haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
<InsurancePlan xmlns="http://hl7.org/fhir">
<id value="H2406-013-000"/>
<meta>
<profile
value="https://haau3.com/fhir/StructureDefinition/haau3-insurance-plan"/>
<profile
value="http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot"/>
</meta>
<text>
<status value="extensions"/>
<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&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 --> 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>: <=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>: <=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>: <=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>: <=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>: <=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>: <=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>: <=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>
</text>
<contained>
<Organization>
<id value="issuer"/>
<identifier>
<type>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/payor-identifier-types-cs"/>
<code value="cms-contract-id"/>
<display value="CMS Contract ID"/>
</coding>
</type>
<system
value="https://haau3.com/fhir/NamingSystem/cms-ma-contract-id"/>
<value value="H2406"/>
</identifier>
<name value="UnitedHealthcare"/>
<alias value="CARE IMPROVEMENT PLUS SOUTH CENTRAL INSURANCE CO."/>
</Organization>
</contained>
<contained>
<Location>
<id value="state-FL"/>
<address>
<state value="FL"/>
</address>
<physicalType>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/location-physical-type"/>
<code value="jdn"/>
<display value="Jurisdiction"/>
</coding>
</physicalType>
</Location>
</contained>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release">
<extension url="release">
<valueString value="ma-2027-2026-10-01"/>
</extension>
<extension url="file">
<extension url="downloadUrl">
<valueUri
value="https://www.cms.gov/files/zip/pbp-benefits-2027.zip"/>
</extension>
<extension url="lastModified">
<valueDate value="2026-10-01"/>
</extension>
<extension url="sha256">
<valueString
value="6d8430e2ecb51acf3cc8547f12dd73506aa73f0dccf034cc3c3393868576ff47"/>
</extension>
</extension>
</extension>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts">
<extension url="specialNeeds">
<valueBoolean value="false"/>
</extension>
<extension url="employerOnly">
<valueBoolean value="false"/>
</extension>
<extension url="partBOnly">
<valueBoolean value="false"/>
</extension>
<extension url="filesCostData">
<valueBoolean value="true"/>
</extension>
<extension url="outOfNetworkBenefit">
<valueBoolean value="true"/>
</extension>
<extension url="pointOfService">
<valueBoolean value="false"/>
</extension>
</extension>
<identifier>
<system value="http://cms.gov/medicare/ma-plan-id"/>
<value value="H2406-013-000"/>
</identifier>
<identifier>
<system value="https://haau3.com/fhir/NamingSystem/cms-ma-bid-id"/>
<value value="H2406_013_0"/>
</identifier>
<status value="active"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/insurance-product-type"/>
<code value="mediadv"/>
<display value="Medicare Advantage"/>
</coding>
</type>
<name value="AARP Medicare Advantage from UHC FL-0021 (PPO)"/>
<period>
<start value="2027"/>
<end value="2027"/>
</period>
<ownedBy>
<reference value="#issuer"/>
<display value="UnitedHealthcare"/>
</ownedBy>
<coverageArea>
<reference value="#state-FL"/>
</coverageArea>
<contact>
<purpose>
<text value="General Questions"/>
</purpose>
<telecom>
<system value="phone"/>
<value value="(866)627-7806"/>
</telecom>
<telecom>
<system value="url"/>
<value value="AARPMedicarePlans.com"/>
</telecom>
</contact>
<contact>
<purpose>
<text value="Provider directory"/>
</purpose>
<telecom>
<system value="url"/>
<value value="AARPMedicarePlans.com"/>
</telecom>
</contact>
<coverage>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="HIP"/>
<display value="health insurance plan policy"/>
</coding>
</type>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="primary-care-visit"/>
<display value="Primary Care Visit"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7a"/>
<display value="Primary Care Physician Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="specialist-visit"/>
<display value="Specialist Visit"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7d"/>
<display value="Physician Specialist Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="urgent-care"/>
<display value="Urgent Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="4b"/>
<display value="Urgently Needed Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="emergency-room-care"/>
<display value="Emergency Room Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="4a"/>
<display value="Emergency Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="hospital-inpatient"/>
<display value="Hospital Inpatient Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="1a"/>
<display value="Inpatient Hospital-Acute"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="hospital-outpatient"/>
<display value="Hospital Outpatient Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9a1"/>
<display value="Outpatient Hospital Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="facility-fee"/>
<display value="Facility Fee"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9b"/>
<display value="Ambulatory Surgical Center (ASC) Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="imaging"/>
<display value="Imaging (CT/PET/MRI)"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="8b1"/>
<display value="Diagnostic Radiological Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="rehabilitation"/>
<display value="Rehabilitation Services"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7i"/>
<display
value="Physical Therapy and Speech-Language Pathology Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="mental-health-outpatient"/>
<display value="Mental/Behavioral Health Outpatient Services"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7e1"/>
<display
value="Individual Sessions for Mental Health Specialty Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="emergency-medical-transport"/>
<display value="Emergency Medical Transportation"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="10a1"/>
<display value="Ground Ambulance Services"/>
</coding>
</type>
</benefit>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="skilled-nursing"/>
<display value="Skilled Nursing Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="2"/>
<display value="Skilled Nursing Facility (SNF)"/>
</coding>
</type>
</benefit>
</coverage>
<plan>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit">
<extension url="category">
<valueCodeableConcept>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="8a2"/>
<display value="Lab Services"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</valueCodeableConcept>
</extension>
<extension url="applicability">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="amount">
<valueQuantity>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</valueQuantity>
</extension>
</extension>
<extension url="cost">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</valueCodeableConcept>
</extension>
<extension url="applicability">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="amount">
<valueQuantity>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</valueQuantity>
</extension>
</extension>
</extension>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit">
<extension url="category">
<valueCodeableConcept>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9a2"/>
<display value="Observation Services"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</valueCodeableConcept>
</extension>
<extension url="applicability">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="qualifier">
<valueCodeableConcept>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-day"/>
<display value="Per day"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="amount">
<valueQuantity>
<value value="550"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</valueQuantity>
</extension>
</extension>
<extension url="cost">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay-percent"/>
<display value="Copayment Percent per service"/>
</coding>
<text value="Coinsurance"/>
</valueCodeableConcept>
</extension>
<extension url="applicability">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="amount">
<valueQuantity>
<value value="40"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</valueQuantity>
</extension>
</extension>
</extension>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit">
<extension url="category">
<valueCodeableConcept>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="6"/>
<display value="Home Health Services"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="cost">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</valueCodeableConcept>
</extension>
<extension url="applicability">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="amount">
<valueQuantity>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</valueQuantity>
</extension>
</extension>
<extension url="cost">
<extension url="type">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay-percent"/>
<display value="Copayment Percent per service"/>
</coding>
<text value="Coinsurance"/>
</valueCodeableConcept>
</extension>
<extension url="applicability">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</valueCodeableConcept>
</extension>
<extension url="amount">
<valueQuantity>
<value value="50"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</valueQuantity>
</extension>
</extension>
</extension>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-plan-type"/>
<code value="PPO"/>
<display value="Preferred Provider Organization (PPO)"/>
</coding>
<text value="Local PPO"/>
</type>
<coverageArea>
<reference value="#state-FL"/>
</coverageArea>
<generalCost>
<type>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type"/>
<code value="monthly-premium"/>
<display value="Monthly premium"/>
</coding>
<text value="Monthly premium"/>
</type>
<cost>
<value value="0"/>
<currency value="USD"/>
</cost>
</generalCost>
<generalCost>
<type>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-general-cost-type"/>
<code value="part-b-premium-reduction"/>
<display value="Part B premium reduction"/>
</coding>
<text value="Part B premium reduction"/>
</type>
<comment value="None"/>
</generalCost>
<generalCost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
<extension url="network">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
<code value="out"/>
<display value="Out of Network"/>
</valueCoding>
</extension>
<extension url="member">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
<code value="individual"/>
<display value="Individual"/>
</valueCoding>
</extension>
<extension url="appliesTo">
<valueCoding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
<code value="medical"/>
<display value="Medical"/>
</valueCoding>
</extension>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="deductible"/>
<display value="Deductible"/>
</coding>
<text value="Individual Deductible"/>
</type>
<cost>
<value value="1000"/>
<currency value="USD"/>
</cost>
<comment value="Out of network, for medical care"/>
</generalCost>
<generalCost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
<extension url="network">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
<code value="in"/>
<display value="In Network"/>
</valueCoding>
</extension>
<extension url="member">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
<code value="individual"/>
<display value="Individual"/>
</valueCoding>
</extension>
<extension url="appliesTo">
<valueCoding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
<code value="medical"/>
<display value="Medical"/>
</valueCoding>
</extension>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="maxoutofpocket"/>
<display value="Maximum out of pocket"/>
</coding>
<text value="Individual Out-of-Pocket Maximum"/>
</type>
<cost>
<value value="7150"/>
<currency value="USD"/>
</cost>
<comment value="In network, for medical care"/>
</generalCost>
<generalCost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
<extension url="network">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-network"/>
<code value="out"/>
<display value="Out of Network"/>
</valueCoding>
</extension>
<extension url="member">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
<code value="individual"/>
<display value="Individual"/>
</valueCoding>
</extension>
<extension url="appliesTo">
<valueCoding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
<code value="medical"/>
<display value="Medical"/>
</valueCoding>
</extension>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="maxoutofpocket"/>
<display value="Maximum out of pocket"/>
</coding>
<text value="Individual Out-of-Pocket Maximum"/>
</type>
<comment value="Out of network, for medical care: none"/>
</generalCost>
<generalCost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope">
<extension url="network">
<valueCoding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
<code value="combined"/>
<display value="In and out of network combined"/>
</valueCoding>
</extension>
<extension url="member">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-unit"/>
<code value="individual"/>
<display value="Individual"/>
</valueCoding>
</extension>
<extension url="appliesTo">
<valueCoding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-scope"/>
<code value="medical"/>
<display value="Medical"/>
</valueCoding>
</extension>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/coverage-copay-type"/>
<code value="maxoutofpocket"/>
<display value="Maximum out of pocket"/>
</coding>
<text value="Individual Out-of-Pocket Maximum"/>
</type>
<cost>
<value value="10750"/>
<currency value="USD"/>
</cost>
<comment value="In and out of network combined, for medical care"/>
</generalCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="primary-care-visit"/>
<display value="Primary Care Visit"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7a"/>
<display value="Primary Care Physician Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="primary-care-visit"/>
<display value="Primary Care Visit"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7a"/>
<display value="Primary Care Physician Services"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="45"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="specialist-visit"/>
<display value="Specialist Visit"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7d"/>
<display value="Physician Specialist Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="specialist-visit"/>
<display value="Specialist Visit"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7d"/>
<display value="Physician Specialist Services"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="65"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="65"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="100"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="urgent-care"/>
<display value="Urgent Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="4b"/>
<display value="Urgently Needed Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="urgent-care"/>
<display value="Urgent Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="4b"/>
<display value="Urgently Needed Services"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="50"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="one-price-both-networks"/>
<display value="One price in and out of network"/>
</coding>
</qualifiers>
<value>
<value value="50"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="50"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="one-price-both-networks"/>
<display value="One price in and out of network"/>
</coding>
</qualifiers>
<value>
<value value="50"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="emergency-room-care"/>
<display value="Emergency Room Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="4a"/>
<display value="Emergency Services"/>
</coding>
</category>
<benefit>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
<extension url="limitText">
<valueString
value="Copay waived if admitted to the hospital within 24 hours"/>
</extension>
</extension>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="emergency-room-care"/>
<display value="Emergency Room Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="4a"/>
<display value="Emergency Services"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="one-price-both-networks"/>
<display value="One price in and out of network"/>
</coding>
</qualifiers>
<value>
<value value="130"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="one-price-both-networks"/>
<display value="One price in and out of network"/>
</coding>
</qualifiers>
<value>
<value value="130"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="hospital-inpatient"/>
<display value="Hospital Inpatient Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="1a"/>
<display value="Inpatient Hospital-Acute"/>
</coding>
</category>
<benefit>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
<extension url="limitText">
<valueString
value="Benefit period (in network): Per Admission or Per Stay"/>
</extension>
</extension>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="hospital-inpatient"/>
<display value="Hospital Inpatient Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="1a"/>
<display value="Inpatient Hospital-Acute"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range">
<valueRange>
<low>
<value value="1"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</low>
<high>
<value value="5"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-day"/>
<display value="Per day"/>
</coding>
</qualifiers>
<value>
<value value="550"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range">
<valueRange>
<low>
<value value="6"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</low>
<high>
<value value="90"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-day"/>
<display value="Per day"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-stay"/>
<display value="Per stay"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay-percent"/>
<display value="Copayment Percent per service"/>
</coding>
<text value="Coinsurance"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-stay"/>
<display value="Per stay"/>
</coding>
</qualifiers>
<value>
<value value="40"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="hospital-outpatient"/>
<display value="Hospital Outpatient Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9a1"/>
<display value="Outpatient Hospital Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="hospital-outpatient"/>
<display value="Hospital Outpatient Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9a1"/>
<display value="Outpatient Hospital Services"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="550"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="550"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay-percent"/>
<display value="Copayment Percent per service"/>
</coding>
<text value="Coinsurance"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="40"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="facility-fee"/>
<display value="Facility Fee"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9b"/>
<display value="Ambulatory Surgical Center (ASC) Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="facility-fee"/>
<display value="Facility Fee"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="9b"/>
<display value="Ambulatory Surgical Center (ASC) Services"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="500"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="500"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay-percent"/>
<display value="Copayment Percent per service"/>
</coding>
<text value="Coinsurance"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="40"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="imaging"/>
<display value="Imaging (CT/PET/MRI)"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="8b1"/>
<display value="Diagnostic Radiological Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="imaging"/>
<display value="Imaging (CT/PET/MRI)"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="8b1"/>
<display value="Diagnostic Radiological Services"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="320"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="320"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay-percent"/>
<display value="Copayment Percent per service"/>
</coding>
<text value="Coinsurance"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="40"/>
<unit value="%"/>
<system value="http://unitsofmeasure.org"/>
<code value="%"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="rehabilitation"/>
<display value="Rehabilitation Services"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7i"/>
<display
value="Physical Therapy and Speech-Language Pathology Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="rehabilitation"/>
<display value="Rehabilitation Services"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7i"/>
<display
value="Physical Therapy and Speech-Language Pathology Services"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="65"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="100"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="mental-health-outpatient"/>
<display value="Mental/Behavioral Health Outpatient Services"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7e1"/>
<display
value="Individual Sessions for Mental Health Specialty Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="mental-health-outpatient"/>
<display value="Mental/Behavioral Health Outpatient Services"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="7e1"/>
<display
value="Individual Sessions for Mental Health Specialty Services"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range">
<valueRange>
<low>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</low>
<high>
<value value="25"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="25"/>
<comparator value="<="/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="40"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="emergency-medical-transport"/>
<display value="Emergency Medical Transportation"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="10a1"/>
<display value="Ground Ambulance Services"/>
</coding>
</category>
<benefit>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="emergency-medical-transport"/>
<display value="Emergency Medical Transportation"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="10a1"/>
<display value="Ground Ambulance Services"/>
</coding>
</type>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<value>
<value value="380"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<value>
<value value="380"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
<specificCost>
<category>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="skilled-nursing"/>
<display value="Skilled Nursing Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="2"/>
<display value="Skilled Nursing Facility (SNF)"/>
</coding>
</category>
<benefit>
<extension
url="http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation">
<extension url="limitText">
<valueString
value="Benefit period (in network): Original Medicare"/>
</extension>
</extension>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category"/>
<code value="skilled-nursing"/>
<display value="Skilled Nursing Care"/>
</coding>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/cms-pbp-service-category"/>
<code value="2"/>
<display value="Skilled Nursing Facility (SNF)"/>
</coding>
</type>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range">
<valueRange>
<low>
<value value="1"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</low>
<high>
<value value="20"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-day"/>
<display value="Per day"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range">
<valueRange>
<low>
<value value="21"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</low>
<high>
<value value="100"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="in-network"/>
<display value="In Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-day"/>
<display value="Per day"/>
</coding>
</qualifiers>
<value>
<value value="221"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<extension
url="https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range">
<valueRange>
<low>
<value value="1"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</low>
<high>
<value value="100"/>
<unit value="d"/>
<system value="http://unitsofmeasure.org"/>
<code value="d"/>
</high>
</valueRange>
</extension>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-day"/>
<display value="Per day"/>
</coding>
</qualifiers>
<value>
<value value="250"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
<cost>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/benefit-type"/>
<code value="copay"/>
<display value="Copayment per service"/>
</coding>
<text value="Copayment"/>
</type>
<applicability>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/applicability"/>
<code value="out-of-network"/>
<display value="Out of Network"/>
</coding>
</applicability>
<qualifiers>
<coding>
<system
value="https://haau3.com/fhir/CodeSystem/plan-benefits-cost-qualifier"/>
<code value="per-stay"/>
<display value="Per stay"/>
</coding>
</qualifiers>
<value>
<value value="0"/>
<unit value="USD"/>
<system value="urn:iso:std:iso:4217"/>
<code value="USD"/>
</value>
</cost>
</benefit>
</specificCost>
</plan>
</InsurancePlan>