Plan Benefits

Plan Benefits answers what a Medicare Advantage or ACA Marketplace plan covers and what a member pays, from the files CMS publishes: the Plan Benefit Package (PBP) Benefits files for Medicare Advantage, and the Marketplace public use files for plans sold through HealthCare.gov. The haau3 platform serves each plan as one InsurancePlan on its FHIR base at api.haau3.com. Each plan has one InsurancePlan, and each cost-sharing reduction variant of a Marketplace plan is a plan of its own. Two examples show the whole shape: H2406-013-000, a Medicare Advantage PPO, and 19898FL0340001-01, a Marketplace plan with two in-network tiers.

Two profiles

Every Plan Benefits InsurancePlan names two profiles in meta.profile: this one, and the SBC InsurancePlan profile of the CARIN Digital Insurance Card guide, http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan|2.0.0-ballot. That guide is a ballot, so this guide does not depend on it: as a dependency it would bring US Core 7.0.0 into a guide built on US Core 6.1.0. This profile therefore restates the SBC rules it keeps, and haau3 checks every example against the SBC profile with the HL7 validator and the ballot package. This profile will derive from SBC once SBC is published as a standard.

What every plan carries

• Identity. A Medicare Advantage plan's id is CMS's plan ID with the segment written with three digits (H2406-013-000), as people know the plan; a Marketplace plan's id is its HIOS plan ID (19898FL0340001-01). A Medicare Advantage plan carries CMS's own ma-plan-id (H2406-013-000, the segment written with three digits) and the key exactly as CMS's files write it, the bid_id (H2406_013_0). A Marketplace plan carries its 17-character HIOS plan ID and its 14-character standard component ID.
• Program and plan type. type is HL7's insurance product type: mediadv (Medicare Advantage) or qhp (Qualified Health Plan). PACE and Medicare cost plans, which CMS's Medicare Advantage files hold but which are not Medicare Advantage plans, carry CMS's plan-type words with no code. plan.type is the SBC guide's plan type where its definition covers the plan: HMO, PPO, and a Medicare Advantage HMO-POS as POS. CMS's words are its text, and the other Medicare Advantage plan types (MSA, PFFS, PSO, cost plans and PACE) carry the words alone.
• The release. Source release names the CMS release the plan was read from. For each of CMS's files in it, it gives the address CMS publishes the file at, the date CMS last changed it and its SHA-256, so anyone can fetch the same file and check it.
• The plan year. period is the plan year, start and end, at year precision (2027 to 2027), as CMS's files state it. A Marketplace plan's effective date is in plan facts, so a plan that takes effect after the year starts says so there. Its PlanExpirationDate is the end of plan selection for enrollment, not the end of coverage, so it is in plan facts too and never in period.
• The issuer. ownedBy is a contained Organization with the issuer's marketing name, its legal name as an alias, and its Medicare Advantage contract number or HIOS issuer ID.
• Contacts. contact gives the member services phone and website ("General Questions", in the SBC guide's words) and the provider directory. A Marketplace plan adds its Summary of Benefits and Coverage, its brochure and its drug list. The Marketplace files hold no member services phone or website, so that contact carries a data-absent reason instead of an invented one.
• Where the plan is sold. The plan's states are contained Locations in coverageArea and plan.coverageArea. They are searched with coverage-area-state, because R4's address-state searches the contact's address instead. The counties a plan is sold in, from the service areas in CMS's files, are searched with coverage-area-county by FIPS code; the resource does not carry them. $counties lists a state's counties and their codes, and sold-to separates the plans a person can buy from those sold only to employer and union groups.
• Which providers are in its network. The resource does not say. $in-network asks the CMS National Provider Directory, for up to 20 NPIs, whether it lists each provider in a network the plan names, for the plan's year, and answers with a status for each: in network, not found in the network's listings, not in the directory, or no network data with a reason. A listing is not a statement of a contract, and not found never means out of network, because the directory's network data is incomplete. Two examples show the answers: a Medicare Advantage plan and a Marketplace plan.
• Plan facts. Plan facts holds what each program files about a plan that InsurancePlan has no element for:
  • Medicare Advantage: whether it is a special needs plan, employer-only or Part B-only, whether it files cost data, and whether it covers care out of network or has a point-of-service option.
  • The Marketplace: its metal level, coded with HL7's plan type and with CMS's words as text (an Expanded Bronze plan, which 45 CFR 156.140(c) makes a bronze plan, carries HL7's bronze and haau3's expanded-bronze), its cost-sharing reduction variant, market and HSA eligibility, its effective date and the end of enrollment, its coverage away from home, and the counts that change when a cost applies.

Services and their two codings

Each service carries two codings: the SBC benefit category, and CMS's own reference. For Medicare Advantage that is the PBP service category; for the Marketplace it is the exact benefit name. A service takes an SBC code only where the code's published definition covers it. The SBC benefit categories bind plan.specificCost as required, so the four services they have no code for appear in the additional benefit extension. That extension's parts mirror specificCost.

Three notes on the table:

• Lab. SBC's diagnostic-test is defined as "X-rays and diagnostic imaging other than CT/PET/MRI", and CMS's own crosswalk maps the SBC form's "Diagnostic test (x-ray, blood work)" to the Marketplace's "X-rays and Diagnostic Imaging", not to its lab benefit.
• Therapy. CMS's crosswalk fills the SBC form's rehabilitation row from the Marketplace benefit "Outpatient Rehabilitation Services", a different benefit from the therapy row here. The SBC code's definition, outpatient physical, occupational and speech therapy, covers the therapy row.
• What is left out. These are the services the CMS Real-Time Benefits workgroup's medical MVP requires, and they are the only ones carried. The SBC guide suggests carrying all of its categories; a category that is absent here is not provided by Plan Benefits. It never means "not covered".

Costs

Every service has at least two costs, each with a type, an applicability (in-network or out-of-network) and a value. A cost carries a number, or a data-absent reason instead of one, never both.

• Type. A copay, a coinsurance and a per-service deductible are HL7's benefit type codes copay, copay-percent and deductible, with the SBC guide's words as text: Copayment, Coinsurance, Deductible. haau3's cost type holds the most a member pays in coinsurance for one visit, and, for a cost with no amount, why it has none:

  Code	Meaning	Data-absent reason
  not-covered	The plan's own filing says it does not cover the service in this network: a Marketplace plan's filing for the service, or a Medicare Advantage plan that files no out-of-network benefit at all	not-applicable
  not-filed	The Medicare Advantage plan filed no cost for the service in this network in CMS's public files. This does not show that the plan excludes it	unknown
  not-stated	CMS's file has an entry but states no cost, such as "Not Applicable"	unknown
  not-part-of-plan	The service is not part of the plan, such as hospital care in a plan covering Part B only	not-applicable
  no-cost-data	The plan files no cost data in CMS's public files, as PACE, medical savings account and cost plans do	unknown

  Every service carries at least two costs, as the SBC guide requires. A Medicare Advantage plan that files no out-of-network benefit therefore carries an out-of-network not-covered cost for each service, and a plan with no cost data carries no-cost-data out of network too. Emergency and urgent care are priced once for both networks. A missing amount is never written as $0. When both a copay and a coinsurance are answered No, the member pays $0. That cost is $0, with the qualifier no-copay-or-coinsurance-filed.

• Qualifiers. Cost qualifiers say:
  • which in-network tier a cost is, for a plan with two;
  • whether it is per visit, per day or per stay;
  • when a plan files one price for both networks, so it appears under both;
  • whether CMS's file says "after deductible" or "with deductible". CMS lists these as different values, and haau3 interprets neither. For both, SBC's deductible-applies is true;
  • whether the service counts toward the out-of-pocket maximum.
• Ranges. Medicare Advantage files each copay and coinsurance as a lowest and a highest amount. When they differ, the value is the highest with the comparator <=, and cost range holds both.
• Stays. Hospital and skilled nursing costs are often filed by day range ($550 a day for days 1 to 5, then $0 a day for days 6 to 90). Each range is its own per-day cost, and day range holds its days.
• CMS's words. Each Marketplace cost carries the file's cell in source text, with leading and trailing spaces removed. The plan's explanation of a service goes in SBC's benefit-limitation limitText, and its exclusions in SBC's excluded-services, both verbatim.

Deductibles and out-of-pocket maximums

They are in plan.generalCost. type is HL7's deductible or maxoutofpocket, with the SBC guide's words as text ("Individual Deductible", "Family Out-of-Pocket Maximum"). comment says the network and what the amount applies to in plain words. Cost scope codes the network, whom the amount covers (one member, each person in a family, or the whole family) and what it applies to (medical care, drugs, or both together). In and out of network are HL7's benefit network codes, and one member and the whole family HL7's benefit unit codes; haau3's cost scope codes hold the rest. A Marketplace plan files each amount for each network and family size, and an amount it does not state carries no cost, only its cell. The premium is a generalCost too. The Marketplace files do not hold premiums, which depend on age and where you live, so that cost says so.

Medicare-defined amounts

Some Medicare Advantage plans file a deductible, or hospital or skilled nursing cost sharing, as Original Medicare's own amount with no number of their own. Medicare-defined names the part (A, B, or both). It also carries Original Medicare's latest published amounts, with the year they belong to and CMS's source. CMS publishes each year's amounts in mid-November of the year before. Until the plan year's amounts are published, the cost's value carries a data-absent reason (temp-unknown), and the amounts in the extension are last year's, labelled with their year. Once they are, a cost that is one of Original Medicare's amounts (the Part A deductible alone, or the Part B deductible alone) carries it as its value. A deductible of both parts, and hospital or skilled nursing cost sharing, are several amounts at once: the value then carries the data-absent reason not-applicable, and the extension lists each amount.

Readings

The numbers are haau3's reading of CMS's files. They are not CMS's data, and CMS's own cells are kept beside them where the files give text. Five readings of the Medicare Advantage files decide values. Four come from the Benefit Plan Standard's PBP importer specification and one is haau3's own. Where a reading has been checked against a plan's own Summary of Benefits, the plan is named:

• A PPO annual deductible whose scope names no in-network services is the out-of-network deductible (Benefit Plan Standard 7.3). Verified on H2406-013-000.
• An HMO-POS plan's out-of-network deductible and maximum describe its point-of-service option (Benefit Plan Standard 7.8). Verified on H1609-028-000.
• A service answered No to a copay and No to a coinsurance costs $0 (Benefit Plan Standard 7.12, and the workgroup's own rule).
• Emergency and urgent care are priced once for both networks (Benefit Plan Standard 7.13).
• haau3's own: a service left out of a plan's out-of-network or point-of-service lists is not filed there, and is written not-filed. H1609-028-000's Summary of Benefits shows "Not Covered" out of network for four such services.

The Marketplace values rest on CMS's PY2026 data dictionary's list of allowable values and on no reading of haau3's own.

Until the SBC guide covers these

Every haau3 extension and code system here covers something the SBC guide (2.0.0-ballot) has no place for, and that HL7's own terminology has no code for: where HL7 has one, the guide uses it. Each gives way when the SBC guide adds one:

Not in these files

The public files do not hold premiums for Marketplace plans or plans from the state-run exchanges. They do not say which providers are in a network, which $in-network asks the CMS National Provider Directory instead. Nor do they hold a member's own numbers, such as the visits used or how much of the deductible is met.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
InsurancePlan.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
InsurancePlan.Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for extension.extension:sourceRelease	S This element must be supported.	1..1	(Complex)	Plan Benefits Source Release URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
InsurancePlan.Slices for extension.extension:planFacts	S This element must be supported.	1..1	(Complex)	Plan Benefits Plan Facts URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
InsurancePlan.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
InsurancePlan.Slices for identifier	S This element must be supported. Σ This element is included in summaries. C	1..*	Identifier	Business Identifier for Product Slice: Unordered, Open by value:system Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for identifier.identifier:maPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:maPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:maPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: http://cms.gov/medicare/ma-plan-id
InsurancePlan.Slices for identifier.identifier:maPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-4 Example General: 123456
InsurancePlan.Slices for identifier.identifier:bidId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:bidId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:bidId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/cms-ma-bid-id
InsurancePlan.Slices for identifier.identifier:bidId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-plan-id
InsurancePlan.Slices for identifier.identifier:hiosPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-5 Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-standard-component-id
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Required Pattern: active
InsurancePlan.type	S This element must be supported. Σ This element is included in summaries.	1..1	CodeableConcept	Kind of product Binding: Insurance Product Type (extensible)
InsurancePlan.name	S This element must be supported. Σ This element is included in summaries. C	1..1	string	Official name
InsurancePlan.period	S This element must be supported.	1..1	Period	When the product is available
InsurancePlan.ownedBy	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(Organization)	Plan issuer
InsurancePlan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.contact	S This element must be supported.	1..*	BackboneElement	Contact for the product
InsurancePlan.contact.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage	S This element must be supported.	1..*	BackboneElement	Coverage details
InsurancePlan.coverage.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.type	S This element must be supported.	1..1	CodeableConcept	Type of coverage
InsurancePlan.coverage.benefit	S This element must be supported.	1..*	BackboneElement	List of benefits
InsurancePlan.coverage.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of benefit
InsurancePlan.coverage.benefit.requirement	S This element must be supported.	0..1	string	Referral requirements
InsurancePlan.plan	S This element must be supported.	1..1	BackboneElement	Plan details
InsurancePlan.plan.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.Slices for extension.extension:additionalBenefit	S This element must be supported.	0..*	(Complex)	Plan Benefits Additional Benefit URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
InsurancePlan.plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.type	S This element must be supported.	0..1	CodeableConcept	Type of plan
InsurancePlan.plan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.plan.generalCost	S This element must be supported.	0..*	BackboneElement	Overall costs
InsurancePlan.plan.generalCost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.generalCost.Slices for extension.extension:scope	S This element must be supported.	0..1	(Complex)	Plan Benefits Cost Scope URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
InsurancePlan.plan.generalCost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.generalCost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.generalCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.generalCost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost
InsurancePlan.plan.generalCost.cost	S This element must be supported.	0..1	Money	Cost value
InsurancePlan.plan.generalCost.comment	S This element must be supported.	0..1	string	Additional cost information
InsurancePlan.plan.specificCost	S This element must be supported.	1..*	BackboneElement	Specific costs
InsurancePlan.plan.specificCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.category	S This element must be supported.	1..1	CodeableConcept	General category of benefit
InsurancePlan.plan.specificCost.benefit	S This element must be supported.	1..*	BackboneElement	Benefits list
InsurancePlan.plan.specificCost.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of specific benefit
InsurancePlan.plan.specificCost.benefit.cost	S This element must be supported. C	2..*	BackboneElement	List of the costs Constraints: plan-benefits-6, plan-benefits-7
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:range	S This element must be supported.	0..1	Range	Plan Benefits Cost Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:days	S This element must be supported.	0..1	Range	Plan Benefits Day Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.specificCost.benefit.cost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.cost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost Binding: Plan Benefits Cost Type (extensible)
InsurancePlan.plan.specificCost.benefit.cost.applicability	S This element must be supported.	1..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
InsurancePlan.plan.specificCost.benefit.cost.qualifiers	S This element must be supported.	0..*	CodeableConcept	Additional information about the cost Binding: Plan Benefits Cost Qualifier (extensible)
InsurancePlan.plan.specificCost.benefit.cost.value	S This element must be supported.	1..1	Quantity	The actual cost value
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
InsurancePlan.identifier:maPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:bidId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosStandardComponentId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.status	Base	required	PublicationStatus	📍4.0.1	FHIR Std.
InsurancePlan.type	Base	extensible	Insurance Product Type	📦1.0.0	THO v7.4
InsurancePlan.plan.specificCost.​benefit.cost.type	Base	extensible	Plan Benefits Cost Type	📦1.0.0	This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability	Base	required	Benefit cost applicability	📍4.0.1	FHIR Std.
InsurancePlan.plan.specificCost.​benefit.cost.qualifiers	Base	extensible	Plan Benefits Cost Qualifier	📦1.0.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	InsurancePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	InsurancePlan	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	InsurancePlan	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()
ipn-1	error	InsurancePlan	The organization SHALL at least have a name or an idendtifier, and possibly more than one	(identifier.count() + name.count()) > 0
plan-benefits-3	error	InsurancePlan.plan.generalCost.extension:medicareDefined, InsurancePlan.plan.specificCost.benefit.cost.extension:medicareDefined	An Original Medicare amount comes with the year it belongs to and its source.	extension('amount').exists() implies (extension('year').exists() and extension('source').exists())
plan-benefits-4	error	InsurancePlan.identifier:maPlanId.value	CMS's ma-plan-id is the contract, plan and segment joined with hyphens, the segment three digits: H2406-013-000.	matches('^[A-Z][0-9]{4}-[0-9]{3}-[0-9]{3}$')
plan-benefits-5	error	InsurancePlan.identifier:hiosPlanId.value	A HIOS plan id is the 14-character standard component, a hyphen and a two-digit variant: 19898FL0340001-01.	matches('^[0-9]{5}[A-Z]{2}[0-9]{7}-[0-9]{2}$')
plan-benefits-6	error	InsurancePlan.plan.specificCost.benefit.cost	A cost has an amount, or a data-absent reason instead of one, never both.	value.value.exists() xor value.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()
plan-benefits-7	error	InsurancePlan.plan.specificCost.benefit.cost	A cost whose type says it has no amount (not covered, not in the public files, not stated, not part of this plan, no cost data) carries no number.	type.coding.where(system = 'https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type' and (code = 'not-covered' or code = 'not-filed' or code = 'not-stated' or code = 'not-part-of-plan' or code = 'no-cost-data')).exists() implies value.value.empty()

This structure is derived from InsurancePlan

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
InsurancePlan		0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
InsurancePlan.Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for extension.extension:sourceRelease	S This element must be supported.	1..1	(Complex)	Plan Benefits Source Release URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
InsurancePlan.Slices for extension.extension:planFacts	S This element must be supported.	1..1	(Complex)	Plan Benefits Plan Facts URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
InsurancePlan.Slices for identifier	S This element must be supported.	1..*	Identifier	Business Identifier for Product Slice: Unordered, Open by value:system Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for identifier.identifier:maPlanId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:maPlanId.system		1..1	uri	The namespace for the identifier value Required Pattern: http://cms.gov/medicare/ma-plan-id
InsurancePlan.Slices for identifier.identifier:maPlanId.value	C	1..1	string	The value that is unique Constraints: plan-benefits-4
InsurancePlan.Slices for identifier.identifier:bidId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:bidId.system		1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/cms-ma-bid-id
InsurancePlan.Slices for identifier.identifier:bidId.value		1..1	string	The value that is unique
InsurancePlan.Slices for identifier.identifier:hiosPlanId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosPlanId.system		1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-plan-id
InsurancePlan.Slices for identifier.identifier:hiosPlanId.value	C	1..1	string	The value that is unique Constraints: plan-benefits-5
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.system		1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-standard-component-id
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.value		1..1	string	The value that is unique
InsurancePlan.status	S This element must be supported.	1..1	code	draft | active | retired | unknown Required Pattern: active
InsurancePlan.type	S This element must be supported.	1..1	CodeableConcept	Kind of product Binding: Insurance Product Type (extensible)
InsurancePlan.name	S This element must be supported.	1..1	string	Official name
InsurancePlan.period	S This element must be supported.	1..1	Period	When the product is available
InsurancePlan.ownedBy	S This element must be supported.	1..1	Reference(Organization)	Plan issuer
InsurancePlan.coverageArea	S This element must be supported.	0..*	Reference(Location)	Where product applies
InsurancePlan.contact	S This element must be supported.	1..*	BackboneElement	Contact for the product
InsurancePlan.coverage	S This element must be supported.	1..*	BackboneElement	Coverage details
InsurancePlan.coverage.type	S This element must be supported.	1..1	CodeableConcept	Type of coverage
InsurancePlan.coverage.benefit	S This element must be supported.	1..*	BackboneElement	List of benefits
InsurancePlan.coverage.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of benefit
InsurancePlan.coverage.benefit.requirement	S This element must be supported.	0..1	string	Referral requirements
InsurancePlan.plan	S This element must be supported.	1..1	BackboneElement	Plan details
InsurancePlan.plan.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.Slices for extension.extension:additionalBenefit	S This element must be supported.	0..*	(Complex)	Plan Benefits Additional Benefit URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
InsurancePlan.plan.type	S This element must be supported.	0..1	CodeableConcept	Type of plan
InsurancePlan.plan.coverageArea	S This element must be supported.	0..*	Reference(Location)	Where product applies
InsurancePlan.plan.generalCost	S This element must be supported.	0..*	BackboneElement	Overall costs
InsurancePlan.plan.generalCost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.generalCost.Slices for extension.extension:scope	S This element must be supported.	0..1	(Complex)	Plan Benefits Cost Scope URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
InsurancePlan.plan.generalCost.Slices for extension.extension:medicareDefined	S This element must be supported.	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined
InsurancePlan.plan.generalCost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.generalCost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost
InsurancePlan.plan.generalCost.cost	S This element must be supported.	0..1	Money	Cost value
InsurancePlan.plan.generalCost.comment	S This element must be supported.	0..1	string	Additional cost information
InsurancePlan.plan.specificCost	S This element must be supported.	1..*	BackboneElement	Specific costs
InsurancePlan.plan.specificCost.category	S This element must be supported.	1..1	CodeableConcept	General category of benefit
InsurancePlan.plan.specificCost.benefit	S This element must be supported.	1..*	BackboneElement	Benefits list
InsurancePlan.plan.specificCost.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of specific benefit
InsurancePlan.plan.specificCost.benefit.cost	S This element must be supported. C	2..*	BackboneElement	List of the costs Constraints: plan-benefits-6, plan-benefits-7
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:range	S This element must be supported.	0..1	Range	Plan Benefits Cost Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:days	S This element must be supported.	0..1	Range	Plan Benefits Day Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:medicareDefined	S This element must be supported.	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.specificCost.benefit.cost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost Binding: Plan Benefits Cost Type (extensible)
InsurancePlan.plan.specificCost.benefit.cost.applicability	S This element must be supported.	1..1	CodeableConcept	in-network | out-of-network | other
InsurancePlan.plan.specificCost.benefit.cost.qualifiers	S This element must be supported.	0..*	CodeableConcept	Additional information about the cost Binding: Plan Benefits Cost Qualifier (extensible)
InsurancePlan.plan.specificCost.benefit.cost.value	S This element must be supported.	1..1	Quantity	The actual cost value
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
InsurancePlan.type	Base	extensible	Insurance Product Type	📦1.0.0	THO v7.4
InsurancePlan.plan.specificCost.​benefit.cost.type	Base	extensible	Plan Benefits Cost Type	📦1.0.0	This IG
InsurancePlan.plan.specificCost.​benefit.cost.qualifiers	Base	extensible	Plan Benefits Cost Qualifier	📦1.0.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
plan-benefits-4	error	InsurancePlan.identifier:maPlanId.value	CMS's ma-plan-id is the contract, plan and segment joined with hyphens, the segment three digits: H2406-013-000.	matches('^[A-Z][0-9]{4}-[0-9]{3}-[0-9]{3}$')
plan-benefits-5	error	InsurancePlan.identifier:hiosPlanId.value	A HIOS plan id is the 14-character standard component, a hyphen and a two-digit variant: 19898FL0340001-01.	matches('^[0-9]{5}[A-Z]{2}[0-9]{7}-[0-9]{2}$')
plan-benefits-6	error	InsurancePlan.plan.specificCost.benefit.cost	A cost has an amount, or a data-absent reason instead of one, never both.	value.value.exists() xor value.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()
plan-benefits-7	error	InsurancePlan.plan.specificCost.benefit.cost	A cost whose type says it has no amount (not covered, not in the public files, not stated, not part of this plan, no cost data) carries no number.	type.coding.where(system = 'https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type' and (code = 'not-covered' or code = 'not-filed' or code = 'not-stated' or code = 'not-part-of-plan' or code = 'no-cost-data')).exists() implies value.value.empty()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
InsurancePlan.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
InsurancePlan.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
InsurancePlan.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
InsurancePlan.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
InsurancePlan.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
InsurancePlan.contained		0..*	Resource	Contained, inline Resources
InsurancePlan.Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for extension.extension:sourceRelease	S This element must be supported.	1..1	(Complex)	Plan Benefits Source Release URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
InsurancePlan.Slices for extension.extension:planFacts	S This element must be supported.	1..1	(Complex)	Plan Benefits Plan Facts URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
InsurancePlan.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
InsurancePlan.Slices for identifier	S This element must be supported. Σ This element is included in summaries. C	1..*	Identifier	Business Identifier for Product Slice: Unordered, Open by value:system Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for identifier.identifier:maPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:maPlanId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:maPlanId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:maPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:maPlanId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:maPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: http://cms.gov/medicare/ma-plan-id
InsurancePlan.Slices for identifier.identifier:maPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-4 Example General: 123456
InsurancePlan.Slices for identifier.identifier:maPlanId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:maPlanId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.Slices for identifier.identifier:bidId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:bidId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:bidId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:bidId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:bidId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:bidId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/cms-ma-bid-id
InsurancePlan.Slices for identifier.identifier:bidId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.Slices for identifier.identifier:bidId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:bidId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.Slices for identifier.identifier:hiosPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosPlanId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:hiosPlanId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:hiosPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosPlanId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:hiosPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-plan-id
InsurancePlan.Slices for identifier.identifier:hiosPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-5 Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosPlanId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:hiosPlanId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-standard-component-id
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Required Pattern: active
InsurancePlan.type	S This element must be supported. Σ This element is included in summaries.	1..1	CodeableConcept	Kind of product Binding: Insurance Product Type (extensible)
InsurancePlan.name	S This element must be supported. Σ This element is included in summaries. C	1..1	string	Official name
InsurancePlan.alias		0..*	string	Alternate names
InsurancePlan.period	S This element must be supported.	1..1	Period	When the product is available
InsurancePlan.ownedBy	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(Organization)	Plan issuer
InsurancePlan.administeredBy	Σ This element is included in summaries.	0..1	Reference(Organization)	Product administrator
InsurancePlan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.contact	S This element must be supported.	1..*	BackboneElement	Contact for the product
InsurancePlan.contact.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.contact.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.contact.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.contact.purpose		0..1	CodeableConcept	The type of contact Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
InsurancePlan.contact.name		0..1	HumanName	A name associated with the contact
InsurancePlan.contact.telecom		0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
InsurancePlan.contact.address		0..1	Address	Visiting or postal addresses for the contact
InsurancePlan.endpoint		0..*	Reference(Endpoint)	Technical endpoint
InsurancePlan.network		0..*	Reference(Organization)	What networks are Included
InsurancePlan.coverage	S This element must be supported.	1..*	BackboneElement	Coverage details
InsurancePlan.coverage.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.coverage.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.coverage.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.type	S This element must be supported.	1..1	CodeableConcept	Type of coverage
InsurancePlan.coverage.network		0..*	Reference(Organization)	What networks provide coverage
InsurancePlan.coverage.benefit	S This element must be supported.	1..*	BackboneElement	List of benefits
InsurancePlan.coverage.benefit.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.coverage.benefit.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.coverage.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of benefit
InsurancePlan.coverage.benefit.requirement	S This element must be supported.	0..1	string	Referral requirements
InsurancePlan.coverage.benefit.limit		0..*	BackboneElement	Benefit limits
InsurancePlan.coverage.benefit.limit.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.coverage.benefit.limit.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.coverage.benefit.limit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.benefit.limit.value		0..1	Quantity	Maximum value allowed
InsurancePlan.coverage.benefit.limit.code		0..1	CodeableConcept	Benefit limit details
InsurancePlan.plan	S This element must be supported.	1..1	BackboneElement	Plan details
InsurancePlan.plan.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.Slices for extension.extension:additionalBenefit	S This element must be supported.	0..*	(Complex)	Plan Benefits Additional Benefit URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
InsurancePlan.plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.identifier	Σ This element is included in summaries.	0..*	Identifier	Business Identifier for Product
InsurancePlan.plan.type	S This element must be supported.	0..1	CodeableConcept	Type of plan
InsurancePlan.plan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.plan.network		0..*	Reference(Organization)	What networks provide coverage
InsurancePlan.plan.generalCost	S This element must be supported.	0..*	BackboneElement	Overall costs
InsurancePlan.plan.generalCost.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.generalCost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.generalCost.Slices for extension.extension:scope	S This element must be supported.	0..1	(Complex)	Plan Benefits Cost Scope URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
InsurancePlan.plan.generalCost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.generalCost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.generalCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.generalCost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost
InsurancePlan.plan.generalCost.groupSize		0..1	positiveInt	Number of enrollees
InsurancePlan.plan.generalCost.cost	S This element must be supported.	0..1	Money	Cost value
InsurancePlan.plan.generalCost.comment	S This element must be supported.	0..1	string	Additional cost information
InsurancePlan.plan.specificCost	S This element must be supported.	1..*	BackboneElement	Specific costs
InsurancePlan.plan.specificCost.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.specificCost.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.plan.specificCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.category	S This element must be supported.	1..1	CodeableConcept	General category of benefit
InsurancePlan.plan.specificCost.benefit	S This element must be supported.	1..*	BackboneElement	Benefits list
InsurancePlan.plan.specificCost.benefit.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.specificCost.benefit.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.plan.specificCost.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of specific benefit
InsurancePlan.plan.specificCost.benefit.cost	S This element must be supported. C	2..*	BackboneElement	List of the costs Constraints: plan-benefits-6, plan-benefits-7
InsurancePlan.plan.specificCost.benefit.cost.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:range	S This element must be supported.	0..1	Range	Plan Benefits Cost Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:days	S This element must be supported.	0..1	Range	Plan Benefits Day Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.specificCost.benefit.cost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.cost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost Binding: Plan Benefits Cost Type (extensible)
InsurancePlan.plan.specificCost.benefit.cost.applicability	S This element must be supported.	1..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
InsurancePlan.plan.specificCost.benefit.cost.qualifiers	S This element must be supported.	0..*	CodeableConcept	Additional information about the cost Binding: Plan Benefits Cost Qualifier (extensible)
InsurancePlan.plan.specificCost.benefit.cost.value	S This element must be supported.	1..1	Quantity	The actual cost value
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
InsurancePlan.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
InsurancePlan.identifier:maPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:maPlanId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.identifier:bidId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:bidId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosPlanId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosStandardComponentId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosStandardComponentId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.status	Base	required	PublicationStatus	📍4.0.1	FHIR Std.
InsurancePlan.type	Base	extensible	Insurance Product Type	📦1.0.0	THO v7.4
InsurancePlan.contact.​purpose	Base	extensible	Contact entity type	📍4.0.1	FHIR Std.
InsurancePlan.plan.specificCost.​benefit.cost.type	Base	extensible	Plan Benefits Cost Type	📦1.0.0	This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability	Base	required	Benefit cost applicability	📍4.0.1	FHIR Std.
InsurancePlan.plan.specificCost.​benefit.cost.qualifiers	Base	extensible	Plan Benefits Cost Qualifier	📦1.0.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	InsurancePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	InsurancePlan	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	InsurancePlan	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()
ipn-1	error	InsurancePlan	The organization SHALL at least have a name or an idendtifier, and possibly more than one	(identifier.count() + name.count()) > 0
plan-benefits-3	error	InsurancePlan.plan.generalCost.extension:medicareDefined, InsurancePlan.plan.specificCost.benefit.cost.extension:medicareDefined	An Original Medicare amount comes with the year it belongs to and its source.	extension('amount').exists() implies (extension('year').exists() and extension('source').exists())
plan-benefits-4	error	InsurancePlan.identifier:maPlanId.value	CMS's ma-plan-id is the contract, plan and segment joined with hyphens, the segment three digits: H2406-013-000.	matches('^[A-Z][0-9]{4}-[0-9]{3}-[0-9]{3}$')
plan-benefits-5	error	InsurancePlan.identifier:hiosPlanId.value	A HIOS plan id is the 14-character standard component, a hyphen and a two-digit variant: 19898FL0340001-01.	matches('^[0-9]{5}[A-Z]{2}[0-9]{7}-[0-9]{2}$')
plan-benefits-6	error	InsurancePlan.plan.specificCost.benefit.cost	A cost has an amount, or a data-absent reason instead of one, never both.	value.value.exists() xor value.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()
plan-benefits-7	error	InsurancePlan.plan.specificCost.benefit.cost	A cost whose type says it has no amount (not covered, not in the public files, not stated, not part of this plan, no cost data) carries no number.	type.coding.where(system = 'https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type' and (code = 'not-covered' or code = 'not-filed' or code = 'not-stated' or code = 'not-part-of-plan' or code = 'no-cost-data')).exists() implies value.value.empty()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
InsurancePlan.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
InsurancePlan.Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for extension.extension:sourceRelease	S This element must be supported.	1..1	(Complex)	Plan Benefits Source Release URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
InsurancePlan.Slices for extension.extension:planFacts	S This element must be supported.	1..1	(Complex)	Plan Benefits Plan Facts URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
InsurancePlan.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
InsurancePlan.Slices for identifier	S This element must be supported. Σ This element is included in summaries. C	1..*	Identifier	Business Identifier for Product Slice: Unordered, Open by value:system Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for identifier.identifier:maPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:maPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:maPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: http://cms.gov/medicare/ma-plan-id
InsurancePlan.Slices for identifier.identifier:maPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-4 Example General: 123456
InsurancePlan.Slices for identifier.identifier:bidId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:bidId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:bidId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/cms-ma-bid-id
InsurancePlan.Slices for identifier.identifier:bidId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-plan-id
InsurancePlan.Slices for identifier.identifier:hiosPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-5 Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-standard-component-id
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Required Pattern: active
InsurancePlan.type	S This element must be supported. Σ This element is included in summaries.	1..1	CodeableConcept	Kind of product Binding: Insurance Product Type (extensible)
InsurancePlan.name	S This element must be supported. Σ This element is included in summaries. C	1..1	string	Official name
InsurancePlan.period	S This element must be supported.	1..1	Period	When the product is available
InsurancePlan.ownedBy	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(Organization)	Plan issuer
InsurancePlan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.contact	S This element must be supported.	1..*	BackboneElement	Contact for the product
InsurancePlan.contact.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage	S This element must be supported.	1..*	BackboneElement	Coverage details
InsurancePlan.coverage.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.type	S This element must be supported.	1..1	CodeableConcept	Type of coverage
InsurancePlan.coverage.benefit	S This element must be supported.	1..*	BackboneElement	List of benefits
InsurancePlan.coverage.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of benefit
InsurancePlan.coverage.benefit.requirement	S This element must be supported.	0..1	string	Referral requirements
InsurancePlan.plan	S This element must be supported.	1..1	BackboneElement	Plan details
InsurancePlan.plan.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.Slices for extension.extension:additionalBenefit	S This element must be supported.	0..*	(Complex)	Plan Benefits Additional Benefit URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
InsurancePlan.plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.type	S This element must be supported.	0..1	CodeableConcept	Type of plan
InsurancePlan.plan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.plan.generalCost	S This element must be supported.	0..*	BackboneElement	Overall costs
InsurancePlan.plan.generalCost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.generalCost.Slices for extension.extension:scope	S This element must be supported.	0..1	(Complex)	Plan Benefits Cost Scope URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
InsurancePlan.plan.generalCost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.generalCost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.generalCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.generalCost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost
InsurancePlan.plan.generalCost.cost	S This element must be supported.	0..1	Money	Cost value
InsurancePlan.plan.generalCost.comment	S This element must be supported.	0..1	string	Additional cost information
InsurancePlan.plan.specificCost	S This element must be supported.	1..*	BackboneElement	Specific costs
InsurancePlan.plan.specificCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.category	S This element must be supported.	1..1	CodeableConcept	General category of benefit
InsurancePlan.plan.specificCost.benefit	S This element must be supported.	1..*	BackboneElement	Benefits list
InsurancePlan.plan.specificCost.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of specific benefit
InsurancePlan.plan.specificCost.benefit.cost	S This element must be supported. C	2..*	BackboneElement	List of the costs Constraints: plan-benefits-6, plan-benefits-7
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:range	S This element must be supported.	0..1	Range	Plan Benefits Cost Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:days	S This element must be supported.	0..1	Range	Plan Benefits Day Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.specificCost.benefit.cost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.cost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost Binding: Plan Benefits Cost Type (extensible)
InsurancePlan.plan.specificCost.benefit.cost.applicability	S This element must be supported.	1..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
InsurancePlan.plan.specificCost.benefit.cost.qualifiers	S This element must be supported.	0..*	CodeableConcept	Additional information about the cost Binding: Plan Benefits Cost Qualifier (extensible)
InsurancePlan.plan.specificCost.benefit.cost.value	S This element must be supported.	1..1	Quantity	The actual cost value
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
InsurancePlan.identifier:maPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:bidId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosStandardComponentId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.status	Base	required	PublicationStatus	📍4.0.1	FHIR Std.
InsurancePlan.type	Base	extensible	Insurance Product Type	📦1.0.0	THO v7.4
InsurancePlan.plan.specificCost.​benefit.cost.type	Base	extensible	Plan Benefits Cost Type	📦1.0.0	This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability	Base	required	Benefit cost applicability	📍4.0.1	FHIR Std.
InsurancePlan.plan.specificCost.​benefit.cost.qualifiers	Base	extensible	Plan Benefits Cost Qualifier	📦1.0.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	InsurancePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	InsurancePlan	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	InsurancePlan	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()
ipn-1	error	InsurancePlan	The organization SHALL at least have a name or an idendtifier, and possibly more than one	(identifier.count() + name.count()) > 0
plan-benefits-3	error	InsurancePlan.plan.generalCost.extension:medicareDefined, InsurancePlan.plan.specificCost.benefit.cost.extension:medicareDefined	An Original Medicare amount comes with the year it belongs to and its source.	extension('amount').exists() implies (extension('year').exists() and extension('source').exists())
plan-benefits-4	error	InsurancePlan.identifier:maPlanId.value	CMS's ma-plan-id is the contract, plan and segment joined with hyphens, the segment three digits: H2406-013-000.	matches('^[A-Z][0-9]{4}-[0-9]{3}-[0-9]{3}$')
plan-benefits-5	error	InsurancePlan.identifier:hiosPlanId.value	A HIOS plan id is the 14-character standard component, a hyphen and a two-digit variant: 19898FL0340001-01.	matches('^[0-9]{5}[A-Z]{2}[0-9]{7}-[0-9]{2}$')
plan-benefits-6	error	InsurancePlan.plan.specificCost.benefit.cost	A cost has an amount, or a data-absent reason instead of one, never both.	value.value.exists() xor value.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()
plan-benefits-7	error	InsurancePlan.plan.specificCost.benefit.cost	A cost whose type says it has no amount (not covered, not in the public files, not stated, not part of this plan, no cost data) carries no number.	type.coding.where(system = 'https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type' and (code = 'not-covered' or code = 'not-filed' or code = 'not-stated' or code = 'not-part-of-plan' or code = 'no-cost-data')).exists() implies value.value.empty()

Differential View

This structure is derived from InsurancePlan

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
InsurancePlan		0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
InsurancePlan.Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for extension.extension:sourceRelease	S This element must be supported.	1..1	(Complex)	Plan Benefits Source Release URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
InsurancePlan.Slices for extension.extension:planFacts	S This element must be supported.	1..1	(Complex)	Plan Benefits Plan Facts URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
InsurancePlan.Slices for identifier	S This element must be supported.	1..*	Identifier	Business Identifier for Product Slice: Unordered, Open by value:system Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for identifier.identifier:maPlanId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:maPlanId.system		1..1	uri	The namespace for the identifier value Required Pattern: http://cms.gov/medicare/ma-plan-id
InsurancePlan.Slices for identifier.identifier:maPlanId.value	C	1..1	string	The value that is unique Constraints: plan-benefits-4
InsurancePlan.Slices for identifier.identifier:bidId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:bidId.system		1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/cms-ma-bid-id
InsurancePlan.Slices for identifier.identifier:bidId.value		1..1	string	The value that is unique
InsurancePlan.Slices for identifier.identifier:hiosPlanId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosPlanId.system		1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-plan-id
InsurancePlan.Slices for identifier.identifier:hiosPlanId.value	C	1..1	string	The value that is unique Constraints: plan-benefits-5
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId	S This element must be supported.	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.system		1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-standard-component-id
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.value		1..1	string	The value that is unique
InsurancePlan.status	S This element must be supported.	1..1	code	draft | active | retired | unknown Required Pattern: active
InsurancePlan.type	S This element must be supported.	1..1	CodeableConcept	Kind of product Binding: Insurance Product Type (extensible)
InsurancePlan.name	S This element must be supported.	1..1	string	Official name
InsurancePlan.period	S This element must be supported.	1..1	Period	When the product is available
InsurancePlan.ownedBy	S This element must be supported.	1..1	Reference(Organization)	Plan issuer
InsurancePlan.coverageArea	S This element must be supported.	0..*	Reference(Location)	Where product applies
InsurancePlan.contact	S This element must be supported.	1..*	BackboneElement	Contact for the product
InsurancePlan.coverage	S This element must be supported.	1..*	BackboneElement	Coverage details
InsurancePlan.coverage.type	S This element must be supported.	1..1	CodeableConcept	Type of coverage
InsurancePlan.coverage.benefit	S This element must be supported.	1..*	BackboneElement	List of benefits
InsurancePlan.coverage.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of benefit
InsurancePlan.coverage.benefit.requirement	S This element must be supported.	0..1	string	Referral requirements
InsurancePlan.plan	S This element must be supported.	1..1	BackboneElement	Plan details
InsurancePlan.plan.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.Slices for extension.extension:additionalBenefit	S This element must be supported.	0..*	(Complex)	Plan Benefits Additional Benefit URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
InsurancePlan.plan.type	S This element must be supported.	0..1	CodeableConcept	Type of plan
InsurancePlan.plan.coverageArea	S This element must be supported.	0..*	Reference(Location)	Where product applies
InsurancePlan.plan.generalCost	S This element must be supported.	0..*	BackboneElement	Overall costs
InsurancePlan.plan.generalCost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.generalCost.Slices for extension.extension:scope	S This element must be supported.	0..1	(Complex)	Plan Benefits Cost Scope URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
InsurancePlan.plan.generalCost.Slices for extension.extension:medicareDefined	S This element must be supported.	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined
InsurancePlan.plan.generalCost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.generalCost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost
InsurancePlan.plan.generalCost.cost	S This element must be supported.	0..1	Money	Cost value
InsurancePlan.plan.generalCost.comment	S This element must be supported.	0..1	string	Additional cost information
InsurancePlan.plan.specificCost	S This element must be supported.	1..*	BackboneElement	Specific costs
InsurancePlan.plan.specificCost.category	S This element must be supported.	1..1	CodeableConcept	General category of benefit
InsurancePlan.plan.specificCost.benefit	S This element must be supported.	1..*	BackboneElement	Benefits list
InsurancePlan.plan.specificCost.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of specific benefit
InsurancePlan.plan.specificCost.benefit.cost	S This element must be supported. C	2..*	BackboneElement	List of the costs Constraints: plan-benefits-6, plan-benefits-7
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:range	S This element must be supported.	0..1	Range	Plan Benefits Cost Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:days	S This element must be supported.	0..1	Range	Plan Benefits Day Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:medicareDefined	S This element must be supported.	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.specificCost.benefit.cost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost Binding: Plan Benefits Cost Type (extensible)
InsurancePlan.plan.specificCost.benefit.cost.applicability	S This element must be supported.	1..1	CodeableConcept	in-network | out-of-network | other
InsurancePlan.plan.specificCost.benefit.cost.qualifiers	S This element must be supported.	0..*	CodeableConcept	Additional information about the cost Binding: Plan Benefits Cost Qualifier (extensible)
InsurancePlan.plan.specificCost.benefit.cost.value	S This element must be supported.	1..1	Quantity	The actual cost value
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
InsurancePlan.type	Base	extensible	Insurance Product Type	📦1.0.0	THO v7.4
InsurancePlan.plan.specificCost.​benefit.cost.type	Base	extensible	Plan Benefits Cost Type	📦1.0.0	This IG
InsurancePlan.plan.specificCost.​benefit.cost.qualifiers	Base	extensible	Plan Benefits Cost Qualifier	📦1.0.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
plan-benefits-4	error	InsurancePlan.identifier:maPlanId.value	CMS's ma-plan-id is the contract, plan and segment joined with hyphens, the segment three digits: H2406-013-000.	matches('^[A-Z][0-9]{4}-[0-9]{3}-[0-9]{3}$')
plan-benefits-5	error	InsurancePlan.identifier:hiosPlanId.value	A HIOS plan id is the 14-character standard component, a hyphen and a two-digit variant: 19898FL0340001-01.	matches('^[0-9]{5}[A-Z]{2}[0-9]{7}-[0-9]{2}$')
plan-benefits-6	error	InsurancePlan.plan.specificCost.benefit.cost	A cost has an amount, or a data-absent reason instead of one, never both.	value.value.exists() xor value.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()
plan-benefits-7	error	InsurancePlan.plan.specificCost.benefit.cost	A cost whose type says it has no amount (not covered, not in the public files, not stated, not part of this plan, no cost data) carries no number.	type.coding.where(system = 'https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type' and (code = 'not-covered' or code = 'not-filed' or code = 'not-stated' or code = 'not-part-of-plan' or code = 'no-cost-data')).exists() implies value.value.empty()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1
InsurancePlan.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
InsurancePlan.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
InsurancePlan.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
InsurancePlan.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
InsurancePlan.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
InsurancePlan.contained		0..*	Resource	Contained, inline Resources
InsurancePlan.Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for extension.extension:sourceRelease	S This element must be supported.	1..1	(Complex)	Plan Benefits Source Release URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
InsurancePlan.Slices for extension.extension:planFacts	S This element must be supported.	1..1	(Complex)	Plan Benefits Plan Facts URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
InsurancePlan.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
InsurancePlan.Slices for identifier	S This element must be supported. Σ This element is included in summaries. C	1..*	Identifier	Business Identifier for Product Slice: Unordered, Open by value:system Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.Slices for identifier.identifier:maPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:maPlanId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:maPlanId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:maPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:maPlanId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:maPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: http://cms.gov/medicare/ma-plan-id
InsurancePlan.Slices for identifier.identifier:maPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-4 Example General: 123456
InsurancePlan.Slices for identifier.identifier:maPlanId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:maPlanId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.Slices for identifier.identifier:bidId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:bidId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:bidId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:bidId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:bidId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:bidId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/cms-ma-bid-id
InsurancePlan.Slices for identifier.identifier:bidId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.Slices for identifier.identifier:bidId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:bidId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.Slices for identifier.identifier:hiosPlanId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosPlanId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:hiosPlanId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:hiosPlanId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosPlanId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:hiosPlanId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-plan-id
InsurancePlan.Slices for identifier.identifier:hiosPlanId.value	Σ This element is included in summaries. C	1..1	string	The value that is unique Constraints: plan-benefits-5 Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosPlanId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:hiosPlanId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId	S This element must be supported. Σ This element is included in summaries. C	0..1	Identifier	Business Identifier for Product
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Required Pattern: https://haau3.com/fhir/NamingSystem/hios-standard-component-id
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.value	Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
InsurancePlan.Slices for identifier.identifier:hiosStandardComponentId.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
InsurancePlan.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Required Pattern: active
InsurancePlan.type	S This element must be supported. Σ This element is included in summaries.	1..1	CodeableConcept	Kind of product Binding: Insurance Product Type (extensible)
InsurancePlan.name	S This element must be supported. Σ This element is included in summaries. C	1..1	string	Official name
InsurancePlan.alias		0..*	string	Alternate names
InsurancePlan.period	S This element must be supported.	1..1	Period	When the product is available
InsurancePlan.ownedBy	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(Organization)	Plan issuer
InsurancePlan.administeredBy	Σ This element is included in summaries.	0..1	Reference(Organization)	Product administrator
InsurancePlan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.contact	S This element must be supported.	1..*	BackboneElement	Contact for the product
InsurancePlan.contact.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.contact.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.contact.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.contact.purpose		0..1	CodeableConcept	The type of contact Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.
InsurancePlan.contact.name		0..1	HumanName	A name associated with the contact
InsurancePlan.contact.telecom		0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
InsurancePlan.contact.address		0..1	Address	Visiting or postal addresses for the contact
InsurancePlan.endpoint		0..*	Reference(Endpoint)	Technical endpoint
InsurancePlan.network		0..*	Reference(Organization)	What networks are Included
InsurancePlan.coverage	S This element must be supported.	1..*	BackboneElement	Coverage details
InsurancePlan.coverage.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.coverage.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.coverage.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.type	S This element must be supported.	1..1	CodeableConcept	Type of coverage
InsurancePlan.coverage.network		0..*	Reference(Organization)	What networks provide coverage
InsurancePlan.coverage.benefit	S This element must be supported.	1..*	BackboneElement	List of benefits
InsurancePlan.coverage.benefit.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.coverage.benefit.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.coverage.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of benefit
InsurancePlan.coverage.benefit.requirement	S This element must be supported.	0..1	string	Referral requirements
InsurancePlan.coverage.benefit.limit		0..*	BackboneElement	Benefit limits
InsurancePlan.coverage.benefit.limit.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.coverage.benefit.limit.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.coverage.benefit.limit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.coverage.benefit.limit.value		0..1	Quantity	Maximum value allowed
InsurancePlan.coverage.benefit.limit.code		0..1	CodeableConcept	Benefit limit details
InsurancePlan.plan	S This element must be supported.	1..1	BackboneElement	Plan details
InsurancePlan.plan.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.Slices for extension.extension:additionalBenefit	S This element must be supported.	0..*	(Complex)	Plan Benefits Additional Benefit URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
InsurancePlan.plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.identifier	Σ This element is included in summaries.	0..*	Identifier	Business Identifier for Product
InsurancePlan.plan.type	S This element must be supported.	0..1	CodeableConcept	Type of plan
InsurancePlan.plan.coverageArea	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(Location)	Where product applies
InsurancePlan.plan.network		0..*	Reference(Organization)	What networks provide coverage
InsurancePlan.plan.generalCost	S This element must be supported.	0..*	BackboneElement	Overall costs
InsurancePlan.plan.generalCost.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.generalCost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.generalCost.Slices for extension.extension:scope	S This element must be supported.	0..1	(Complex)	Plan Benefits Cost Scope URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
InsurancePlan.plan.generalCost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.generalCost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.generalCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.generalCost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost
InsurancePlan.plan.generalCost.groupSize		0..1	positiveInt	Number of enrollees
InsurancePlan.plan.generalCost.cost	S This element must be supported.	0..1	Money	Cost value
InsurancePlan.plan.generalCost.comment	S This element must be supported.	0..1	string	Additional cost information
InsurancePlan.plan.specificCost	S This element must be supported.	1..*	BackboneElement	Specific costs
InsurancePlan.plan.specificCost.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.specificCost.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.plan.specificCost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.category	S This element must be supported.	1..1	CodeableConcept	General category of benefit
InsurancePlan.plan.specificCost.benefit	S This element must be supported.	1..*	BackboneElement	Benefits list
InsurancePlan.plan.specificCost.benefit.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.specificCost.benefit.extension		0..*	Extension	Additional content defined by implementations
InsurancePlan.plan.specificCost.benefit.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.type	S This element must be supported.	1..1	CodeableConcept	Type of specific benefit
InsurancePlan.plan.specificCost.benefit.cost	S This element must be supported. C	2..*	BackboneElement	List of the costs Constraints: plan-benefits-6, plan-benefits-7
InsurancePlan.plan.specificCost.benefit.cost.id		0..1	string	Unique id for inter-element referencing
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:range	S This element must be supported.	0..1	Range	Plan Benefits Cost Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:days	S This element must be supported.	0..1	Range	Plan Benefits Day Range URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:medicareDefined	S This element must be supported. C	0..1	(Complex)	Plan Benefits Medicare-Defined Amount URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined Constraints: plan-benefits-3
InsurancePlan.plan.specificCost.benefit.cost.Slices for extension.extension:sourceText	S This element must be supported.	0..1	string	Plan Benefits Source Text URL: https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
InsurancePlan.plan.specificCost.benefit.cost.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
InsurancePlan.plan.specificCost.benefit.cost.type	S This element must be supported.	1..1	CodeableConcept	Type of cost Binding: Plan Benefits Cost Type (extensible)
InsurancePlan.plan.specificCost.benefit.cost.applicability	S This element must be supported.	1..1	CodeableConcept	in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.
InsurancePlan.plan.specificCost.benefit.cost.qualifiers	S This element must be supported.	0..*	CodeableConcept	Additional information about the cost Binding: Plan Benefits Cost Qualifier (extensible)
InsurancePlan.plan.specificCost.benefit.cost.value	S This element must be supported.	1..1	Quantity	The actual cost value
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
InsurancePlan.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
InsurancePlan.identifier:maPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:maPlanId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.identifier:bidId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:bidId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosPlanId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosPlanId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosStandardComponentId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
InsurancePlan.identifier:hiosStandardComponentId.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
InsurancePlan.status	Base	required	PublicationStatus	📍4.0.1	FHIR Std.
InsurancePlan.type	Base	extensible	Insurance Product Type	📦1.0.0	THO v7.4
InsurancePlan.contact.​purpose	Base	extensible	Contact entity type	📍4.0.1	FHIR Std.
InsurancePlan.plan.specificCost.​benefit.cost.type	Base	extensible	Plan Benefits Cost Type	📦1.0.0	This IG
InsurancePlan.plan.specificCost.​benefit.cost.applicability	Base	required	Benefit cost applicability	📍4.0.1	FHIR Std.
InsurancePlan.plan.specificCost.​benefit.cost.qualifiers	Base	extensible	Plan Benefits Cost Qualifier	📦1.0.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	InsurancePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	InsurancePlan	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	InsurancePlan	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	InsurancePlan	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()
ipn-1	error	InsurancePlan	The organization SHALL at least have a name or an idendtifier, and possibly more than one	(identifier.count() + name.count()) > 0
plan-benefits-3	error	InsurancePlan.plan.generalCost.extension:medicareDefined, InsurancePlan.plan.specificCost.benefit.cost.extension:medicareDefined	An Original Medicare amount comes with the year it belongs to and its source.	extension('amount').exists() implies (extension('year').exists() and extension('source').exists())
plan-benefits-4	error	InsurancePlan.identifier:maPlanId.value	CMS's ma-plan-id is the contract, plan and segment joined with hyphens, the segment three digits: H2406-013-000.	matches('^[A-Z][0-9]{4}-[0-9]{3}-[0-9]{3}$')
plan-benefits-5	error	InsurancePlan.identifier:hiosPlanId.value	A HIOS plan id is the 14-character standard component, a hyphen and a two-digit variant: 19898FL0340001-01.	matches('^[0-9]{5}[A-Z]{2}[0-9]{7}-[0-9]{2}$')
plan-benefits-6	error	InsurancePlan.plan.specificCost.benefit.cost	A cost has an amount, or a data-absent reason instead of one, never both.	value.value.exists() xor value.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()
plan-benefits-7	error	InsurancePlan.plan.specificCost.benefit.cost	A cost whose type says it has no amount (not covered, not in the public files, not stated, not part of this plan, no cost data) carries no number.	type.coding.where(system = 'https://haau3.com/fhir/CodeSystem/plan-benefits-cost-type' and (code = 'not-covered' or code = 'not-filed' or code = 'not-stated' or code = 'not-part-of-plan' or code = 'no-cost-data')).exists() implies value.value.empty()

This structure is derived from InsurancePlan

Summary

Mandatory: 15 elements(9 nested mandatory elements)
Must-Support: 43 elements

Extensions

This structure refers to these extensions:

• https://haau3.com/fhir/StructureDefinition/plan-benefits-source-release
• https://haau3.com/fhir/StructureDefinition/plan-benefits-plan-facts
• https://haau3.com/fhir/StructureDefinition/plan-benefits-additional-benefit
• https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-scope
• https://haau3.com/fhir/StructureDefinition/plan-benefits-medicare-defined
• https://haau3.com/fhir/StructureDefinition/plan-benefits-source-text
• https://haau3.com/fhir/StructureDefinition/plan-benefits-cost-range
• https://haau3.com/fhir/StructureDefinition/plan-benefits-day-range

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of InsurancePlan.identifier