- 1 InsurancePlan
- 1.1 Owning work group name
- 1.2 Committee Approval Date:
- 1.3 Contributing or Reviewing Work Groups
- 1.4 FHIR Resource Development Project Insight ID
- 1.5 Scope of coverage
- 1.6 RIM scope
- 1.7 Resource appropriateness
- 1.8 Expected implementations
- 1.9 Content sources
- 1.10 Example Scenarios
- 1.11 Resource Relationships
- 1.12 Timelines
- 1.13 gForge Users
- 1.14 When Resource Proposal Is Complete
- 1.15 FMG Notes
Formerly called ProductPlan
Owning work group name
Committee Approval Date:
11 July 2018 (with renaming to InsurancePlan)
Contributing or Reviewing Work Groups
- Financial Management
- Seeking other interested workgroups
FHIR Resource Development Project Insight ID
Scope of coverage
The InsurancePlan resource describes a total health insurance offering, including the list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan). A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. (e.g. Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Dental, Vision, etc)
Elements associated with a product include:
- â€œDemographicâ€� information about the product, e.g. who owns/administers it, where itâ€™s available, what itâ€™s called, what networks itâ€™s associated with, etc.
- Information about the productâ€™s covered benefits, e.g. type of coverage (medical, dental, drug, etc.), type of benefit (primary care visit, specialist visit, inpatient hospital services, etc.), limits on the benefit (number of visits per month, days per admission, hours per visit, etc.)
For example, an insurer may offer a product which provides medical and dental coverage, comprising benefits such as primary care visits, inpatient hospital services, outpatient surgical services, specialist visits, routine dental services/cleanings etc. through an HMO network.
A plan pairs the health insurance coverage benefits under a product with a particular cost sharing structure offered to the consumer. A given product may have multiple plans (e.g. in the US individual health insurance marketplace, plans have a â€œmetalâ€� level that indicates the general percentage of costs a consumer is responsible for). Elements associated with a plan include:
- â€œDemographicâ€� information about the plan, e.g. the type of plan (bronze, silver, gold, high deductible, etc.), where the plan is offered to consumers,
- General costs to the consumer, e.g. the planâ€™s premium, deductible, and out-of-pocket limit/cap
- Specific costs associated with specific benefits, e.g. a copay for a prescription, coinsurance for a primary care provider visit, etc.
The InsurancePlan does not represent the details for a specific patient, that is the Coverage resource.
A catalog to discover providers that provide specific insurance products is useful for both patients/consumers, and also for providers to verify details.
The information from the catalog will also be able to be utilized in Patient Coverage resources.
The ONC has indicated that they desire to create a service that uses this capability where they will be distributing aggregated healthcare directory data from a central service to Organizations for local usage (based on a specific data usage agreement)
- Centralized Healthcare Directory service
- Distributed/Federated Provider Directory service
- Aggregated Directory Service
Reference(any) - Our initial requirements are needed against:
We do not currently expect other resources to specifically reference InsurancePlan
Sept Ballot 2018 - draft was in Jan 2018 Comment ballot
- Cooper Thompson
- Andrew Torres
When Resource Proposal Is Complete
When you have completed your proposal, please send an email to FMGcontact@HL7.org