{ "resourceType": "Bundle", "id": "bps-uhc-choice-plus-hsa-gold-1700", "type": "collection", "entry": [ { "fullUrl": "urn:uuid:b4bcac85-e536-5c7d-a5c3-77ed65fb8d34", "resource": { "resourceType": "InsurancePlan", "id": "uhc-choice-plus-hsa-gold-1700", "meta": { "profile": [ "http://hl7.org/fhir/us/insurance-card/StructureDefinition/sbc-insurance-plan" ] }, "text": { "status": "generated", "div": "

UnitedHealthcare® UHC Choice Plus HSA Gold 1700-4

Carrier: UnitedHealthcare. Plan type: POS. Period: 2026-01-01 to 2026-12-31.

26 benefits are placed in CARIN SBC benefit categories. 3 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 UHC_CHOICE_PLUS_HSA_GOLD_1700 (schema version 1.1.0).

" }, "extension": [ { "extension": [ { "url": "schemaVersion", "valueString": "1.1.0" }, { "url": "planYear", "valueInteger": 2026 }, { "url": "market", "valueString": "small_group" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-plan-metadata" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "UHC Choice Plus HSA Gold 1700-4 | Coverage Period: 01/01/2026 - 12/31/2026 | Coverage for: Employee/Family | Plan Type: POS" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "What is the overall deductible? Designated Network and Network: $1,700 Individual / $3,400 Family; out-of-Network: $5,000 Individual / $10,000 Family Per Calendar year." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 1 }, { "url": "excerpt", "valueString": "What is the out-of-pocket limit for this plan? Designated Network and Network: $4,500 Individual / $9,000 Family; out-of-Network: $10,000 Individual / $20,000 Family. (This file carries the $9,000 family limit and not the $4,500 individual limit.)" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Primary care visit to treat an injury or illness: $10 copay per visit (Designated Network and Network); 40% coinsurance out-of-Network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Specialist visit: Designated Network $30 copay per visit / Network Provider $60 copay per visit; 40% coinsurance out-of-Network. (This file carries the Designated Network value.)" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Preventive care/screening/immunization: No Charge; Out-of-Network: Not Covered" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Diagnostic test: Designated Network Lab: 0% coinsurance / Free Standing/Office X-ray: $30 copay per service; 40% coinsurance out-of-Network. (The document prints the lab and x-ray prices separately; this file carries both in one in-network entry, as a $30 copay step and a 0% coinsurance step.)" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 2 }, { "url": "excerpt", "valueString": "Imaging (CT/PET scans, MRIs): Designated Network $150 copay per service / Free Standing/Office $500 copay per service; 40% coinsurance out-of-Network. (This file carries the Designated Network value.)" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 3 }, { "url": "excerpt", "valueString": "Tier 1 - Your Lowest-Cost Option: Retail: $10 copay. Tier 2 - Your Midrange-Cost Option: Retail: $40 copay. Tier 3 - Your Midrange-Cost Option: Retail: $75 copay. Tier 4 - Additional High-Cost Options: Retail: $125 copay. (The document also prints mail-order and specialty-pharmacy prices; this file carries only the retail values.)" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Outpatient surgery - Facility fee: Ambulatory Surgery Center: $200 copay per visit / Hospital: $400 copay per visit; 40% coinsurance out-of-Network. Physician/surgeon fees: 20% coinsurance" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Emergency room care: $400 copay per visit (all tiers). Emergency medical transportation: 20% coinsurance." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Urgent care: $40 copay per visit; 40% coinsurance out-of-Network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Hospital stay - Facility fee: $350 copay per admission; 40% coinsurance out-of-Network. Physician/surgeon fees: 20% coinsurance" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Mental health outpatient services: $30 copay per visit; out-of-Network: 0% coinsurance. Inpatient services: $350 copay per admission; 40% coinsurance out-of-Network" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 4 }, { "url": "excerpt", "valueString": "Childbirth/delivery professional services: 20% coinsurance. Childbirth/delivery facility services: $350 copay per admission" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "Home health care: 20% coinsurance. Limited to 90 visits up to 4 hours per visit per episode of care." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "Rehabilitation services: $10 copay per outpatient visit. Habilitation services: $10 copay per outpatient visit." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "Skilled nursing care: $350 copay per admission. Skilled Nursing Facility is limited to 60 days per calendar year." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 5 }, { "url": "excerpt", "valueString": "Durable medical equipment: 20% coinsurance; Out-of-Network: Not Covered. Hospice services: 20% coinsurance." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 6 }, { "url": "excerpt", "valueString": "Children's eye exam: $10 copay per visit, deductible does not apply; Out-of-Network: 50% coinsurance. Children's glasses: 50% coinsurance. Children's dental check-up: No Charge." } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 7 }, { "url": "excerpt", "valueString": "Services Your Plan Generally Does NOT Cover: Bariatric surgery, Long-term care, Cosmetic surgery, Dental care (Adult)" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "pageNumber", "valueInteger": 7 }, { "url": "excerpt", "valueString": "Other Covered Services: Chiropractic care, Acupuncture - Anesthesia only, Infertility treatment, Hearing aids - $2,500/Calendar year" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-source-reference" }, { "extension": [ { "url": "benefitId", "valueString": "HOME_HEALTH_CARE" }, { "url": "canonicalKey", "valueString": "home_health_care" }, { "url": "serviceName", "valueString": "Home health care" }, { "url": "category", "valueString": "HOME_HEALTH" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "BARIATRIC_SURGERY" }, { "url": "canonicalKey", "valueString": "bariatric_surgery" }, { "url": "serviceName", "valueString": "Bariatric surgery" }, { "url": "category", "valueString": "BARIATRIC_SURGERY" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" }, { "extension": [ { "url": "benefitId", "valueString": "INFERTILITY_TREATMENT" }, { "url": "canonicalKey", "valueString": "infertility_treatment" }, { "url": "serviceName", "valueString": "Infertility treatment" }, { "url": "category", "valueString": "DURABLE_MEDICAL_EQUIPMENT" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-unmapped-benefit" } ], "identifier": [ { "system": "https://benefitplanstandard.org/plan-id", "value": "UHC_CHOICE_PLUS_HSA_GOLD_1700" } ], "status": "active", "type": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/insurance-plan-type", "code": "medical", "display": "Medical" } ] } ], "name": "UnitedHealthcare® UHC Choice Plus HSA Gold 1700-4", "period": { "start": "2026-01-01", "end": "2026-12-31" }, "ownedBy": { "reference": "urn:uuid:4a72258b-52f4-552e-829d-568baff19b9b", "display": "UnitedHealthcare" }, "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": "Primary care visit to treat an injury or illness" }, { "url": "moopApplicability", "valueString": "plan_default" } ], "url": "https://benefitplanstandard.org/fhir/StructureDefinition/bps-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 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": 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