ProductPlan Resource Proposal

InsurancePlan

Formerly called ProductPlan

Owning work group name

Patient Administration

Committee Approval Date:

11 July 2018 (with renaming to InsurancePlan)

Contributing or Reviewing Work Groups

• Financial Management
• Seeking other interested workgroups

FHIR Resource Development Project Insight ID

1345

Scope of coverage

The InsurancePlan resource describes a total health insurance offering, including the list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan). A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. (e.g. Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Dental, Vision, etc)

Elements associated with a product include:

• “Demographic” information about the product, e.g. who owns/administers it, where it’s available, what it’s called, what networks it’s associated with, etc.
• Information about the product’s covered benefits, e.g. type of coverage (medical, dental, drug, etc.), type of benefit (primary care visit, specialist visit, inpatient hospital services, etc.), limits on the benefit (number of visits per month, days per admission, hours per visit, etc.)

For example, an insurer may offer a product which provides medical and dental coverage, comprising benefits such as primary care visits, inpatient hospital services, outpatient surgical services, specialist visits, routine dental services/cleanings etc. through an HMO network.

A plan pairs the health insurance coverage benefits under a product with a particular cost sharing structure offered to the consumer. A given product may have multiple plans (e.g. in the US individual health insurance marketplace, plans have a “metal” level that indicates the general percentage of costs a consumer is responsible for). Elements associated with a plan include:

• “Demographic” information about the plan, e.g. the type of plan (bronze, silver, gold, high deductible, etc.), where the plan is offered to consumers,
• General costs to the consumer, e.g. the plan’s premium, deductible, and out-of-pocket limit/cap
• Specific costs associated with specific benefits, e.g. a copay for a prescription, coinsurance for a primary care provider visit, etc.

The InsurancePlan does not represent the details for a specific patient, that is the Coverage resource.

RIM scope

unknown

Resource appropriateness

A catalog to discover providers that provide specific insurance products is useful for both patients/consumers, and also for providers to verify details.

The information from the catalog will also be able to be utilized in Patient Coverage resources.

Expected implementations

The ONC has indicated that they desire to create a service that uses this capability where they will be distributing aggregated healthcare directory data from a central service to Organizations for local usage (based on a specific data usage agreement)

Example Scenarios

• Centralized Healthcare Directory service
• Distributed/Federated Provider Directory service
• Aggregated Directory Service

Resource Relationships

Reference(any) - Our initial requirements are needed against:

• Organization
• Location

We do not currently expect other resources to specifically reference InsurancePlan

Timelines

Sept Ballot 2018 - draft was in Jan 2018 Comment ballot

gForge Users

• brian_pos
• Cooper Thompson
• Andrew Torres

When Resource Proposal Is Complete

When you have completed your proposal, please send an email to FMGcontact@HL7.org