [ fhir:value "Diagnostic Radiological 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 "imaging" ] ;
             fhir:Coding.display [ fhir:value "Imaging (CT/PET/MRI)" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "8b1" ] ;
             fhir:Coding.display [ fhir:value "Diagnostic Radiological 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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 fhir:Quantity.value [ fhir:value "320"^^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: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.value [
             fhir:Quantity.value [ fhir:value "320"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             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: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.value [
             fhir:Quantity.value [ fhir:value "40"^^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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7i" ] ;
           fhir:Coding.display [ fhir:value "Physical Therapy and Speech-Language Pathology 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 "rehabilitation" ] ;
             fhir:Coding.display [ fhir:value "Rehabilitation Services" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "7i" ] ;
             fhir:Coding.display [ fhir:value "Physical Therapy and Speech-Language Pathology Services" ]
           ]
         ] ;
         fhir:InsurancePlan.plan.specificCost.benefit.cost [
           fhir:index 0 ;
           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.value [
             fhir:Quantity.value [ fhir:value "65"^^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: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.value [
             fhir:Quantity.value [ fhir:value "100"^^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 9 ;
       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 "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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "7e1" ] ;
           fhir:Coding.display [ fhir:value "Individual Sessions for Mental Health Specialty 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 "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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "7e1" ] ;
             fhir:Coding.display [ fhir:value "Individual Sessions for Mental Health Specialty 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-cost-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "0"^^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:Range.high [
                 fhir:Quantity.value [ fhir:value "25"^^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: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.value [
             fhir:Quantity.value [ fhir:value "25"^^xsd:decimal ] ;
             fhir:Quantity.comparator [ fhir:value "<=" ] ;
             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: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.value [
             fhir:Quantity.value [ fhir:value "40"^^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 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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "10a1" ] ;
           fhir:Coding.display [ fhir:value "Ground Ambulance 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 "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-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "10a1" ] ;
             fhir:Coding.display [ fhir:value "Ground Ambulance Services" ]
           ]
         ] ;
         fhir:InsurancePlan.plan.specificCost.benefit.cost [
           fhir:index 0 ;
           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.value [
             fhir:Quantity.value [ fhir:value "380"^^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: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.value [
             fhir:Quantity.value [ fhir:value "380"^^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-pbp-service-category" ] ;
           fhir:Coding.code [ fhir:value "2" ] ;
           fhir:Coding.display [ fhir:value "Skilled Nursing Facility (SNF)" ]
         ]
       ] ;
       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 "Benefit period (in network): Original Medicare" ]
           ] ;
           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 "skilled-nursing" ] ;
             fhir:Coding.display [ fhir:value "Skilled Nursing Care" ]
           ], [
             fhir:index 1 ;
             fhir:Coding.system [ fhir:value "https://haau3.com/fhir/CodeSystem/cms-pbp-service-category" ] ;
             fhir:Coding.code [ fhir:value "2" ] ;
             fhir:Coding.display [ fhir:value "Skilled Nursing Facility (SNF)" ]
           ]
         ] ;
         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-day-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "1"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ] ;
               fhir:Range.high [
                 fhir:Quantity.value [ fhir:value "20"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ]
             ]
           ] ;
           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 "per-day" ] ;
               fhir:Coding.display [ fhir:value "Per day" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "0"^^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-day-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "21"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ] ;
               fhir:Range.high [
                 fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ]
             ]
           ] ;
           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 "per-day" ] ;
               fhir:Coding.display [ fhir:value "Per day" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "221"^^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-day-range" ] ;
             fhir:Extension.valueRange [
               fhir:Range.low [
                 fhir:Quantity.value [ fhir:value "1"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ] ;
               fhir:Range.high [
                 fhir:Quantity.value [ fhir:value "100"^^xsd:decimal ] ;
                 fhir:Quantity.unit [ fhir:value "d" ] ;
                 fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ] ;
                 fhir:Quantity.code [ fhir:value "d" ]
               ]
             ]
           ] ;
           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 "per-day" ] ;
               fhir:Coding.display [ fhir:value "Per day" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "250"^^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 3 ;
           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 "per-stay" ] ;
               fhir:Coding.display [ fhir:value "Per stay" ]
             ]
           ] ;
           fhir:InsurancePlan.plan.specificCost.benefit.cost.value [
             fhir:Quantity.value [ fhir:value "0"^^xsd:decimal ] ;
             fhir:Quantity.unit [ fhir:value "USD" ] ;
             fhir:Quantity.system [ fhir:value "urn:iso:std:iso:4217" ] ;
             fhir:Quantity.code [ fhir:value "USD" ]
           ]
         ]
       ]
     ]
  ] .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/InsurancePlan/H2406-013-000.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/InsurancePlan/H2406-013-000.ttl> .