Insurance plan clarification

Hi all,

I’m trying to use InsurancePlan resource but currently it has maturity level 0 and there are no examples on it so i’m posting this to get some clarifications.

  • Why InsurancePlan.type has same suggested codes for InsurancePlan.Coverage.type ?
  • Suppose that i want to define Coverage (Vision) with 2 benefits (Inpatient & Outpatient), for Outpatient i have 3 limits (max number of checkups = 2, max cost for eyeglasses = 300$, max number of eyeglasses = 1). Is this right usage of that structure ?
  • Related to above structure, how can i define limit on Coverage level (2000$) - for whole Vision related treatments ?

Now going to plans level (InsurancePlan.plan), suppose i have 2 plans :

  • Gold
  • Silver =>
    limit : 100000$ (generalCost.value)
    Specific cost : Coverage.category = Vision, 2 benefits (Inpatient , Outpatient), for Outpatient i have 2 costs (copay : 30$, individual-cap : 100$)

Based on above if i receive request from patient connected to this plan on Silver category for Vision treatment & Outpatient encounter i have all those details :

  • Max number of checkups : 2
  • Max cost for eyeglasses = 300$
  • Max number of eye glasses = 1
  • Copay 20$
  • Individual-cap 100$

As you noticed above i collected his limits & coverage details from 2 levels InsurancePlan & specific sub-plan, is this usage correct ?

I noticed difference in suggested codes for Coverage.beneift.type & Plan.SpecificCost.Benefit.type but i supposed them the same, is that correct ?
How to give gold plan higher limit for eyeglasses (400$ for example) ?

Sorry for this number of questions, let me know if you need more clarifications.


I think that this is best discussed here:

The purpose of the InsurancePlan is to describe plans offered by an insurer, for example to provide to an exchange, so the meaning of .type is different.

Thanks for your reply, sorry didn’t get it, could you please provide more details ?