{ "resourceType": "Bundle", "id": "bps-humana-gold-plus-h1036-025-hmo", "type": "collection", "entry": [ { "fullUrl": "urn:uuid:1ab60e2d-4601-5aa9-9809-cf274a4be518", "resource": { "resourceType": "InsurancePlan", "id": "humana-gold-plus-h1036-025-hmo", "meta": { "profile": [ "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan" ] }, "text": { "status": "generated", "div": "

Humana Gold Plus H1036-025 (HMO)

Carrier: Humana. Plan type: HMO. Period: 2026 to 2026.

26 benefits are placed in CARIN SBC benefit categories. 46 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 HUMANA_GOLD_PLUS_H1036_025_HMO (schema version 1.2.0).

" }, "extension": [ { "extension": [ { "url": "schemaVersion", "valueString": "1.2.0" }, { "url": "planYear", "valueInteger": 2026 }, { "url": "market", "valueString": "medicare_advantage" }, { "url": "serviceAreaState", "valueString": "FL" }, { "url": "serviceAreaCounty", "valueString": "Hernando" }, { "url": "serviceAreaCounty", "valueString": "Hillsborough" }, { "url": "serviceAreaCounty", "valueString": "Pasco" }, { "url": "serviceAreaCounty", "valueString": "Pinellas" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-plan-metadata" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "2026 | Summary of Benefits | Humana Gold Plus H1036-025 (HMO) | Tampa | Hernando, Hillsborough, Pasco, Pinellas counties" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "Our service area includes the following county/counties in Florida: Hernando, Hillsborough, Pasco, Pinellas." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Benefits, premiums and/or copays/coinsurance may change on January 1, 2027." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory)." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "Humana Gold Plus H1036-025 (HMO) is a Medicare Advantage HMO plan with a Medicare contract." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "Humana Gold Plus H1036-025 (HMO) has a network of doctors, hospitals, pharmacies and other providers. If you use providers who aren't in our network, the plan may not pay for these services." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Monthly plan premium | $0; You must keep paying your Medicare Part B premium." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Part B premium reduction | Your plan will reduce your Monthly Part B premium by up to $3 but by no more than Original Medicare's Part B Premium for 2026." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Medical deductible | This plan does not have a deductible." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Pharmacy (Part D) deductible | $0 deductible for Tier 1, Tier 2 and Tier 3; $615 deductible for Tier 4 and Tier 5" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Medical Maximum out-of-pocket responsibility | $2,000 in-network; The most you pay for copays, coinsurance and other costs for covered medical services for the year." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other providers in the network. This is called a \"referral.\" This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 8 }, { "url": "excerpt", "valueString": "Copayments, coinsurances, and deductibles paid for supplemental benefits do not count toward your maximum out-of-pocket amount." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 10 }, { "url": "excerpt", "valueString": "DEDUCTIBLE | $0 deductible for Tier 1, Tier 2 and Tier 3. This plan has a $615 deductible for Tier 4 and Tier 5 drugs. You pay the full cost of these drugs until you reach $615. Then, you only pay your cost-share." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 10 }, { "url": "excerpt", "valueString": "INITIAL COVERAGE | You pay the following until your total out-of-pocket costs reach $2,100. Once you reach this amount, you will enter the Catastrophic Stage." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 11 }, { "url": "excerpt", "valueString": "CATASTROPHIC COVERAGE | After your total out-of-pocket costs reach $2,100 you pay $0 for plan-covered Part D and Excluded drugs." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 12 }, { "url": "excerpt", "valueString": "EXTRA HELP | If you receive Extra Help for your drugs, you will have a $0 deductible." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 12 }, { "url": "excerpt", "valueString": "If you reside at an in-network long-term care facility, you pay the same as you would at an in-network retail pharmacy. Under certain situations you may be able to get drugs from an out-of-network pharmacy but may pay more than you would pay at an in-network pharmacy." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 16 }, { "url": "excerpt", "valueString": "Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different for Original Medicare telehealth." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "benefitId", "valueString": "DIAGNOSTIC_COLONOSCOPY" }, { "url": "serviceName", "valueString": "Diagnostic colonoscopy" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "NUCLEAR_MEDICINE" }, { "url": "serviceName", "valueString": "Nuclear medicine" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "SLEEP_STUDY" }, { "url": "serviceName", "valueString": "Sleep study" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "THERAPEUTIC_RADIOLOGY" }, { "url": "canonicalKey", "valueString": "radiation_therapy" }, { "url": "serviceName", "valueString": "Radiation therapy" }, { "url": "category", "valueString": "RADIATION_THERAPY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DIAGNOSTIC_MAMMOGRAPHY" }, { "url": "serviceName", "valueString": "Diagnostic mammography" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_MEDICARE" }, { "url": "serviceName", "valueString": "Hearing services (Medicare-covered)" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_EXAM_ROUTINE" }, { "url": "serviceName", "valueString": "Routine hearing exam and fitting/evaluation" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_AID_VALUE" }, { "url": "serviceName", "valueString": "Hearing aid, Value Technology" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_AID_ADVANCED" }, { "url": "serviceName", "valueString": "Hearing aid, Advanced Technology" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "HEARING_AID_PREMIUM" }, { "url": "serviceName", "valueString": "Hearing aid, Premium Technology" }, { "url": "category", "valueString": "HEARING" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DENTAL_MEDICARE" }, { "url": "serviceName", "valueString": "Dental services (Medicare-covered)" }, { "url": "category", "valueString": "DENTAL" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DENTAL_ALLOWANCE" }, { "url": "serviceName", "valueString": "Supplemental dental allowance (preventive, basic and major services)" }, { "url": "category", "valueString": "DENTAL" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DENTAL_DENTURES_BRIDGES" }, { "url": "serviceName", "valueString": "Dentures and bridges" }, { "url": "category", "valueString": "DENTAL" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EYEWEAR_POST_CATARACT" }, { "url": "serviceName", "valueString": "Eyewear after cataract surgery" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DIABETIC_EYE_EXAM" }, { "url": "serviceName", "valueString": "Diabetic eye exam (Medicare-covered)" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "VISION_MEDICARE" }, { "url": "serviceName", "valueString": "Vision services (Medicare-covered)" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "VISION_EXAM_ROUTINE" }, { "url": "serviceName", "valueString": "Routine eye exam" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EYEWEAR_ALLOWANCE" }, { "url": "serviceName", "valueString": "Routine eyewear allowance" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EYEGLASSES_NO_COST" }, { "url": "serviceName", "valueString": "Select eyeglasses at no cost" }, { "url": "category", "valueString": "VISION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "TRANSPORTATION_SUPPLEMENTAL" }, { "url": "serviceName", "valueString": "Transportation to plan-approved locations" }, { "url": "category", "valueString": "TRANSPORTATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "TRANSPORTATION_UNIFORMITY_FLEXIBILITY" }, { "url": "serviceName", "valueString": "Transportation for members with chronic kidney disease, end stage renal disease, or cancer" }, { "url": "category", "valueString": "TRANSPORTATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PART_B_ALLERGY" }, { "url": "canonicalKey", "valueString": "allergy_injections" }, { "url": "serviceName", "valueString": "Allergy shots and serum" }, { "url": "category", "valueString": "PART_B_DRUGS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PART_B_CHEMOTHERAPY" }, { "url": "canonicalKey", "valueString": "chemotherapy" }, { "url": "serviceName", "valueString": "Chemotherapy drugs (Part B)" }, { "url": "category", "valueString": "PART_B_DRUGS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PART_B_OTHER" }, { "url": "serviceName", "valueString": "Other Part B drugs" }, { "url": "category", "valueString": "PART_B_DRUGS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PART_B_INSULIN" }, { "url": "serviceName", "valueString": "Part B insulin" }, { "url": "category", "valueString": "PART_B_DRUGS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "RX_TIER4" }, { "url": "serviceName", "valueString": "Tier 4 non-preferred drugs" }, { "url": "category", "valueString": "PHARMACY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "RX_INSULIN" }, { "url": "serviceName", "valueString": "Insulin (Part D)" }, { "url": "category", "valueString": "PHARMACY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PART_D_VACCINES" }, { "url": "serviceName", "valueString": "Adult Part D vaccines" }, { "url": "category", "valueString": "PHARMACY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EXCLUDED_DRUGS_ED" }, { "url": "serviceName", "valueString": "Erectile dysfunction drugs (excluded drug coverage)" }, { "url": "category", "valueString": "PHARMACY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "EXCLUDED_DRUGS_VITAMINS" }, { "url": "serviceName", "valueString": "Prescription vitamins (excluded drug coverage)" }, { "url": "category", "valueString": "PHARMACY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "ACUPUNCTURE_MEDICARE" }, { "url": "canonicalKey", "valueString": "acupuncture" }, { "url": "serviceName", "valueString": "Acupuncture for chronic low back pain (Medicare-covered)" }, { "url": "category", "valueString": "ACUPUNCTURE" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "CHIROPRACTIC_MEDICARE" }, { "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": "PODIATRY_MEDICARE" }, { "url": "serviceName", "valueString": "Podiatry services (Medicare-covered)" }, { "url": "category", "valueString": "PODIATRY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "CONTINUOUS_GLUCOSE_MONITOR" }, { "url": "serviceName", "valueString": "Continuous glucose monitor" }, { "url": "category", "valueString": "DURABLE_MEDICAL_EQUIPMENT" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "DIABETIC_SUPPLIES" }, { "url": "canonicalKey", "valueString": "diabetic_supplies" }, { "url": "serviceName", "valueString": "Diabetic monitoring supplies" }, { "url": "category", "valueString": "DURABLE_MEDICAL_EQUIPMENT" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "MEDICAL_SUPPLIES" }, { "url": "serviceName", "valueString": "Medical supplies" }, { "url": "category", "valueString": "DURABLE_MEDICAL_EQUIPMENT" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PROSTHETICS" }, { "url": "canonicalKey", "valueString": "prosthetics" }, { "url": "serviceName", "valueString": "Prosthetic devices and related supplies" }, { "url": "category", "valueString": "DURABLE_MEDICAL_EQUIPMENT" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "CARDIAC_REHAB" }, { "url": "canonicalKey", "valueString": "cardiac_rehabilitation" }, { "url": "serviceName", "valueString": "Cardiac rehabilitation" }, { "url": "category", "valueString": "REHABILITATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "PULMONARY_REHAB" }, { "url": "canonicalKey", "valueString": "pulmonary_rehabilitation" }, { "url": "serviceName", "valueString": "Pulmonary rehabilitation" }, { "url": "category", "valueString": "REHABILITATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "SUPERVISED_EXERCISE_THERAPY_PAD" }, { "url": "serviceName", "valueString": "Supervised exercise therapy for peripheral artery disease" }, { "url": "category", "valueString": "REHABILITATION" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "ACUPUNCTURE_ROUTINE" }, { "url": "canonicalKey", "valueString": "acupuncture" }, { "url": "serviceName", "valueString": "Routine acupuncture" }, { "url": "category", "valueString": "ACUPUNCTURE" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "FOOT_CARE_ROUTINE" }, { "url": "serviceName", "valueString": "Routine foot care" }, { "url": "category", "valueString": "PODIATRY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "MEALS_POST_DISCHARGE" }, { "url": "serviceName", "valueString": "Home-delivered meals after an inpatient stay (Humana Well Dine)" }, { "url": "category", "valueString": "MEALS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "OTC_ALLOWANCE" }, { "url": "serviceName", "valueString": "Over-the-counter mail order allowance" }, { "url": "category", "valueString": "OVER_THE_COUNTER" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "POST_DISCHARGE_HOME_CARE" }, { "url": "serviceName", "valueString": "Post-discharge personal home care" }, { "url": "category", "valueString": "IN_HOME_SUPPORT" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "FITNESS" }, { "url": "serviceName", "valueString": "Fitness program (SilverSneakers)" }, { "url": "category", "valueString": "FITNESS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" } ], "identifier": [ { "system": "https://benefitplanstandard.org/plan-id", "value": "HUMANA_GOLD_PLUS_H1036_025_HMO" }, { "system": "https://benefitplanstandard.org/fhir/identifier/cms_contract_plan_segment", "value": "H1036-025-000" }, { "system": "https://benefitplanstandard.org/fhir/identifier/cms_contract_id", "value": "H1036" }, { "system": "https://benefitplanstandard.org/fhir/identifier/cms_pbp_id", "value": "025" } ], "status": "active", "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/insurance-plan-type", "code": "medical", "display": "Medical" } ] } ], "name": "Humana Gold Plus H1036-025 (HMO)", "period": { "start": "2026", "end": "2026" }, "ownedBy": { "reference": "urn:uuid:2cee3e88-ac21-5df2-94f7-865a9dc719f7", "display": "Humana" }, "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": "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": "This plan covers an unlimited number of days for an inpatient stay" }, { "url": "placeOfService", "valueString": "inpatient_hospital" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "INPATIENT HOSPITAL COVERAGE > This plan covers an unlimited number of days for an inpatient stay | $50 copay per day for days 1-6; $0 copay per day for days 7-90" } ], "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" } } ] }, { "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_SURGERY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "SURGICAL_SERVICES" }, { "url": "rawLabel", "valueString": "Surgery services" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "OUTPATIENT HOSPITAL COVERAGE > Surgery services | $85 copay" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "AMBULATORY SURGERY CENTER > Surgery services | $10 copay" } ], "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 surgery" } } ] }, { "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": "Primary Care Provider (PCP)" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "DOCTOR VISITS > Primary Care Provider (PCP) | PCP's office: $0 copay; Telehealth: $0 copay" } ], "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 visit" } } ] }, { "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": "Specialist" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "type", "valueString": "referral" }, { "url": "description", "valueString": "Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other providers in the network. This is called a \"referral.\"" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-condition" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "DOCTOR VISITS > Specialist | Specialist's office: $10 copay; Telehealth: $10 copay" } ], "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": "Specialist visit" }, "requirement": "Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other providers in the network. This is called a \"referral.\"" } ] }, { "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_CARE" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "PREVENTIVE_CARE" }, { "url": "rawLabel", "valueString": "This plan covers all Medicare preventive services including:" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "PREVENTIVE CARE > This plan covers all Medicare preventive services including: | $0 copay" } ], "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 preventive services" } } ] }, { "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_ROOM" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "Emergency services at emergency room" }, { "url": "placeOfService", "valueString": "emergency_room" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "EMERGENCY CARE > Emergency services at emergency room | $150 copay | If you are admitted to the same hospital within 24 hours for the same condition, you pay $0 for the emergency care you received. We cover emergency services worldwide. If you have an emergency outside of the U.S. and its territories, you will be responsible to pay for the rendered service(s) upfront and can request reimbursement." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "EMERGENCY CARE > Emergency services at emergency room | When placed in observation, member pays observation cost-share instead of emergency room cost-share." } ], "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 room" } } ] }, { "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": "URGENTLY NEEDED SERVICES" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 6 }, { "url": "excerpt", "valueString": "URGENTLY NEEDED SERVICES | Telehealth: $0 copay; Urgent care center: $0 copay | We cover urgently needed services worldwide. If you have an urgently needed service outside of the U.S. and its territories, you will be responsible to pay for the rendered service(s) upfront and can request reimbursement." } ], "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": "imaging", "display": "Imaging (CT/PET/MRI)" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "ADVANCED_IMAGING" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "Advanced imaging services (MRI, MRA, PET and CT scans)" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 6 }, { "url": "excerpt", "valueString": "DIAGNOSTIC SERVICES, LABS & IMAGING > Advanced imaging services (MRI, MRA, PET and CT scans) | Freestanding radiological facility: $50 copay; Outpatient hospital: $75 copay; PCP's office: $50 copay; Specialist's office: $50 copay" } ], "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": "Advanced imaging (MRI, MRA, PET, CT)" } } ] }, { "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": "XRAYS" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "Basic radiological services (X-rays)" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 6 }, { "url": "excerpt", "valueString": "DIAGNOSTIC SERVICES, LABS & IMAGING > Basic radiological services (X-rays) | Freestanding radiological facility: $0 copay; Outpatient hospital: $20 copay; PCP's office: $0 copay; Specialist's office: $5 copay; Urgent care center: $0 copay" } ], "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": "X-rays" } }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "DIAGNOSTIC_TESTS" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "Diagnostic procedures and tests" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 6 }, { "url": "excerpt", "valueString": "DIAGNOSTIC SERVICES, LABS & IMAGING > Diagnostic procedures and tests | Outpatient hospital: $25 copay; PCP's office: $0 copay; Specialist's office: $10 copay; Urgent care center: $0 copay" } ], "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" } }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "LAB_SERVICES" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "DIAGNOSTIC_SERVICES" }, { "url": "rawLabel", "valueString": "Lab services" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 6 }, { "url": "excerpt", "valueString": "DIAGNOSTIC SERVICES, LABS & IMAGING > Lab services | Freestanding laboratory: $0 copay; Outpatient hospital: $20 copay; PCP's office: $0 copay; Specialist's office: $0 copay; Urgent care center: $0 copay" } ], "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" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-inpatient", "display": "Mental/Behavioral Health Inpatient Services" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "limitText", "valueString": "This plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital" }, { "url": "limitType", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type", "code": "days", "display": "Days" } ] } }, { "url": "limitValue", "valueQuantity": { "value": 190, "unit": "days" } }, { "url": "limitPeriod", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-period", "code": "lifetime", "display": "Lifetime" } ] } } ], "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" }, { "extension": [ { "url": "benefitId", "valueString": "MENTAL_HEALTH_INPATIENT" }, { "url": "benefitType", "valueString": "behavioral_health" }, { "url": "category", "valueString": "BEHAVIORAL_HEALTH" }, { "url": "rawLabel", "valueString": "Inpatient" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 8 }, { "url": "excerpt", "valueString": "MENTAL HEALTH SERVICES > Inpatient | $50 copay per day for days 1-6; $0 copay per day for days 7-90 | This plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-inpatient", "display": "Mental/Behavioral Health Inpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "mental_health_inpatient", "display": "Mental health inpatient" } ], "text": "Inpatient mental health" } } ] }, { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" } ] }, "benefit": [ { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "MENTAL_HEALTH_OUTPATIENT" }, { "url": "benefitType", "valueString": "behavioral_health" }, { "url": "category", "valueString": "BEHAVIORAL_HEALTH" }, { "url": "rawLabel", "valueString": "Mental health therapy visits" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 8 }, { "url": "excerpt", "valueString": "MENTAL HEALTH SERVICES > Mental health therapy visits | Outpatient hospital: $0 copay; Specialist's office: $5 copay; Telehealth: $5 copay" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "mental_health_outpatient", "display": "Mental health outpatient" } ], "text": "Mental health therapy visits" } }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "SUBSTANCE_USE_OUTPATIENT" }, { "url": "benefitType", "valueString": "behavioral_health" }, { "url": "category", "valueString": "BEHAVIORAL_HEALTH" }, { "url": "rawLabel", "valueString": "Outpatient substance abuse services" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 8 }, { "url": "excerpt", "valueString": "MENTAL HEALTH SERVICES > Outpatient substance abuse services | Outpatient hospital: $0 copay; Specialist's office: $5 copay; Telehealth: $5 copay" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "substance_use_outpatient", "display": "Substance use outpatient" } ], "text": "Outpatient substance use 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": "limitText", "valueString": "This plan covers up to 100 days in a SNF" }, { "url": "limitType", "valueCodeableConcept": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/limit-type", "code": "days", "display": "Days" } ] } }, { "url": "limitValue", "valueQuantity": { "value": 100, "unit": "days" } } ], "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/benefit-limitation" }, { "extension": [ { "url": "benefitId", "valueString": "SKILLED_NURSING_FACILITY" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "SKILLED_NURSING" }, { "url": "rawLabel", "valueString": "This plan covers up to 100 days in a SNF" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 9 }, { "url": "excerpt", "valueString": "SKILLED NURSING FACILITY (SNF) > This plan covers up to 100 days in a SNF | $0 copay per day for days 1-20; $160 copay per day for days 21-100" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" } ], "type": { "coding": [ { "system": 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9 }, { "url": "excerpt", "valueString": "AMBULANCE > Air | 20% of the cost" } ], "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" } }, { "extension": [ { "extension": [ { "url": "benefitId", "valueString": "AMBULANCE_GROUND" }, { "url": "benefitType", "valueString": "medical" }, { "url": "category", "valueString": "EMERGENCY_CARE" }, { "url": "rawLabel", "valueString": "Ground" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-benefit" }, { "extension": [ { "url": "pageNumber", "valueInteger": 9 }, { 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"system": "http://terminology.hl7.org/CodeSystem/applicability", "code": "in-network", "display": "In Network" } ] }, "qualifiers": [ { "text": "Specialist's office" } ], "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": false }, { "extension": [ { "url": "tierId", "valueString": "SITE_URGENT_CARE_CENTER" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Urgent care center" } ], "value": { "value": 0, "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": "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": "SITE_FREESTANDING_LAB" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Freestanding laboratory" } ], "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": "SITE_OUTPATIENT_HOSPITAL" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Outpatient hospital" } ], "value": { "value": 20, "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": "SITE_PCP_OFFICE" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "PCP's office" } ], "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": "SITE_SPECIALIST_OFFICE" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Specialist's office" } ], "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": "SITE_URGENT_CARE_CENTER" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Urgent care center" } ], "value": { "value": 0, "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": "mental-health-inpatient", "display": "Mental/Behavioral Health Inpatient Services" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-inpatient", "display": "Mental/Behavioral Health Inpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "mental_health_inpatient", "display": "Mental health inpatient" } ], "text": "Inpatient mental health" }, "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": 6 } ], "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": 50, "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": 7 }, { "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" } } ] } ] }, { "category": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "mental_health_outpatient", "display": "Mental health outpatient" } ], "text": "Mental health therapy visits" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "SITE_OUTPATIENT_HOSPITAL" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Outpatient hospital" } ], "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": "SITE_SPECIALIST_OFFICE" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Specialist's office" } ], "value": { "value": 5, "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": "SITE_TELEHEALTH" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier", "code": "virtual", "display": "Virtual Visit" } ], "text": "Telehealth" } ], "value": { "value": 5, "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": "mental-health-outpatient", "display": "Mental/Behavioral Health Outpatient Services" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "substance_use_outpatient", "display": "Substance use outpatient" } ], "text": "Outpatient substance use services" }, "cost": [ { "extension": [ { "url": "http://hl7.org/fhir/us/insurance-card/StructureDefinition/deductible-applies", "valueBoolean": false }, { "extension": [ { "url": "tierId", "valueString": "SITE_OUTPATIENT_HOSPITAL" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Outpatient hospital" } ], "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": "SITE_SPECIALIST_OFFICE" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "text": "Specialist's office" } ], "value": { "value": 5, "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": "SITE_TELEHEALTH" }, { "url": "sequence", "valueInteger": 1 }, { "url": "appliesToMoop", "valueBoolean": true } ], "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" } ] }, "qualifiers": [ { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/cost-tier", "code": "virtual", "display": "Virtual Visit" } ], "text": "Telehealth" } ], "value": { "value": 5, "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": "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": "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": 160, "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": "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": "Air ambulance" }, "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": "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": "%" } }, { "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" } ] } } ] }, { "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" }, "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_date_of_service" }, { "url": "appliesToMoop", "valueBoolean": true } ], "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": 150, "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": "generic-drugs", "display": "Generic Drugs" } ] }, "benefit": [ { "type": { "coding": [ { "system": "http://hl7.org/fhir/us/insurance-card/CodeSystem/sbc-benefit-category", "code": "generic-drugs", "display": "Generic Drugs" }, { "system": "https://benefitplanstandard.org/fhir/CodeSystem/canonical-benefits", "code": "preferred_generic_drugs", "display": "Preferred generic drugs" } ], "text": "Tier 1 preferred generic drugs" }, "cost": [ { "extension": [ { "extension": [ { "url": "tierId", "valueString": "SITE_PART_D_RETAIL" }, { "url": "sequence", "valueInteger": 1 }, { "url": "basis", "valueString": "per_30_day_supply" }, { "url": "appliesToDeductible", "valueBoolean": false }, { "url": "appliesToMoop", "valueBoolean": false }, { "url": "deductibleRef", "valueString": "pharmacy" }, { "url": "note", "valueString": "Retail cost-sharing (includes all in-network retail pharmacies), 30-day supply. The page 10 grid also prices Standard and Preferred mail-order and 100-day supplies (quoted in source_references). 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