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Difference between revisions of "ProductPlan Resource Proposal"

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This page documents a [[:category:Pending FHIR Resource Proposal|Pending]] [[:category:FHIR Resource Proposal|FHIR Resource Proposal]]
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This page documents a [[:category:Approved FHIR Resource Proposal|Approved]] [[:category:FHIR Resource Proposal|FHIR Resource Proposal]]
 
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[[Category:FHIR Resource Proposal]]
 
[[Category:FHIR Resource Proposal]]
[[Category:Pending FHIR Resource Proposal]]
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[[Category:Approved FHIR Resource Proposal]]
  
=ProductPlan=
+
=InsurancePlan=
 +
Formerly called ProductPlan
  
 
==Owning work group name==
 
==Owning work group name==
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==Committee Approval Date:==
 
==Committee Approval Date:==
 
+
11 July 2018 (with renaming to InsurancePlan)
  
 
==Contributing or Reviewing Work Groups==
 
==Contributing or Reviewing Work Groups==
 
* Financial Management
 
* Financial Management
* Seeking interested workgroups
+
* Seeking other interested workgroups
  
 
==FHIR Resource Development Project Insight ID==
 
==FHIR Resource Development Project Insight ID==
Line 25: Line 26:
  
 
==Scope of coverage==
 
==Scope of coverage==
A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. A given payer’s products typically differ by network type and/or coverage benefits. A plan pairs the health insurance coverage benefits under a product with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans.  
+
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.)
  
ProductPlan describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, 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.
  
<!-- Define the full scope of coverage for the resource.  The scope must be clearly delineated such that it does not overlap with any other existing or expected resource.  The scope will be used to govern "what is the set of potential applications to consider when evaluating what elements are 'core' – i.e. in the 80%"
+
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:
  
Scope should consider numerous aspects of breadth of scope, including:
+
* “Demographic” information about the plan, e.g. the type of plan (bronze, silver, gold, high deductible, etc.), where the plan is offered to consumers,  
* Subject: Human vs. non-human vs. non-patient (e.g. lab bench medicine)
+
* General costs to the consumer, e.g. the plan’s premium, deductible, and out-of-pocket limit/cap
* Disciplines: Environmental Health, Palliative, Respiratory, Psychology, Maternity, Clinical Research
+
* Specific costs associated with specific benefits, e.g. a copay for a prescription, coinsurance for a primary care provider visit, etc.
* Delivery environment (Community, Geriatric, Home care, Emergency, Inpatient, Intensive, Neonatal, Pediatric, Primary)
 
* Locale: Country, region
 
  
As a rule, resources should encompass all of these aspects.
+
The InsurancePlan does not represent the details for a specific patient, that is the Coverage resource.
-->
 
  
 
==RIM scope==
 
==RIM scope==
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==Resource appropriateness==
 
==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.
  
<!-- Does the resource meet the following characteristics?
+
The information from the catalog will also be able to be utilized in Patient Coverage resources.
 
 
Must
 
* Represents a well understood, "important" concept in the business of healthcare
 
* Represents a concept expected to be tracked with distinct, reliable, unique ids
 
* Reasonable for the resource to be independently created, queried and maintained
 
 
 
Should
 
* Declared interest in need for standardization of data exchange</span>
 
* Resource is expected to contain an appropriate number of "core" (non-extension) data elements (in most cases, somewhere in the range of 20-50)
 
* Have the characteristics of high cohesion & low coupling – need to explore whether coupling is good some places, not elsewhere – layers from Bo’s document
 
-->
 
  
 
==Expected implementations==
 
==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)
 
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)
 
<!--Key resources are justified by CCDA, for resources not deemed "key", what interest is there by implementers in using this particular resource. Provide named implementations if possible - ideally provide multiple independent implementations. -->
 
  
 
==Content sources==
 
==Content sources==
 
 
<!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult
 
<!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult
  
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* Location
 
* Location
  
We do not currently expect other resources to specifically reference ProductPlan
+
We do not currently expect other resources to specifically reference InsurancePlan
  
 
==Timelines==
 
==Timelines==

Latest revision as of 21:23, 29 August 2018

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)

Content sources

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

FMG Notes