{ "resourceType": "Bundle", "id": "bps-aetna-medicare-select-extra-hmo-pos-h1609-028-000", "type": "collection", "entry": [ { "fullUrl": "urn:uuid:cc720b18-33e7-514c-a279-fc97c844eed7", "resource": { "resourceType": "InsurancePlan", "id": "aetna-medicare-select-extra-hmo-pos-h1609-028-000", "meta": { "profile": [ "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan" ] }, "text": { "status": "generated", "div": "

Aetna Medicare Select Extra (HMO-POS)

Carrier: Aetna Medicare. Plan type: HMO_POS. Period: 2027 to 2027.

16 benefits are placed in CARIN SBC benefit categories. 22 benefits have no code in the SBC benefit category code system and are listed, by identity only, in the bps-unmapped-benefit extension.

Converted from Benefit Plan Standard document AETNA_MEDICARE_SELECT_EXTRA_HMO_POS_H1609_028_000 (schema version 1.2.0).

" }, "extension": [ { "extension": [ { "url": "schemaVersion", "valueString": "1.2.0" }, { "url": "planYear", "valueInteger": 2027 }, { "url": "market", "valueString": "medicare_advantage" }, { "url": "serviceAreaState", "valueString": "FL" }, { "url": "serviceAreaCounty", "valueString": "Charlotte" }, { "url": "serviceAreaCounty", "valueString": "Clay" }, { "url": "serviceAreaCounty", "valueString": "Duval" }, { "url": "serviceAreaCounty", "valueString": "Hillsborough" }, { "url": "serviceAreaCounty", "valueString": "Manatee" }, { "url": "serviceAreaCounty", "valueString": "Marion" }, { "url": "serviceAreaCounty", "valueString": "Osceola" }, { "url": "serviceAreaCounty", "valueString": "Pinellas" }, { "url": "serviceAreaCounty", "valueString": "Polk" }, { "url": "serviceAreaCounty", "valueString": "Sarasota" }, { "url": "serviceAreaCounty", "valueString": "Seminole" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-plan-metadata" }, { "extension": [ { "url": "excerpt", "valueString": "CMS Plan Benefit Package (PBP) Benefits, contract year 2027, release \"PBP Benefits-2027\" (https://www.cms.gov/files/zip/pbp-benefits-2027.zip), downloaded 2026-10-06. Files read: pbp_Section_A.txt, pbp_Section_C.txt, pbp_Section_C_OON.txt, pbp_Section_C_POS.txt, pbp_Section_D.txt, pbp_b10_amb_trans.txt, pbp_b13_other_services.txt, pbp_b14_preventive.txt, pbp_b16_dental.txt, pbp_b17_eye_exams_wear.txt, pbp_b18_hearing_exams_aids.txt, pbp_b1a_inpat_hosp.txt, pbp_b1b_inpat_hosp.txt, pbp_b2_snf.txt, pbp_b4_emerg_urgent.txt, pbp_b6_home_health.txt, pbp_b7_health_prof.txt, pbp_b8_clin_diag_ther.txt, pbp_b9_outpat_hosp.txt, PlanArea.txt, PlanRegionArea.txt. PBP key: pbp_a_hnumber \"H1609\", pbp_a_plan_identifier \"028\", segment_id \"0\" (written padded to 3 digits in plan_identifiers)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Plan type: pbp_a_plan_type \"02\" (HMOPOS), written as plan_type \"HMO_POS\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Section A values with no Benefit Plan Standard field, verbatim: bid_id \"H1609_028_0\"; version \"4\"; orgtype \"01\"; pbp_a_org_name \"AETNA HEALTH INC. (FL)\"; pbp_a_org_type \"01\"; pbp_a_ben_cov \"1\"; pbp_a_plan_geog_name \"North FL, Central FL, Southwest FL, West FL\"; pbp_a_eghp_yn \"2\"; pbp_a_special_need_flag \"2\"; pbp_a_contract_partd_flag \"1\"; pbp_a_continue_yn \"2\"; pbp_a_formulary_web_addr \"www.aetnamedicare.com/formulary\"; pbp_a_pharmacy_website \"www.aetnamedicare.com/findpharmacy\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Contacts and the provider directory from Section A: pbp_a_curmbr_phone \"(833)570-6670\" (Customer Service Contact Phone Number for Current Medicare Beneficiaries), written as contacts.member_services_phone; pbp_a_org_website \"www.aetna.com/medicare\", not written as contacts.website: it has no scheme, so it is not a URI, and the importer does not add one; pbp_a_phys_web_addr \"www.aetnamedicare.com/findprovider\", not written as network_tiers[tier_id=IN].provider_directory_url: it has no scheme, so it is not a URI, and the importer does not add one. Section A gives 1 provider directory address per plan, so it belongs to the in-network tier only." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Service area from PlanArea.txt, 11 counties in FL. county_code is the SSA state and county code, not FIPS, so service_area.counties[].fips is null. Each county as county_code, county, stcd, and the partial_flag and eghp_flag values on its rows: 10070 Charlotte FL partial_flag \"\" eghp_flag \"0\"; 10090 Clay FL partial_flag \"\" eghp_flag \"0\"; 10150 Duval FL partial_flag \"\" eghp_flag \"0\"; 10280 Hillsborough FL partial_flag \"\" eghp_flag \"0\"; 10400 Manatee FL partial_flag \"\" eghp_flag \"0\"; 10410 Marion FL partial_flag \"\" eghp_flag \"0\"; 10480 Osceola FL partial_flag \"\" eghp_flag \"0\"; 10510 Pinellas FL partial_flag \"\" eghp_flag \"0\"; 10520 Polk FL partial_flag \"\" eghp_flag \"0\"; 10570 Sarasota FL partial_flag \"\" eghp_flag \"0\"; 10580 Seminole FL partial_flag \"\" eghp_flag \"0\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Premium from Section D: pbp_d_mplusc_premium \"0.00\" (Plan Premium Amount (A/B)), written as premium.amount in USD; the file states no period, so premium.period is not written; pbp_d_mco_pay_reduct_yn \"2\" (the plan does not use its MA rebates to reduce the Part B premium), so part_b_premium_reduction is not written." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "In-network deductible: the plan says it has none (pbp_d_inn_deduct_yn \"2\", pbp_d_inn_deduct_partb_yn \"\", pbp_d_inn_deduct_amt \"\"); no slot is written." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Out-of-network deductible written as oon_individual_deductible with network_tier POS (decision 4, docs/specs/pbp-importer.md section 7): the plan is an HMO-POS and declares a point-of-service option, not an out-of-network benefit. The file says: pbp_d_oon_deduct_yn \"1\", pbp_d_oon_deduct_partb_yn \"2\", pbp_d_oon_deduct_amt \"500.00\", pbp_d_oon_deduct_bens \"01\", pbp_d_oon_deduct_m_yn \"1\", pbp_d_oon_deduct_m_cats \"1a;1b;2;3-1;3-2;3-3;3-4;5a;5b;6;7b;7d;7f;7g;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;10a1;10a2;12;\", pbp_d_oon_deduct_nm_yn \"\", pbp_d_oon_deduct_nm_cats \"\". To be confirmed against the Aetna H1609-028 Summary of Benefits." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Point-of-service deductible as Section C states it, verbatim: pbp_c_pos_ded_yn \"1\", pbp_c_pos_ded_amt \"500.00\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Combined in-network and out-of-network deductible: the plan says it has none (pbp_d_comb_deduct_yn \"2\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "In-network out-of-pocket maximum type, no Benefit Plan Standard field (schema gap, spec section 9.1): pbp_d_out_pocket_amt_type \"3\" (Intermediate)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Combined in-network and out-of-network out-of-pocket maximum, no Benefit Plan Standard slot (schema gap, spec section 9.1): pbp_d_comb_max_enr_amt \"10100.00\"; pbp_d_comb_max_enr_amt_type \"3\" (Intermediate)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Point-of-service maximum as Section C states it, verbatim: pbp_c_pos_maxenr_oopc_yn \"\", pbp_c_pos_maxenr_oopc_amt \"\", pbp_c_pos_maxenr_oopc_per \"\", pbp_c_pos_maxenr_oopc_per_d \"\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Every non-blank Section D deductible and out-of-pocket cell, verbatim, in file order: pbp_d_inn_deduct_yn \"2\"; pbp_d_comb_deduct_yn \"2\"; pbp_d_oon_deduct_yn \"1\"; pbp_d_oon_deduct_partb_yn \"2\"; pbp_d_oon_deduct_amt \"500.00\"; pbp_d_oon_deduct_bens \"01\"; pbp_d_oon_deduct_m_yn \"1\"; pbp_d_oon_deduct_m_cats \"1a;1b;2;3-1;3-2;3-3;3-4;5a;5b;6;7b;7d;7f;7g;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;10a1;10a2;12;\"; pbp_d_out_pocket_amt_yn \"1\"; pbp_d_out_pocket_amt_type \"3\"; pbp_d_out_pocket_amt \"6750.00\"; pbp_d_inn_max_enr_oopc_bens \"11\"; pbp_d_inn_max_enr_m_yn \"1\"; pbp_d_inn_max_enr_m_cat_ex \"1a;1b;2;3-1;3-2;3-3;3-4;4a;4b;5a;5b;6;7a;7b;7c;7d;7e1;7e2;7f;7g;7h1;7h2;7i;7j;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c1;9c2;9d;10a1;10a2;11a;11b1;11b2;11c1;11c2;11c3;12;14a;14d;14e1;14e2;14e4;14e5;15-1-I;15-2;15-3;16a;17a;17b;18a;\"; pbp_d_inn_max_enr_nm_yn \"2\"; pbp_d_inn_max_enr_nm_cat_ex \"1a1;4c1;4c2;4c3;13d;13e;14b;14c1;14c3;14c4;14c7;14c15;18a1;18a2;\"; pbp_d_comb_max_enr_amt_yn \"1\"; pbp_d_comb_max_enr_amt_type \"3\"; pbp_d_comb_max_enr_amt \"10100.00\"; pbp_d_comb_max_enr_oopc_bens \"1111\"; pbp_d_comb_max_enr_inn_m_yn \"1\"; pbp_d_comb_max_enr_inn_mcat_ex \"1a;1b;2;3-1;3-2;3-3;3-4;4a;4b;5a;5b;6;7a;7b;7c;7d;7e1;7e2;7f;7g;7h1;7h2;7i;7j;7k;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;9c1;9c2;9d;10a1;10a2;11a;11b1;11b2;11c1;11c2;11c3;12;14a;14d;14e1;14e2;14e4;14e5;15-1-I;15-2;15-3;16a;17a;17b;18a;\"; pbp_d_comb_max_enr_inn_nm_yn \"2\"; pbp_d_comb_max_enr_inn_nmcatex \"1a1;4c1;4c2;4c3;13d;13e;14b;14c1;14c3;14c4;14c7;14c15;18a1;18a2;\"; pbp_d_comb_max_enr_oon_m_yn \"1\"; pbp_d_comb_max_enr_oon_mcat_ex \"1a;1b;2;3-1;3-2;3-3;3-4;5a;5b;6;7b;7d;7f;7g;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;10a1;10a2;12;14a;\"; pbp_d_comb_max_enr_oon_nm_yn \"1\"; pbp_d_comb_max_enr_oon_nmcatex \"13d;13e;14c15;\"; pbp_d_oon_max_enr_oopc_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Benefits: the 41 service categories in fhir/pbp-crosswalk.json (the workgroup MVP), 38 written. Other PBP service categories are not imported yet (docs/specs/pbp-importer.md section 8)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "benefitId", "valueString": "OBSERVATION" }, { "url": "canonicalKey", "valueString": "observation_care" }, { "url": "serviceName", "valueString": "Observation services" }, { "url": "category", "valueString": "HOSPITAL_SERVICES" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "THERAPEUTIC_RADIOLOGY" }, { "url": "canonicalKey", "valueString": "radiation_therapy" }, { "url": "serviceName", "valueString": "Therapeutic radiological services" }, { "url": "category", "valueString": "RADIATION_THERAPY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PHYSICAL_AND_SPEECH_THERAPY" }, { "url": "canonicalKey", "valueString": "physical_and_speech_therapy" }, { "url": "serviceName", "valueString": "Physical therapy and speech-language pathology services" }, { "url": "category", "valueString": "REHABILITATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "CHIROPRACTIC" }, { "url": "canonicalKey", "valueString": "chiropractic_care" }, { "url": "serviceName", "valueString": "Chiropractic services (Medicare-covered)" }, { "url": "category", "valueString": "CHIROPRACTIC" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "CHIROPRACTIC_ROUTINE" }, { "url": "canonicalKey", "valueString": "chiropractic_care" }, { "url": "serviceName", "valueString": "Routine chiropractic care" }, { "url": "category", "valueString": "CHIROPRACTIC" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PODIATRY" }, { "url": "serviceName", "valueString": "Podiatry services (Medicare-covered)" }, { "url": "category", "valueString": "PODIATRY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PODIATRY_ROUTINE" }, { "url": "canonicalKey", "valueString": "routine_foot_care" }, { "url": "serviceName", "valueString": "Routine foot care" }, { "url": "category", "valueString": "PODIATRY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "ACUPUNCTURE" }, { "url": "canonicalKey", "valueString": "acupuncture" }, { "url": "serviceName", "valueString": "Acupuncture treatments" }, { "url": "category", "valueString": "ACUPUNCTURE" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_EXAM" }, { "url": "serviceName", "valueString": "Hearing exams (Medicare-covered)" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_EXAM_ROUTINE" }, { "url": "canonicalKey", "valueString": "hearing_exam" }, { "url": "serviceName", "valueString": "Routine hearing exams" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EYE_EXAM" }, { "url": "serviceName", "valueString": "Eye exams (Medicare-covered)" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EYE_EXAM_ROUTINE" }, { "url": "canonicalKey", "valueString": "routine_eye_exam" }, { "url": "serviceName", "valueString": "Routine eye exams" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_AIDS" }, { "url": "canonicalKey", "valueString": "hearing_aids" }, { "url": "serviceName", "valueString": "Prescription hearing aids (all types)" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "MENTAL_HEALTH_INDIVIDUAL" }, { "url": "canonicalKey", "valueString": "mental_health_office_visit" }, { "url": "serviceName", "valueString": "Mental health specialty services, individual sessions" }, { "url": "category", "valueString": "BEHAVIORAL_HEALTH" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HOME_HEALTH" }, { "url": "canonicalKey", "valueString": "home_health_care" }, { "url": "serviceName", "valueString": "Home health services" }, { "url": "category", "valueString": "HOME_HEALTH" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DENTAL_CLEANING" }, { "url": "canonicalKey", "valueString": "dental_cleaning" }, { "url": "serviceName", "valueString": "Dental cleaning (prophylaxis)" }, { "url": "category", "valueString": "DENTAL" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DENTAL_FILLINGS" }, { "url": "canonicalKey", "valueString": "dental_filling" }, { "url": "serviceName", "valueString": "Dental restorative services (fillings)" }, { "url": "category", "valueString": "DENTAL" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EYEGLASSES" }, { "url": "canonicalKey", "valueString": "eyeglasses" }, { "url": "serviceName", "valueString": "Eyeglasses (lenses and frames)" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "OTC_ITEMS" }, { "url": "canonicalKey", "valueString": "otc_allowance" }, { "url": "serviceName", "valueString": "Over-the-counter (OTC) items" }, { "url": "category", "valueString": "OVER_THE_COUNTER" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "MEALS" }, { "url": "canonicalKey", "valueString": "meals" }, { "url": "serviceName", "valueString": "Meal benefit" }, { "url": "category", "valueString": "MEALS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "TRANSPORTATION" }, { "url": "canonicalKey", "valueString": "transportation" }, { "url": "serviceName", "valueString": "Transportation services" }, { "url": "category", "valueString": "TRANSPORTATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "FITNESS" }, { "url": "canonicalKey", "valueString": "fitness_benefit" }, { "url": "serviceName", "valueString": "Fitness benefit" }, { "url": "category", "valueString": "FITNESS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" } ], "identifier": [ { "system": "https://benefitplanstandard.org/plan-id", "value": "AETNA_MEDICARE_SELECT_EXTRA_HMO_POS_H1609_028_000" }, { "system": "https://benefitplanstandard.org/fhir/identifier/cms_contract_plan_segment", "value": "H1609-028-000" }, { "system": "https://benefitplanstandard.org/fhir/identifier/cms_contract_id", "value": "H1609" }, { "system": "https://benefitplanstandard.org/fhir/identifier/cms_pbp_id", "value": "028" } ], "status": "active", "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/insurance-plan-type", "code": "medical", "display": "Medical" } ] } ], "name": "Aetna Medicare Select Extra (HMO-POS)", "period": { "start": "2027", "end": "2027" }, "ownedBy": { "reference": "urn:uuid:b74bdad4-a7fe-5d8e-b1d5-072930b6416d", "display": "Aetna Medicare" }, "contact": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unknown" } ], "purpose": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/contactentity-type", "code": "PAYOR", "display": "Payor" } ] } } ], "coverage": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "primary-care-visit", "display": "Primary Care Visit" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "PRIMARY_CARE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PHYSICIAN_SERVICES" }, { "url": "rawLabel", "valueString": "7a: Primary Care Physician Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 7a: Primary Care Physician Services (pbp_b7_health_prof.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b7a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "primary-care-visit", "display": "Primary Care Visit" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "primary_care", "display": "Primary care visit" } ], "text": "Primary care physician services" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "specialist-visit", "display": "Specialist Visit" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "SPECIALIST" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PHYSICIAN_SERVICES" }, { "url": "rawLabel", "valueString": "7d: Physician Specialist Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 7d: Physician Specialist Services (pbp_b7_health_prof.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b7d_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "specialist-visit", "display": "Specialist Visit" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "specialist", "display": "Specialist visit" } ], "text": "Physician specialist services" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "hospital-inpatient", "display": "Hospital Inpatient Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "INPATIENT_HOSPITAL" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "HOSPITAL_SERVICES" }, { "url": "rawLabel", "valueString": "1a: Inpatient Hospital-Acute" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b1a_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 1a: Inpatient Hospital-Acute (pbp_b1a_inpat_hosp.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b1a_maxenr_yn \"2\"; pbp_b1a_hosp_ben_period \"3\"; pbp_b1a_cost_discharge_yn \"2\"; pbp_b1a_bendesc_yn \"1\"; pbp_b1a_bendesc_ad_up_nmcs \"010\"; pbp_b1a_bendesc_amo_ad \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "inpatient_hospital", "display": "Inpatient hospital" } ], "text": "Inpatient hospital, acute" }, "requirement": "Authorization required (pbp_b1a_auth_yn \"1\")." } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "hospital-outpatient", "display": "Hospital Outpatient Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "OUTPATIENT_HOSPITAL" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "HOSPITAL_SERVICES" }, { "url": "rawLabel", "valueString": "9a1: Outpatient Hospital Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b9a_auth_ohs_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 9a1: Outpatient Hospital Services (pbp_b9_outpat_hosp.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b9a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "outpatient_surgery", "display": "Outpatient surgery" } ], "text": "Outpatient hospital services" }, "requirement": "Authorization required (pbp_b9a_auth_ohs_yn \"1\")." }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "AMBULATORY_SURGICAL_CENTER" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "SURGICAL_SERVICES" }, { "url": "rawLabel", "valueString": "9b: Ambulatory Surgical Center (ASC) Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b9b_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 9b: Ambulatory Surgical Center (ASC) Services (pbp_b9_outpat_hosp.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b9b_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "outpatient_surgery_facility", "display": "Outpatient surgery facility" } ], "text": "Ambulatory surgical center services" }, "requirement": "Authorization required (pbp_b9b_auth_yn \"1\")." } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-room-care", "display": "Emergency Room Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "EMERGENCY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "4a: Emergency Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 4a: Emergency Services (pbp_b4_emerg_urgent.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b4a_deduct_yn \"2\"; pbp_b4a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-room-care", "display": "Emergency Room Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "emergency_room", "display": "Emergency room" } ], "text": "Emergency services" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "urgent-care", "display": "Urgent Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "URGENT_CARE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "URGENT_CARE" }, { "url": "rawLabel", "valueString": "4b: Urgently Needed Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 4b: Urgently Needed Services (pbp_b4_emerg_urgent.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b4b_deduct_yn \"2\"; pbp_b4b_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "urgent-care", "display": "Urgent Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "urgent_care", "display": "Urgent care" } ], "text": "Urgently needed services" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "AMBULANCE_GROUND" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "10a1: Ground Ambulance Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b10a_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 10a1: Ground Ambulance Services (pbp_b10_amb_trans.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b10a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "ambulance", "display": "Ambulance services" } ], "text": "Ground ambulance services" }, "requirement": "Authorization required (pbp_b10a_auth_yn \"1\")." }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "AMBULANCE_AIR" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "10a2: Air Ambulance Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b10a_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 10a2: Air Ambulance Services (pbp_b10_amb_trans.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b10a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "ambulance", "display": "Ambulance services" } ], "text": "Air ambulance services" }, "requirement": "Authorization required (pbp_b10a_auth_yn \"1\")." } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "DIAGNOSTIC_TESTS" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "8a1: Diagnostic Procedures/Tests" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b8a_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 8a1: Diagnostic Procedures/Tests (pbp_b8_clin_diag_ther.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b8a_copay_max_yn \"2\"; pbp_b8a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "diagnostic_test", "display": "Diagnostic test" } ], "text": "Diagnostic procedures and tests" }, "requirement": "Authorization required (pbp_b8a_auth_yn \"1\")." }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "LAB_SERVICES" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "8a2: Lab Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b8a_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 8a2: Lab Services (pbp_b8_clin_diag_ther.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b8a_copay_max_yn \"2\"; pbp_b8a_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "diagnostic_lab", "display": "Diagnostic lab" } ], "text": "Lab services" }, "requirement": "Authorization required (pbp_b8a_auth_yn \"1\")." }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "XRAY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "8b3: Outpatient X-Ray Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b8b_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 8b3: Outpatient X-Ray Services (pbp_b8_clin_diag_ther.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b8b_copay_max_yn \"2\"; pbp_b8b_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "imaging_standard", "display": "Standard imaging" } ], "text": "Outpatient X-ray services" }, "requirement": "Authorization required (pbp_b8b_auth_yn \"1\")." } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "imaging", "display": "Imaging (CT/PET/MRI)" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "DIAGNOSTIC_RADIOLOGY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "8b1: Diagnostic Radiological Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b8b_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 8b1: Diagnostic Radiological Services (pbp_b8_clin_diag_ther.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b8b_copay_max_yn \"2\"; pbp_b8b_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "imaging", "display": "Imaging (CT/PET/MRI)" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "imaging_advanced", "display": "Advanced imaging" } ], "text": "Diagnostic radiological services" }, "requirement": "Authorization required (pbp_b8b_auth_yn \"1\")." } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "rehabilitation", "display": "Rehabilitation Services" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "OCCUPATIONAL_THERAPY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "REHABILITATION" }, { "url": "rawLabel", "valueString": "7c: Occupational Therapy Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 7c: Occupational Therapy Services (pbp_b7_health_prof.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b7c_maxenr_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "rehabilitation", "display": "Rehabilitation Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "occupational_therapy", "display": "Occupational therapy" } ], "text": "Occupational therapy services" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "skilled-nursing", "display": "Skilled Nursing Care" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "SKILLED_NURSING_FACILITY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "SKILLED_NURSING" }, { "url": "rawLabel", "valueString": "2: Skilled Nursing Facility (SNF)" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "authorization" }, { "url": "description", "valueString": "Authorization required (pbp_b2_auth_yn \"1\")." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 2: Skilled Nursing Facility (SNF) (pbp_b2_snf.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "excerpt", "valueString": "Values with no Benefit Plan Standard field, verbatim: pbp_b2_maxenr_yn \"2\"; pbp_b2_hosp_ben_period \"1\"; pbp_b2_bendesc_yn \"1\"; pbp_b2_bendesc_pr_hosp_yn \"1\"; pbp_b2_bendesc_pr_hosp_num \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "skilled-nursing", "display": "Skilled Nursing Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "skilled_nursing_facility", "display": "Skilled nursing facility" } ], "text": "Skilled nursing facility" }, "requirement": "Authorization required (pbp_b2_auth_yn \"1\")." } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "preventive-care", "display": "Preventive Care/Screening/Immunization" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "PREVENTIVE_SERVICES" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PREVENTIVE_CARE" }, { "url": "rawLabel", "valueString": "14a: Medicare-covered Zero Dollar Preventive Services" }, { "url": "coverageBasis", "valueString": "medicare_covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "excerpt", "valueString": "PBP service category 14a: Medicare-covered Zero Dollar Preventive Services (pbp_b14_preventive.txt), mapped by fhir/pbp-crosswalk.json." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "preventive-care", "display": "Preventive Care/Screening/Immunization" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "preventive_care", "display": "Preventive care" } ], "text": "Medicare-covered zero dollar preventive services" } } ] } ], "plan": [ { "type": { "text": "HMO_POS" }, "generalCost": [ { "extension": [ { "extension": [ { "url": "slot", "valueString": "individual_oop_max" }, { "url": "networkTier", "valueString": "IN" }, { "url": "appliesTo", "valueString": "medical" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-accumulator" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "maxoutofpocket", "display": "Maximum out of pocket" } ], "text": "Individual out-of-pocket maximum, IN" }, "cost": { "value": 6750, "currency": "USD" }, "comment": "IN" }, { "extension": [ { "extension": [ { "url": "slot", "valueString": "oon_individual_deductible" }, { "url": "networkTier", "valueString": "POS" }, { "url": "appliesTo", "valueString": "medical" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-accumulator" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "deductible", "display": "Deductible" } ], "text": "Individual deductible, POS" }, "cost": { "value": 500, "currency": "USD" }, "comment": "POS" }, { "type": { "text": "Premium" }, "cost": { "value": 0, "currency": "USD" } } ], "specificCost": [ { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "primary-care-visit", "display": "Primary Care Visit" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "primary-care-visit", "display": "Primary Care Visit" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "primary_care", "display": "Primary care visit" } ], "text": "Primary care physician services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b7_health_prof.txt cells: pbp_b7a_copay_yn \"1\", pbp_b7a_copay_amt_mc_min \"0.00\", pbp_b7a_copay_amt_mc_max \"0.00\", pbp_b7a_coins_yn \"2\", pbp_b7a_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 0, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "type": { "text": "Not stated in the BPS document" }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unknown" } ] } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "specialist-visit", "display": "Specialist Visit" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "specialist-visit", "display": "Specialist Visit" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "specialist", "display": "Specialist visit" } ], "text": "Physician specialist services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "amountMin", "valueDecimal": 0 }, { "url": "amountMax", "valueDecimal": 38 }, { "url": "note", "valueString": "pbp_b7_health_prof.txt cells: pbp_b7d_copay_yn \"1\", pbp_b7d_copay_amt_mc_min \"0.00\", pbp_b7d_copay_amt_mc_max \"38.00\", pbp_b7d_coins_yn \"2\", pbp_b7d_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unsupported" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 4 (label \"$70.00 copay\", pbp_c_pos_outpt_mc_bencats \"7d;\"): pbp_c_pos_outpt_copay_yn \"1\", pbp_c_pos_outpt_copay_min_amt \"70.00\", pbp_c_pos_outpt_copay_max_amt \"70.00\", pbp_c_pos_outpt_coins_yn \"2\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 70, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "hospital-inpatient", "display": "Hospital Inpatient Care" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "inpatient_hospital", "display": "Inpatient hospital" } ], "text": "Inpatient hospital, acute" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "basis", "valueString": "per_day" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "unitRangeFrom", "valueInteger": 1 }, { "url": "unitRangeTo", "valueInteger": 5 }, { "url": "note", "valueString": "pbp_b1a_inpat_hosp.txt cells: pbp_b1a_copay_yn \"1\", pbp_b1a_copay_mcs_amt_t1 \"0.00\", pbp_b1a_copay_mcs_int_num_t1 \"3\", pbp_b1a_copay_mcs_amt_int1_t1 \"375.00\", pbp_b1a_copay_mcs_bgnd_int1_t1 \"1\", pbp_b1a_copay_mcs_endd_int1_t1 \"5\", pbp_b1a_copay_mcs_amt_int2_t1 \"0.00\", pbp_b1a_copay_mcs_bgnd_int2_t1 \"6\", pbp_b1a_copay_mcs_endd_int2_t1 \"90\", pbp_b1a_copay_ad_intrvl_num_t1 \"1\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 375, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 2 }, { "url": "basis", "valueString": "per_day" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "unitRangeFrom", "valueInteger": 6 }, { "url": "unitRangeTo", "valueInteger": 90 } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 0, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "basis", "valueString": "per_stay" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C (pbp_c_pos_mc_bendesc_subcats lists 1a): pbp_c_pos_coins_ihs_yn \"1\", pbp_c_pos_coins_ihs_ben_type \"11\", pbp_c_pos_coins_iha_pct \"50\", pbp_c_pos_coins_iha_intrvl_num \"1\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "hospital-outpatient", "display": "Hospital Outpatient Care" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "outpatient_surgery", "display": "Outpatient surgery" } ], "text": "Outpatient hospital services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "basis", "valueString": "per_visit" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "amountMin", "valueDecimal": 0 }, { "url": "amountMax", "valueDecimal": 350 }, { "url": "note", "valueString": "pbp_b9_outpat_hosp.txt cells: pbp_b9a_copay_yn \"1\", pbp_b9a_copay_ehc \"11\", pbp_b9a_copay_ohs_amt_min \"0.00\", pbp_b9a_copay_ohs_amt_max \"350.00\", pbp_b9a_coins_yn \"2\", pbp_b9a_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unsupported" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 6 (label \"50% coinsurance\", pbp_c_pos_outpt_mc_bencats \"3-1;3-2;3-3;3-4;5a;5b;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"50\", pbp_c_pos_outpt_coins_max_pct \"50\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "facility-fee", "display": "Facility Fee" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "outpatient_surgery_facility", "display": "Outpatient surgery facility" } ], "text": "Ambulatory surgical center services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "amountMin", "valueDecimal": 0 }, { "url": "amountMax", "valueDecimal": 300 }, { "url": "note", "valueString": "pbp_b9_outpat_hosp.txt cells: pbp_b9b_copay_yn \"1\", pbp_b9b_copay_mc_amt \"0.00\", pbp_b9b_copay_mc_amt_max \"300.00\", pbp_b9b_coins_yn \"2\", pbp_b9b_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unsupported" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 6 (label \"50% coinsurance\", pbp_c_pos_outpt_mc_bencats \"3-1;3-2;3-3;3-4;5a;5b;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"50\", pbp_c_pos_outpt_coins_max_pct \"50\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-room-care", "display": "Emergency Room Care" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-room-care", "display": "Emergency Room Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "emergency_room", "display": "Emergency room" } ], "text": "Emergency services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "Waived if admitted to the hospital within 24 hours (pbp_b4a_copay_wavdia_yn \"1\", pbp_b4a_copay_wavdia_mi_dh \"2\", pbp_b4a_copay_wavd_dh \"24\")." }, { "url": "note", "valueString": "pbp_b4_emerg_urgent.txt cells: pbp_b4a_copay_yn \"1\", pbp_b4a_copay_amt_mc_min \"130.00\", pbp_b4a_copay_amt_mc_max \"130.00\", pbp_b4a_coins_yn \"2\". pbp_b4_emerg_urgent.txt prices 4a once, with no network, and no pbp_Section_C_POS.txt group lists 4a, so the cost share is written on the in-network tier only (decision 5, docs/specs/pbp-importer.md section 7.13)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 130, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "type": { "text": "Not stated in the BPS document" }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unknown" } ] } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "urgent-care", "display": "Urgent Care" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "urgent-care", "display": "Urgent Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "urgent_care", "display": "Urgent care" } ], "text": "Urgently needed services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b4_emerg_urgent.txt cells: pbp_b4b_copay_yn \"1\", pbp_b4b_copay_amt_mc_min \"30.00\", pbp_b4b_copay_amt_mc_max \"30.00\", pbp_b4b_coins_yn \"2\". pbp_b4_emerg_urgent.txt prices 4b once, with no network, and no pbp_Section_C_POS.txt group lists 4b, so the cost share is written on the in-network tier only (decision 5, docs/specs/pbp-importer.md section 7.13)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 30, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "type": { "text": "Not stated in the BPS document" }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unknown" } ] } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "ambulance", "display": "Ambulance services" } ], "text": "Ground ambulance services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b10_amb_trans.txt cells: pbp_b10a_copay_yn \"1\", pbp_b10a_copay_ehc \"01\", pbp_b10a_copay_gas_amt_min \"250.00\", pbp_b10a_copay_gas_amt_max \"250.00\", pbp_b10a_coins_yn \"1\", pbp_b10a_coins_ehc \"10\", pbp_b10a_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 250, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 3 (label \"$250.00 copay\", pbp_c_pos_outpt_mc_bencats \"10a1;\"): pbp_c_pos_outpt_copay_yn \"1\", pbp_c_pos_outpt_copay_min_amt \"250.00\", pbp_c_pos_outpt_copay_max_amt \"250.00\", pbp_c_pos_outpt_coins_yn \"2\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 250, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "emergency-medical-transport", "display": "Emergency Medical Transportation" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "ambulance", "display": "Ambulance services" } ], "text": "Air ambulance services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b10_amb_trans.txt cells: pbp_b10a_copay_yn \"1\", pbp_b10a_copay_ehc \"01\", pbp_b10a_coins_yn \"1\", pbp_b10a_coins_ehc \"10\", pbp_b10a_coins_aas_pct_min \"20\", pbp_b10a_coins_aas_pct_max \"20\", pbp_b10a_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 20, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 5 (label \"20% coinsurance\", pbp_c_pos_outpt_mc_bencats \"10a2;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"20\", pbp_c_pos_outpt_coins_max_pct \"20\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 20, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "diagnostic_test", "display": "Diagnostic test" } ], "text": "Diagnostic procedures and tests" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "amountMin", "valueDecimal": 0 }, { "url": "amountMax", "valueDecimal": 200 }, { "url": "note", "valueString": "pbp_b8_clin_diag_ther.txt cells: pbp_b8a_copay_yn \"1\", pbp_b8a_copay_ehc \"11\", pbp_b8a_copay_min_dmc_amt \"0.00\", pbp_b8a_copay_max_dmc_amt \"200.00\", pbp_b8a_coins_yn \"2\", pbp_b8a_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unsupported" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 6 (label \"50% coinsurance\", pbp_c_pos_outpt_mc_bencats \"3-1;3-2;3-3;3-4;5a;5b;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"50\", pbp_c_pos_outpt_coins_max_pct \"50\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "diagnostic_lab", "display": "Diagnostic lab" } ], "text": "Lab services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "amountMin", "valueDecimal": 0 }, { "url": "amountMax", "valueDecimal": 30 }, { "url": "note", "valueString": "pbp_b8_clin_diag_ther.txt cells: pbp_b8a_copay_yn \"1\", pbp_b8a_copay_ehc \"11\", pbp_b8a_lab_copay_amt \"0.00\", pbp_b8a_lab_copay_amt_max \"30.00\", pbp_b8a_coins_yn \"2\", pbp_b8a_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unsupported" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 6 (label \"50% coinsurance\", pbp_c_pos_outpt_mc_bencats \"3-1;3-2;3-3;3-4;5a;5b;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"50\", pbp_c_pos_outpt_coins_max_pct \"50\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "diagnostic-test", "display": "Diagnostic Test" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "imaging_standard", "display": "Standard imaging" } ], "text": "Outpatient X-ray services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b8_clin_diag_ther.txt cells: pbp_b8b_copay_yn \"1\", pbp_b8b_copay_ehc \"110\", pbp_b8b_copay_mc_amt \"10.00\", pbp_b8b_copay_mc_amt_max \"10.00\", pbp_b8b_coins_yn \"1\", pbp_b8b_coins_ehc \"001\", pbp_b8b_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 10, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 6 (label \"50% coinsurance\", pbp_c_pos_outpt_mc_bencats \"3-1;3-2;3-3;3-4;5a;5b;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"50\", pbp_c_pos_outpt_coins_max_pct \"50\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "imaging", "display": "Imaging (CT/PET/MRI)" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "imaging", "display": "Imaging (CT/PET/MRI)" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "imaging_advanced", "display": "Advanced imaging" } ], "text": "Diagnostic radiological services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "amountMin", "valueDecimal": 0 }, { "url": "amountMax", "valueDecimal": 200 }, { "url": "note", "valueString": "pbp_b8_clin_diag_ther.txt cells: pbp_b8b_copay_yn \"1\", pbp_b8b_copay_ehc \"110\", pbp_b8b_copay_amt_drs \"0.00\", pbp_b8b_copay_amt_drs_max \"200.00\", pbp_b8b_coins_yn \"1\", pbp_b8b_coins_ehc \"001\", pbp_b8b_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unsupported" } ] } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 6 (label \"50% coinsurance\", pbp_c_pos_outpt_mc_bencats \"3-1;3-2;3-3;3-4;5a;5b;6;7b;7f;8a1;8a2;8b1;8b2;8b3;9a1;9a2;9b;12;\"): pbp_c_pos_outpt_copay_yn \"2\", pbp_c_pos_outpt_coins_yn \"1\", pbp_c_pos_outpt_coins_min_pct \"50\", pbp_c_pos_outpt_coins_max_pct \"50\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "rehabilitation", "display": "Rehabilitation Services" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "rehabilitation", "display": "Rehabilitation Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "occupational_therapy", "display": "Occupational therapy" } ], "text": "Occupational therapy services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b7_health_prof.txt cells: pbp_b7c_copay_yn \"1\", pbp_b7c_copay_mc_amt_min \"35.00\", pbp_b7c_copay_mc_amt_max \"35.00\", pbp_b7c_coins_yn \"2\", pbp_b7c_ded_yn \"2\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 35, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "type": { "text": "Not stated in the BPS document" }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "value": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason", "valueCode": "unknown" } ] } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "skilled-nursing", "display": "Skilled Nursing Care" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "skilled-nursing", "display": "Skilled Nursing Care" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "skilled_nursing_facility", "display": "Skilled nursing facility" } ], "text": "Skilled nursing facility" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "basis", "valueString": "per_day" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "unitRangeFrom", "valueInteger": 1 }, { "url": "unitRangeTo", "valueInteger": 20 }, { "url": "note", "valueString": "pbp_b2_snf.txt cells: pbp_b2_copay_yn \"1\", pbp_b2_copay_mcs_int_num_t1 \"3\", pbp_b2_copay_mcs_amt_int1_t1 \"0.00\", pbp_b2_copay_mcs_bgnd_int1_t1 \"1\", pbp_b2_copay_mcs_endd_int1_t1 \"20\", pbp_b2_copay_mcs_amt_int2_t1 \"221.00\", pbp_b2_copay_mcs_bgnd_int2_t1 \"21\", pbp_b2_copay_mcs_endd_int2_t1 \"100\"." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 0, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 2 }, { "url": "basis", "valueString": "per_day" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "unitRangeFrom", "valueInteger": 21 }, { "url": "unitRangeTo", "valueInteger": 100 } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 221, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "basis", "valueString": "per_stay" }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C (pbp_c_pos_mc_bendesc_subcats lists 2): pbp_c_pos_coins_snf_yn \"1\", pbp_c_pos_coins_snf_pct \"50\", pbp_c_pos_coins_snf_intrvl_num \"1\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copaypct", "display": "Copay Percentage" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 50, "unit": "%", "system": "http://unitsofmeasure.org", "code": "%" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "preventive-care", "display": "Preventive Care/Screening/Immunization" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "preventive-care", "display": "Preventive Care/Screening/Immunization" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "preventive_care", "display": "Preventive care" } ], "text": "Medicare-covered zero dollar preventive services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "IN" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_b14_preventive.txt cells: pbp_b14a_mc_prevent_attest \"1\", whose dictionary text is \"I attest that there is no coinsurance, copayment, or deductible for all Original Medicare preventive services that are offered at zero dollar cost sharing.\" Written as a $0 copay that does not apply to the deductible (docs/specs/pbp-importer.md section 5.4)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "value": { "value": 0, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } }, { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": true }, { "extension": [ { "url": "tierId", "valueString": "POS" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true }, { "url": "note", "valueString": "pbp_Section_C_POS.txt group 2 (label \"$0.00 copay\", pbp_c_pos_outpt_mc_bencats \"14a;\"): pbp_c_pos_outpt_copay_yn \"1\", pbp_c_pos_outpt_copay_min_amt \"0.00\", pbp_c_pos_outpt_copay_max_amt \"0.00\", pbp_c_pos_outpt_coins_yn \"2\", pbp_c_pos_outpt_deduct_yn \"2\", pbp_c_pos_outpt_maxplan_yn \"2\". applies_to_moop refers to the combined in-network and out-of-network maximum (pbp_d_comb_max_enr_amt \"10100.00\"), which has no accumulator slot (spec section 9.1)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-cost-share" } ], "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/coverage-copay-type", "code": "copay", "display": "Copay Amount" } ] }, "applicability": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "out-of-network", "display": "Out of Network" } ] }, "qualifiers": [ { "text": "Point-of-service option" } ], "value": { "value": 0, "unit": "USD", "system": "urn:iso:std:iso:4217", "code": "USD" } } ] } ] } ] } ] } }, { "fullUrl": "urn:uuid:b74bdad4-a7fe-5d8e-b1d5-072930b6416d", "resource": { "resourceType": "Organization", "id": "org-aetna-medicare", "text": { "status": "generated", "div": "

Aetna Medicare

" }, "name": "Aetna Medicare" } } ] }