# Medical

Ideon processes and standardizes medical health plan benefits and metadata for plan offerings across all markets. Each year, tens of thousands of files from hundreds of carrier sources - including SBCs, QHPs, SERFF filings, custom carrier documents, and more - are processed to build a complete medical health plan inventory. For a complete medical health plan schema as delivered by Ideon's API, the Medical Plan Show endpoint ([API docs](https://docs.ideonapi.com/#major-medical-plans-major-medical-plans-get)) can be referenced.

This page is organized into sections to cover all data for medical health plans, including their metadata and benefits. All sections are included on a single page to enable cmd+f searching based on schema keys or conventional terminology. The navigation pane in the top-right of the page can be used to quickly jump between sections.

## Plan Metadata

A plan's metadata includes all information that is not considered a cost share based benefit. Fields such as plan type, actuarial value, hosted SBC links, and more are included. Given the breadth of data included, format, and data type varies by metadata field. The below tables list all fields included in Ideon's medical health plan dataset and summaries of how the data is presented.

### Plan Identifiers

<table data-full-width="true"><thead><tr><th width="149.9918212890625">Metadata Field</th><th width="150.055419921875">API Schema Key</th><th width="100.34765625">Data Type</th><th width="200.1495361328125">Example</th><th>Notes</th></tr></thead><tbody><tr><td>HIOS ID</td><td>identifiers[type="hios_id"].value<br><br><em>Previously used field: id</em></td><td>string</td><td>"43283NC0020046"</td><td>HIOS IDs are a 14-character, unique identifier for plans, by year. When caching benefits for use with real-time quoting workflows, HIOS IDs should be used along with the plan year to determine uniqueness.</td></tr><tr><td>Carrier-specific Identifiers</td><td>identifiers[type="contract_id","package_code"].value</td><td>string</td><td>"DX98-K35S"</td><td>The identifier(s) used by the carrier to reference the plan or benefit availability associated to the plan. One or more identifiers with the same or different <code>type</code> can be included for a single plan. More information can be found in the <a href="#carrier-identifiers">Carrier Identifiers Section</a>.</td></tr></tbody></table>

#### HIOS ID Variants

Extensions, in the structure of "-XX", are appended to HIOS IDs to indicate important variant and carrier-specific information. This section details important HIOS ID extensions and how they are used.

**-00, -01, -02, -03:** not used by Ideon. -00 and -01, which indicate on or off market availability, is communicated in the Market Availability fields, found in the [Miscellaneous Metadata table](#miscellaneous-metadata).

**-04, -05, -06, -07, -90, -95, -99:** indicate CSR plan variants for Individual Medical plans. Details on how Ideon quotes CSR plans can be found in the [Subsidies and Tax Credit section](/quote-and-select/quote-individuals/aca-medical/quote-applicants/subsidies-and-tax-credits.md) for Individual Medical Quoting.&#x20;

**-11:** used in some cases for association plans for Anthem.

**-13:** indicates a fake HIOS ID created by Ideon, in lieu of a standardized HIOS ID produced by the carrier.

**-33:** indicates a plan with the chiropractic rider included, specific to Health Net plans.

**-77 (Small Group):** used for private exchange plans that do not have standard HIOS IDs. Currently implemented for CalChoice (California) and HealthPass (New York).

**-99 (Small Group):** indicates a UnitedHealthcare "B2B" plan in the Small Group market. These plans are privileged and, depending on the state, require approval from UHC to be able to quote. They are quotable through Ideon's API only, as quotes are routed in real-time through UHC's quoting API services.

**-90, -95, -99 (Individual):** used for some individual-market plans in New Mexico to designate plans under the State Out-of-Pocket Assistance (SOPA) program. These plans are a form of expanded CSR and additionally labeled as "Turquoise" plans. See the [Subsidies and Tax Credits section](/quote-and-select/quote-individuals/aca-medical/quote-applicants/subsidies-and-tax-credits.md#cost-share-reduction-plans-csr) for Individual Quoting for more information.

#### Carrier Identifiers

Some carriers - primarily Anthem/BCBS and UHC - maintain and provide internal identifiers for their plans. These are included in the `identifiers[]` array with a `type` of *contract\_id*. Additionally, in some states, UHC uses package codes for their plans, which are included with a `type` of *package\_code*. Multiple contract ids and package codes can be included for a single plan. These identifiers are almost exclusively used in the Small Group market.

### Carrier and Issuer Data

<table data-full-width="true"><thead><tr><th width="149.981201171875">Metadata Field</th><th width="149.50140380859375">API Schema Key</th><th width="99.9853515625">Data Type</th><th width="199.6097412109375">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Carrier Info - ID</td><td>carrier.id</td><td>string</td><td>"d31dc8f5-00bd-422d-bcb3-44caa4227b38"</td><td>Unique identifier for the carrier, consistent across Ideon's Quote and Select data.</td></tr><tr><td>Carrier Info - Name</td><td><p>carrier.name</p><p><br><em>Previously used field: carrier_name</em></p></td><td>string</td><td>"Cigna Healthcare"</td><td>The carrier's brand or marketing name.</td></tr><tr><td>Carrier Info - Logo URL</td><td>carrier.logo_url</td><td>string</td><td>"https://d1hm12jr612u3r.cloudfront.net/images/logos/353/thumb.png?1724342730"</td><td>Carrier logos are presented in thumb size by default. To access a higher resolution image, replace "thumb" in the URL with "medium".</td></tr><tr><td>Carrier Info - Issuer ID</td><td>carrier.issuer_id<br><br><em>Previously used field: hios_issuer_id</em></td><td>string</td><td>"40064"</td><td>The 5-digit HIOS Issuer ID of the licensed carrier offering the plan.</td></tr><tr><td>Carrier Disclaimers</td><td>carrier_disclaimers</td><td>string</td><td>"To meet the Affordable Care Act requirements, Cigna Individual and Family medical plans that are not sold through the Federally Facilitated Exchange also include a pediatric dental policy for children under the age of 19."</td><td>Disclaimers are open-text strings that pass through important information from the carrier. They are only used when the disclaimer is specifically requested to be included by the carrier providing the data. Disclaimers are typically between 50 - 500 characters. Rarely, they can exceed 1,000 characters in length.</td></tr></tbody></table>

#### Small Group Private Exchanges

In the Small Group Medical market, there are three private exchanges for which data is included through additional fields. These include CoveredCA and CalChoice in California and HealthPass in New York. Plans that are offered through these exchanges are freely available.&#x20;

For these private exchange plans, the `carrier` object will retain data that reflects the carrier - for example, "Kaiser Permanente". Carriers may offer plans both on the private exchange and through themselves directly under the same `issuer_id`. Plans that are available on the private exchange can be identified in two ways.&#x20;

* The `carrier_name` field will detail the private exchange name: "CalChoice", "CoveredCA", or "HealthPass"
* The `hios_issuer_id` field will show a unique, internal issuer ID specific to that exchange in the format of "P000X"
  * "P0003" = CalChoice
  * "P0004" = HealthPass
  * "P0006" = CoveredCA

### Plan Documents and URLs

<table data-full-width="true"><thead><tr><th width="150.2261962890625">Metadata Field</th><th width="149.678955078125">API Schema Key</th><th width="100.1806640625">Data Type</th><th width="200.074951171875">Example</th><th>Notes</th></tr></thead><tbody><tr><td>SBC - Summary of Benefits and Coverage</td><td>plan_documents[type="summary_of_benefits_and_coverage"].url</td><td>string</td><td>"https://d2ed110nmrd591.cloudfront.net/blobs/op3EnjSm5higG5YtyJpfZq58.pdf"</td><td>SBCs are included in the <code>plan_documents</code> array, when available. If an SBC is not available for a plan, the SBC object will not be included in the <code>plan_documents</code> array.<br>If both the SBC and SOB are not available for a plan, the <code>plan_documents</code> array will be included in the response as an empty array - <code>[]</code>. </td></tr><tr><td>SOB - Summary of Benefits (or Schedule of Benefits)</td><td>plan_documents[type="summary_of_benefits"].url</td><td>string</td><td>"https://d2ed110nmrd591.cloudfront.net/blobs/3bjCTpvZGiDDeifmfZT8RuKJ.pdf"</td><td>SOBs are included in the <code>plan_documents</code> array, when available. If an SOB is not available for a plan, the SOB object will not be included in the <code>plan_documents</code> array.</td></tr><tr><td>Drug Formulary URL</td><td>drug_formulary_url</td><td>string</td><td>"https://www.sutterhealthplan.org/pharmacy"</td><td>Drug Formulary URLs are included based on availability in carrier source data. The <code>drug_forumlary_url</code> field in the API schema will return null if not available.</td></tr><tr><td>Provider Directory URL</td><td>networks[].provider_directory_url</td><td>string</td><td>"https://ambetter.superiorhealthplan.com/findadoc"</td><td>Provider Directory URLs are sourced from the CMS Network PUF and included for Individual Medical plans, when available. If a plan does not have a Provider Directory URL - as would be the case with Small Group plans - the <code>provider_directory_url</code> field will not be rendered in the API response schema.</td></tr></tbody></table>

### Riders

<table data-full-width="true"><thead><tr><th width="149.67218017578125">Metadata Field</th><th width="149.90625">API Schema Key</th><th width="99.72265625">Data Type</th><th width="199.868896484375">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Abortion Rider</td><td>abortion_rider</td><td>boolean</td><td>true, false, or null</td><td><em>True</em> indicates that abortion is covered in some instances, even if those are limited to certain scenarios. If carrier documentation does not include any abortion rider information, then <em>null</em> will be passed.</td></tr><tr><td>Age 29 Rider</td><td>age29_rider</td><td>boolean</td><td>true or false</td><td>Specific to New York. Indicates whether or not the age 29 rider is excluded, meaning a <em>true</em> value means the age 29 rider is <strong>not</strong> included. <em>False</em> indicates that dependents up to age 29 are eligible.</td></tr><tr><td>Domestic Partner Rider Excluded</td><td>dp_rider</td><td>boolean</td><td>true or false</td><td>Specific to New York. Indicates whether or not the domestic partner rider is excluded, meaning a <em>true</em> value means the domestic partner rider is <strong>not</strong> included. <em>False</em> indicates that domestic partners are eligible for coverage.</td></tr><tr><td>Family Planning Rider Excluded</td><td>fp_rider</td><td>boolean</td><td>true or false</td><td>Specific to New York. Indicates whether or not the family planning rider is excluded, meaning a <em>true</em> value means the family planning rider is <strong>not</strong> included. <em>False</em> indicates that family planning coverage is included.</td></tr><tr><td>Skilled Nursing Facility 365</td><td>skilled_nursing_facility_365</td><td>enum</td><td>"unlimited"</td><td>Specific to New York. Valid values are <em>unlimited</em> or <em>unknown</em>. A value of <em>unlimited</em> indicates 365-day coverage at a SNF.</td></tr><tr><td>Infertility Treatment Rider</td><td>infertility_treatment_rider</td><td>boolean</td><td>true, false, or null</td><td>True indicates that covered options are available for infertility treatments. If carrier documentation does not include any infertility treatment rider information, then <em>null</em> will be passed.</td></tr></tbody></table>

### CMS Fields

<table data-full-width="true"><thead><tr><th width="149.89599609375">Metadata Field</th><th width="149.9417724609375">API Schema Key</th><th width="99.6978759765625">Data Type</th><th width="200.14599609375">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Standardized Plan</td><td>standardized_plan</td><td>boolean</td><td>true or false</td><td>Indicates the plan meets the criteria set by CMS, summarized as "standardized plan options are Qualified Health Plans (QHPs) that offer standardized cost-sharing
 and pre-deductible coverage at every product network type". This is sourced from the CMS PUF for Individual market plans. Additional information can be found through <a href="https://www.cms.gov/files/document/updated-standardized-plan-options-information-bulletin07122024.pdf">CMS</a>.</td></tr><tr><td>CMS Star Ratings</td><td>ratings[]</td><td>string</td><td>"4"</td><td><p>CMS Star Ratings are sourced from the CMS PUF for Individual market plans. Ratings can range from 1 to 5; a <em>null</em> <code>value</code> indicates that the plan was not rated. If ratings data for a plan is not available through the CMS PUF, the <code>ratings</code> key will be included in the response schema as an empty array. Additional information can be found through <a href="https://www.cms.gov/marketplace/resources/data/public-use-files">CMS</a>. Valid types for CMS star ratings include:</p><p><br><em>cms_quality_ratings_overall</em></p><p><em>cms_quality_ratings_medical_care</em></p><p><em>cms_quality_ratings_member_experience</em></p><p><em>cms_quality_ratings_plan_administration</em></p></td></tr></tbody></table>

### Additional Metadata

<table data-full-width="true"><thead><tr><th width="150.43927001953125">Metadata Field</th><th width="149.96307373046875">API Schema Key</th><th width="99.5167236328125">Data Type</th><th width="200.2027587890625">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Plan Name</td><td>name</td><td>string</td><td>"Premier Blue Copay 50/50 $4500"</td><td>The name of the plan as detailed in carrier documentation.</td></tr><tr><td>Display Name</td><td>display_name</td><td>string</td><td>"Premier Blue Copay 50/50 $4500"</td><td>In the vast majority of cases, <code>display_name</code> mirrors the <code>name</code>. If a plan's marketing name differs from the legally filed <code>name</code> and <code>sbc_name</code>, it will be returned as the <code>display_name</code>.</td></tr><tr><td>SBC Name</td><td>sbc_name</td><td>string</td><td>"Premier Blue Copay 50/50 $4500"</td><td>The name of the plan as given in the header of the SBC.</td></tr><tr><td>Metal Level</td><td>level</td><td>enum</td><td>"silver"</td><td>Valid values are <em>platinum</em>, <em>gold</em>, <em>silver</em>, <em>bronze</em>, <em>expanded_bronze</em>, or <em>catastrophic</em>. Metal levels are categorized by the plan's actuarial value.</td></tr><tr><td>Plan Type</td><td>plan_type</td><td>enum</td><td>"PPO"</td><td>Valid values are <em>EPO</em>, <em>HMO</em>, <em>PPO</em>, <em>POS</em>, or <em>Indemnity</em>.</td></tr><tr><td>Actuarial Value (AV)</td><td>actuarial_value</td><td>float</td><td>70.06</td><td>Sourced from carrier documentation. A small minority of plans do not have an AV value included, typically those that are sourced from limited public filings.</td></tr><tr><td>Estimated Actuarial Value</td><td>estimated_actuarial_value</td><td>float</td><td>70.06</td><td>The Estimated AV is calculated by Ideon, using CMS's filings on calculation methodology for AV. This value should only be used if the <code>actuarial_value</code> is not available for a plan.</td></tr><tr><td>Data Source</td><td>source</td><td>enum</td><td>"carrier"</td><td>Valid values are <em>carrier</em>, <em>cms</em>, and <em>state</em>. A value of <em>carrier</em> indicates that some or all of the plan is built from documentation produced by the carrier - files received directly from them, SBCs, or other carrier website data. Plans indicated as <em>cms</em> or <em>state</em> are entirely built from data sourced through public filings: federal or state, respectively.<br><br>For information on carriers that Ideon maintains a direct relationship with for data sourcing, please reference <a href="https://planwatch.ideonapi.com/">Planwatch</a>.</td></tr><tr><td>Market Availability</td><td>plan_market</td><td>enum</td><td>"on_market"</td><td><p>Both the <code>plan_market</code> and a combination of <code>on_market</code> and <code>off_market</code> fields deliver the same information: whether the plan is available on the public marketplace, off of it, or both.<br><br>Valid values are:</p><p><em>on_market</em> - the plan is available only on the public marketplace</p><p><em>off_market</em> - the plan is available only off the public marketplace </p><p><em>both_markets</em> - the plan is available both on and off the public marketplace</p></td></tr><tr><td>Market Availability</td><td>on_market</td><td>boolean</td><td>true or false</td><td>Indicates whether or not the plan is available on the public marketplace.</td></tr><tr><td>Market Availability</td><td>off_market</td><td>boolean</td><td>true or false</td><td>Indicates whether or not the plan is available off the public marketplace.</td></tr><tr><td>Mail Order RX</td><td>mail_order_rx</td><td>float</td><td>2.0</td><td>Represents the cost of home delivery prescriptions, equalling the cost of home delivery divided by retail cost.</td></tr><tr><td>Embedded Deductible</td><td>embedded_deductible</td><td>enum</td><td>"embedded"</td><td>Valid values are <em>embedded</em>, <em>non_embedded</em>, or <em>unknown</em>. An <em>unknown</em> or <em>null</em> value indicates carrier documentation does not include a clear definition, typically occurring with $0 deductibles.</td></tr><tr><td>Gated</td><td>gated</td><td>boolean</td><td>true, false, or null</td><td>Indicates whether or not the plan requires referrals to see a specialist.</td></tr><tr><td>HSA Eligible</td><td>hsa_eligible</td><td>boolean</td><td>true, false, or null</td><td>Internally-calculated field that indicates whether or not the plan meets HSA eligibility requirements set forth by the IRS. Additional information can be found through <a href="https://www.healthcare.gov/high-deductible-health-plan/">CMS</a>.</td></tr><tr><td>Essential Health Benefits Percentage</td><td>essential_health_benefits_percentage</td><td>float</td><td>100.0</td><td>Internally-calculated field that represents the percentage of CMS-defined essential health benefits are covered by the plan. Additional information can be found through <a href="https://www.healthcare.gov/glossary/essential-health-benefits/">CMS</a>.</td></tr><tr><td>Plan Ancestors</td><td>plan_ancestors[]</td><td>array of objects</td><td>{<br>      "id": "67138CA0700018",<br>      "year": 2024<br>}</td><td>The plan ancestors array is a list of objects that list plans in Ideon's dataset from prior years with the same HIOS ID as the given plan. Plan ancestry does not extend beyond HIOS ID matching.</td></tr><tr><td>Telemedicine</td><td>telemedicine</td><td>boolean</td><td>true, false, or null</td><td>Indicates whether or not the plan includes options for virtual healthcare. </td></tr><tr><td>Adult Dental</td><td>adult_dental</td><td>boolean</td><td>true, false, or null</td><td>Indicates whether or not the plan includes options for adult dental care.</td></tr><tr><td>Chiropractic Services</td><td>chiropractic_services</td><td>boolean</td><td>true, false, or null</td><td>Indicates whether or not the plan includes options for chiropractic care.</td></tr><tr><td>Network</td><td>networks[]</td><td>array of objects</td><td>{<br>      "id": 102126,<br>      "name": "AMBETTER PPO IFP"<br>}</td><td>While the <code>networks</code> key is returned as an array, Ideon currently returns only a single provider-network for each plan. The <code>id</code> represents the unique network identifier, internal to Ideon. </td></tr><tr><td>Quoted via Carrier's API</td><td>quoted_via_carrier_api</td><td>boolean</td><td>true or false</td><td>Indicates whether or not the plan is quoted in real-time through an integration to the carrier's API. Currently, this is only true for UHC B2B plans. All other plans, with a false value in this field, are quoted by Ideon's rating engine.</td></tr><tr><td>Plan Calendar</td><td>plan_calendar</td><td>string</td><td>"calendar_year"</td><td>Valid values are <em>calendar_year</em> or <em>plan_year</em>. A <em>calendar_year</em> value is typical of Individual market plans, where coverage begins on January 1st. A <em>plan_year</em> value indicates plan coverage will last for a 12-month period from the effective date of coverage.</td></tr><tr><td>Last Updated Timestamp</td><td>updated_at</td><td>string</td><td>"2024-11-21T21:34:37.850Z"</td><td>The ISO 8601 UTC timestamp indicating when the plan's benefit data was last updated by Ideon. </td></tr></tbody></table>

## Deductibles and MOOPs

Plan deductibles and maximum out of pocket amounts (MOOPs) are included in the plan benefits schema; the table shows what specific fields are included and where they are typically found in SBCs.&#x20;

<table data-full-width="true"><thead><tr><th width="150.50921630859375">Benefit Field</th><th width="186.88067626953125">API Schema Key</th><th width="207.386962890625">Location in SBC (format: Header | Row)</th><th>Definition</th></tr></thead><tbody><tr><td>Individual Medical Deductible</td><td>individual_medical_deductible</td><td>Important Questions | <em>What is the overall deductible?</em></td><td>The amount an individual needs to spend on covered medical services before the plan’s coverage will go into effect.</td></tr><tr><td>Family Medical Deductible</td><td>family_medical_deductible</td><td>Important Questions | <em>What is the overall deductible?</em></td><td>The amount a family needs to spend on covered medical services before the plan’s coverage will go into effect.</td></tr><tr><td>Individual Drug Deductible</td><td>individual_drug_deductible</td><td>Important Questions | <em>Are there other deductibles for specific services?</em></td><td>The amount an individual needs to spend on covered prescription drugs before the plan’s coverage will go into effect.</td></tr><tr><td>Family Drug Deductible</td><td>family_drug_deductible</td><td>Important Questions | <em>Are there other deductibles for specific services?</em></td><td>The amount a family needs to spend on covered prescription drugs before the plan’s coverage will go into effect.</td></tr><tr><td>Individual Medical MOOP</td><td>individual_medical_moop</td><td>Important Questions | <em>What is the out-of-pocket limit for this plan?</em></td><td>The maximum amount an individual can spend on covered medical services during a plan’s benefit period. After this limit is hit (includes deductibles, copays, and coinsurance), the health plan pays for 100% of covered medical services.</td></tr><tr><td>Family Medical MOOP</td><td>family_medical_moop</td><td>Important Questions | <em>What is the out-of-pocket limit for this plan?</em></td><td>The maximum amount a family can spend on covered medical services during a plan’s benefit period. After this limit is hit (includes deductibles, copays, and coinsurance), the health plan pays for 100% of covered medical services.</td></tr><tr><td>Individual Drug MOOP</td><td>individual_drug_moop</td><td>Important Questions | <em>What is the out-of-pocket limit for this plan?</em></td><td>The maximum amount an individual can spend on covered prescription drugs during a plan’s benefit period. After this limit is hit (includes deductibles, copays, and coinsurance), the health plan pays for 100% of covered prescription drugs.</td></tr><tr><td>Family Drug MOOP</td><td>family_drug_moop</td><td>Important Questions | <em>What is the out-of-pocket limit for this plan?</em></td><td>The maximum amount a family can spend on covered prescription drugs during a plan’s benefit period. After this limit is hit (includes deductibles, copays, and coinsurance), the health plan pays for 100% of covered prescription drugs.</td></tr></tbody></table>

Deductibles and MOOPs have a limited set of grammar used to define a plan's coverage. These are represented in the `in_network` and `out_of_network`  keys. If the plan has multiple tiers added, presented with the `in_network_tier_x` structure, deductibles and moops will be presented separately for each tier, as necessary. The `limit` key is rarely used; in very limited edge cases "see carrier documentation for more information" will be included if there is an unrepresented deductible or MOOP. The valid grammar for deductibles and MOOPs is detailed in the table below.

<table data-full-width="true"><thead><tr><th width="175.10015869140625">Grammar Format</th><th width="134.12744140625">Structure</th><th width="134.367919921875">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Standard Deductible or MOOP</td><td>$X</td><td>$5,000</td><td></td></tr><tr><td>Drug Included in Medical</td><td>Included in Medical</td><td>Included in Medical</td><td>This is used when plan expenditures on covered services for drugs are included in the accumulation of medical deductible or MOOP values. This indicates there is not a separate, standalone drug deductible for the associated field.</td></tr><tr><td>Unlimited MOOP</td><td>Unlimited</td><td>Unlimited</td><td>This indicates that there is no maximum out of pocket amount for the associated field and tier. This is used for <code>out_of_network</code> values for plans where there is out of network coverage, but not a point that the plan will pay for 100% of services if a certain accumulation is reached.</td></tr><tr><td>Not Covered Deductible</td><td>Not Covered</td><td>Not Covered</td><td>Deductibles can be presented as not covered for <code>out_of_network</code> values. This is used for plans that offer no out of network coverage. In these cases, the plan benefits will also be reflected as Not Covered.</td></tr></tbody></table>

## Plan Benefits

Plan benefits are presented as the cost share the plan enrollee is responsible for. Data for each benefit includes the cost shares for seeing In-Network and Out-of-Network providers as well as any limitations on usage. If the plan is structured with multiple In-Network tiers, the additional In-Network tier cost shares (`in_network_tier_x`) will be displayed as needed - if they differ from the tier 1 values. The specialist benefit below shows an example of how this might be presented.

```json
"specialist": {
    "in_network": "$40",
    "in_network_tier_2": "10% after deductible",
    "out_of_network": "30% after deductible",
    "limit": "20 visit(s) per year"
}
```

For grammar formats and notes, the most common use cases are included. This is not an exhaustive list of all cost share and limit formats; values not listed here are rarely used to handle edge case scenarios.

### Cost Share Formats

Benefit cost shares, presented in the `in_network`, `out_of_network`, and `in_network_tier_x` (if applicable) keys in the plan response, are represented as the cost share the plan enrollee is responsible for. For example, if the cost share is presented as *20%*, the enrollee is responsible for 20% of the service cost while the plan will pay 80%. The most common cost share formats are included in the table below.

<table data-full-width="true"><thead><tr><th width="181.1484375">Cost Share Format</th><th width="148.28515625">Structure</th><th width="145.50390625">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Standard Copay</td><td>$X</td><td>$25</td><td>A $0 copay indicates the carrier documentation presents the benefit as a $0 copay or a 0% coinsurance.</td></tr><tr><td>Standard Coinsurance</td><td>X%</td><td>20%</td><td>If two coinsurances are documented for the same benefit and tier, the higher value is captured.</td></tr><tr><td>Cost Share with Deductible</td><td>$X after deductible<br>X% after deductible</td><td>$25 after deductible<br>20% after deductible</td><td>This represents cost shares that come into effect after the deductible amount for the plan is reached. Prior to that, the enrollee must pay all costs from providers.</td></tr><tr><td>Copay plus Coinsurance</td><td>$X plus Y%</td><td>$25 plus 20%</td><td>Enrollees are responsible for a copay plus a coinsurance for the billed service.</td></tr><tr><td>Copay Range</td><td>$X - $Y</td><td>$25 - $100</td><td>When multiple or a range of copays are shown for a benefit in a single tier, the range of values is shown.</td></tr><tr><td>Varying Cost Share by Visit</td><td>first X visit(s) Y then Z</td><td>first 3 visit(s) $25 then 20% after deductible</td><td>The cost shares denoted as Y and Z follow the above formats. The enrollee is responsible for Y for the first X visits, then they are responsible for Z for additional visits.</td></tr><tr><td>Varying Cost Share by Day</td><td>first X day(s) Y then Z</td><td>first 5 day(s) $250 then $0</td><td>The cost shares denoted as Y and Z follow the above formats. The enrollee is responsible for Y for the first X days, then they are responsible for Z for additional days.</td></tr><tr><td>Allowances</td><td>X after Y allowance</td><td>100% after $150 allowance</td><td>Allowances are typically only used with child-only benefits, such as eyewear. This format indicates the enrollee receives Y as an allowance that they can spend on materials or services for that benefit, after which they pay X for any future purchases or claims.</td></tr><tr><td>Not Covered</td><td>Not Covered</td><td>Not Covered</td><td>This denotes a benefit that is not covered by a plan - the enrollee is responsible for all costs. </td></tr><tr><td>Unknown</td><td>null</td><td>null</td><td>Unknowns in Ideon's dataset are very rare; they indicate that details of the benefit cost share were not referenced in the plan documentation received.</td></tr></tbody></table>

### Limit Formats

Benefit limits are included where applicable to detail standardized limitations or additional details for the benefit's cost shares. The most common limit formats are included in the table below.

<table data-full-width="true"><thead><tr><th width="181.1484375">Limit Format</th><th width="148.28515625">Structure</th><th width="145.50390625">Example</th><th>Notes</th></tr></thead><tbody><tr><td>Standard Limit</td><td>X {measured service}(s) per {time period}</td><td>20 visit(s) per year</td><td>For most benefit limitations, {measured service} is a visit or day. The {time period} is typically a year; some other possible values include benefit period and lifetime.</td></tr><tr><td>Condition-Based Limit</td><td>X {measured service}(s) per condition per {time period}</td><td>20 visit(s) per condition per benefit period</td><td>Condition-based limits add the "per condition" qualifier to the standard limit.</td></tr><tr><td>Waived if Admitted</td><td>waived if admitted</td><td>waived if admitted</td><td>Used exclusively for Emergency Room (ER) benefit. When included, indicates that the cost share for the enrollee for ER is waived if they are admitted to the hospital.</td></tr><tr><td>Documentation Reference</td><td>see carrier documentation for more information</td><td>see carrier documentation for more information</td><td>The documentation reference limit is included when important information is included in the SBC or other carrier document for the benefit that is non-standardizable. This is most commonly used in cases in which the additional information could impact the amount the enrollee would pay for the benefit. This limit is also commonly used when visit limits are aggregated with other benefits.</td></tr><tr><td>No Limit Included</td><td>null</td><td>null</td><td>If no limit is included for the benefit, the limit string will return null.</td></tr></tbody></table>

### Tiered Plan Benefits

Multiple in-network tiers will be used for plans offering multiple levels of coverage under different networks of providers. The price of a service will vary depending on the tier a specific provider falls under, with lower tiers often providing less coverage than higher tiers. Additional tiers are always appended as necessary to `in_network` using the `in_network_tier_x` structure. Most commonly, plans will be tiered with `in_network_tier_2` or `in_network_tier_3`.

In-network tiers are typically indicated in SBCs with added columns in the benefit grid or other carrier documentation with separate cost share values for different network types. This is usually represented with language such as carrier-specific providers vs. all other providers or preferred/non-preferred network providers.

Plans with multiple tiers in Ideon's dataset follow a set of rules for how cost shares are displayed.&#x20;

* The `in_network` and `out_of_network` tiers are always included and considered baseline. The `in_network` tier can be considered as in-network tier 1 when additional tiers are added.
* Additional tiers are used as necessary with the `in_network_tier_x` structure - `in_network_tier_2`, for example. These additional tiers will only be included in each individual benefit object if the cost share for it differs from the tier one level above it. For example:
  * The `in_network_tier_2` cost share will be included if there is a second tier and the cost shares differs from the  `in_network` cost share for that benefit.
  * The `in_network_tier_3` cost share will be included if there is a third tier and the cost shares differs from the `in_network_tier_2` cost share for that benefit.
* The lowest value cost share, as it is represented in carrier documentation, is used for the lowest tier displayed for each plan.

### Benefits by Field

The below table includes a list of all supported benefit fields in Ideon's plan schema. The commonly used formats for the benefit `limit` and cost share units are included. Note that these are the most commonly used formats, not a full catalog of every possible value.&#x20;

In the benefit grammar delivered in Ideon's dataset, implied units are not shown. If no units are specifically included, it should be assumed that the implied units apply. If a different unit applies to the benefit, then that unit will be included in the grammar string - the common alternative units of this type are included in the table below in addition to the implied unit. For example, if the in-network cost share for the Ambulance benefit is `$300`, then it is assumed that the benefit is "$300 per trip". If carrier documentation specifically indicates the Ambulance benefit applies per transport, then the Ambulance benefit would be presented as `$300 per transport`.

<table data-full-width="true"><thead><tr><th width="132.69921875">Benefit Field</th><th width="129.93359375">API Schema Key</th><th width="134.05859375">Unit(s)</th><th width="158.37109375">Common Limit Format</th><th>Location in SBC (format: Header | Row)</th></tr></thead><tbody><tr><td>Ambulance</td><td>ambulance</td><td><p>Implied: per trip</p><p><em>Alternative: per transport</em></p></td><td></td><td><p>Common Medical Event | <em>If you need immediate medical attention</em></p><p>Services You May Need | <em>Emergency medical transportation</em></p></td></tr><tr><td>Child Dental</td><td>child_dental</td><td><p>Implied: per visit</p><p><em>Alternative: per exam</em></p></td><td>X exam(s) per benefit period</td><td><p>Common Medical Event | <em>If your child needs dental or eye care</em></p><p>Services You May Need | <em>Children's dental check-up</em></p></td></tr><tr><td>Child Eye Exam</td><td>child_eye_exam</td><td><p>Implied: per visit</p><p><em>Alternative: per exam</em></p></td><td>X exam(s) per year</td><td><p>Common Medical Event | <em>If your child needs dental or eye care</em></p><p>Services You May Need | <em>Children's eye exam</em></p></td></tr><tr><td>Child Eyewear</td><td>child_eyewear</td><td>Implied: per item</td><td>X item(s) per year</td><td><p>Common Medical Event | <em>If your child needs dental or eye care</em></p><p>Services You May Need | <em>Children's glasses</em></p></td></tr><tr><td>Diagnostic Test</td><td>diagnostic_test</td><td><p>Implied: per visit</p><p><em>Alternative: per procedure, per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you have a test</em></p><p>Services You May Need | <em>Diagnostic test (x-ray, blood work)</em></p></td></tr><tr><td>Durable Medical Equipment</td><td>durable_medical_equipment</td><td>Implied: per item</td><td>X item(s) per Y year(s)</td><td><p>Common Medical Event | <em>If you need help recovering or have other special health needs</em></p><p>Services You May Need | <em>Durable medical equipment</em></p></td></tr><tr><td>Emergency Room</td><td>emergency_room</td><td>Implied: per visit</td><td>waived if admitted</td><td><p>Common Medical Event | <em>If you need medical attention</em></p><p>Services You May Need | <em>Emergency room care</em></p></td></tr><tr><td>Habilitation Services</td><td>habilitation_services</td><td>Implied: per visit</td><td>X visit(s) per year</td><td><p>Common Medical Event | <em>If you need help recovering or have other special health needs</em></p><p>Services You May Need | <em>Habilitation Services</em></p></td></tr><tr><td>Home Health Care</td><td>home_health_care</td><td><p>Implied: per visit</p><p><em>Alternative: per day</em></p></td><td>X visit(s) per year</td><td><p>Common Medical Event | <em>If you need help recovering or have other special health needs</em></p><p>Services You May Need | <em>Home health care</em></p></td></tr><tr><td>Hospice</td><td>hospice_service</td><td><p>Implied: per admission</p><p><em>Alternative: per day</em></p></td><td>X day(s) per benefit period</td><td><p>Common Medical Event | <em>If you need help recovering or have other special health needs</em></p><p>Services You May Need | <em>Hospice services</em></p></td></tr><tr><td>Imaging Center</td><td>imaging_center</td><td>per visit, <em>per procedure</em></td><td></td><td><p>Common Medical Event | <em>If you have a test</em></p><p>Services You May Need | <em>Imaging (CT/PET scans, MRIs)</em></p></td></tr><tr><td>Imaging Physician</td><td>imaging_physician</td><td>per visit, <em>per procedure</em></td><td></td><td><p>Common Medical Event | <em>If you have a test</em></p><p>Services You May Need | <em>Imaging (CT/PET scans, MRIs)</em></p></td></tr><tr><td>Inpatient Birth</td><td>inpatient_birth</td><td><p>Implied: per admission</p><p><em>Alternative: per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you are pregnant</em></p><p>Services You May Need | <em>Childbirth/delivery facility services</em></p></td></tr><tr><td>Inpatient Birth Physician</td><td>inpatient_birth_physician</td><td>per admission, <em>per procedure, per pregnancy</em></td><td></td><td><p>Common Medical Event | <em>If you are pregnant</em></p><p>Services You May Need | <em>Childbirth/delivery professional services</em></p></td></tr><tr><td>Inpatient Facility</td><td>inpatient_facility</td><td><p>Implied: per admission</p><p><em>Alternative: per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you have a hospital stay</em></p><p>Services You May Need | <em>Facility fee (e.g., hospital room)</em></p></td></tr><tr><td>Inpatient Mental Health</td><td>inpatient_mental_health</td><td><p>Implied: per admission</p><p><em>Alternative: per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you need mental health, behavioral health, or substance abuse services</em></p><p>Services You May Need | <em>Inpatient services</em></p></td></tr><tr><td>Inpatient Physician</td><td>inpatient_physician</td><td>Implied: per admission</td><td></td><td><p>Common Medical Event | <em>If you have a hospital stay</em></p><p>Services You May Need | <em>Physician/surgeon fees</em></p></td></tr><tr><td>Inpatient Substance</td><td>inpatient_substance</td><td><p>Implied: per admission</p><p><em>Alternative: per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you need mental health, behavioral health, or substance abuse services</em></p><p>Services You May Need | <em>Inpatient services</em></p></td></tr><tr><td>Lab Test</td><td>lab_test</td><td><p>Implied: per visit</p><p>Alternative: <em>per procedure, per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you have a test</em></p><p>Services You May Need | <em>Diagnostic test (x-ray, blood work)</em></p></td></tr><tr><td>Outpatient Ambulatory Care Center</td><td>outpatient_ambulatory_care_center</td><td><p>Implied: per visit</p><p><em>Alternative: per procedure, per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you have outpatient surgery</em></p><p>Services You May Need | <em>Facility fee (e.g., ambulatory surgery center)</em></p></td></tr><tr><td>Outpatient Facility</td><td>outpatient_facility</td><td><p>Implied: per visit</p><p><em>Alternative: per procedure, per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you have outpatient surgery</em></p><p>Services You May Need | <em>Facility fee (e.g., ambulatory surgery center)</em></p></td></tr><tr><td>Outpatient Mental Health</td><td>outpatient_mental_health</td><td>Implied: per visit</td><td>see carrier documentation for more information</td><td><p>Common Medical Event | <em>If you need mental health, behavioral health, or substance abuse services</em></p><p>Services You May Need | <em>Outpatient services</em></p></td></tr><tr><td>Outpatient Physician</td><td>outpatient_physician</td><td>Implied: per visit</td><td></td><td><p>Common Medical Event | <em>If you have outpatient surgery</em></p><p>Services You May Need | <em>Physician/surgeon fees</em></p></td></tr><tr><td>Outpatient Substance</td><td>outpatient_substance</td><td>Implied: per visit</td><td>see carrier documentation for more information</td><td><p>Common Medical Event | <em>If you need mental health, behavioral health, or substance abuse services</em></p><p>Services You May Need | <em>Outpatient services</em></p></td></tr><tr><td>Postnatal Care</td><td>postnatal_care</td><td><p>Implied: per visit</p><p>Alternative: <em>per pregnancy, per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you are pregnant</em></p><p>Services You May Need | <em>Office visits</em></p></td></tr><tr><td>Prenatal Care</td><td>prenatal_care</td><td><p>Implied: per visit</p><p>Alternative: <em>per pregnancy, per day</em></p></td><td></td><td><p>Common Medical Event | <em>If you are pregnant</em></p><p>Services You May Need | <em>Office visits</em></p></td></tr><tr><td>Preventative Care</td><td>preventative_care</td><td>Implied: per visit</td><td></td><td><p>Common Medical Event | <em>If you visit a health care provider's office or clinic</em></p><p>Services You May Need | <em>Preventive care/screening/immunization</em></p></td></tr><tr><td>Primary Care Physician</td><td>primary_care_physician</td><td><p>Implied: per visit</p><p><em>Alternative: per procedure, per day</em></p></td><td>see carrier documentation for more information</td><td><p>Common Medical Event | <em>If you visit a health care provider's office or clinic</em></p><p>Services You May Need | <em>Primary care visit to treat an injury or illness</em></p></td></tr><tr><td>Rehabilitation Services</td><td>rehabilitation_services</td><td>Implied: per visit</td><td>X visit(s) per year</td><td><p>Common Medical Event | <em>If you need help recovering or have other special health needs</em></p><p>Services You May Need | <em>Rehabilitation services</em></p></td></tr><tr><td>Skilled Nursing</td><td>skilled_nursing</td><td><p>Implied: per admission</p><p><em>Alternative: per day</em></p></td><td>X day(s) per admission</td><td><p>Common Medical Event | <em>If you need help recovering or have other special health needs</em></p><p>Services You May Need | <em>Skilled nursing care</em></p></td></tr><tr><td>Specialist</td><td>specialist</td><td><p>Implied: per visit</p><p><em>Alternative: per procedure, per day</em></p></td><td>see carrier documentation for more information</td><td><p>Common Medical Event | <em>If you visit a health care provider's office or clinic</em></p><p>Services You May Need | <em>Specialist visit</em></p></td></tr><tr><td>Urgent Care</td><td>urgent_care</td><td><p>Implied: per visit</p><p><em>Alternative: per procedure, per day</em></p></td><td>see carrier documentation for more information</td><td><p>Common Medical Event | <em>If you need immediate medical attention</em></p><p>Services You May Need | <em>Urgent care</em></p></td></tr></tbody></table>

### Prescription Drugs

Cost shares for prescription drug benefits are included in up to six separate tiers, documented in the table below. There is a high degree of variance in how each carrier maps various drug tiers - Tier 1, 2, 3, or 4 as indicated in the SBC, for example - to practical definitions. Ideon handles this variance in carrier mapping to accurately portray drug benefits in generic, brand, and specialty categories. A common structure for this tiering is as follows:

* Tier 1 -> (Preferred) Generic Drugs
* Tier 2 -> Preferred Brand Drugs
* Tier 3 -> Non-Preferred Brand Drugs
* Tier 4 -> (Preferred) Specialty Drugs

Occasionally, a `limit` will be included for drug fields. The only valid `limit` that Ideon supports for drugs is "see carrier documentation for more information". This is primarily used in two cases: when reimbursement is available for the drug or when there's an additional charge for pharmacies or RX.&#x20;

The assumed unit for all drug fields is "per fill"; like other benefits, this means that if no specific unit is included, then "per fill" should be assumed. The only other valid unit is "per script", which will be included if applicable.

<table data-full-width="true"><thead><tr><th width="125.90625">Benefit Field</th><th width="137.0703125">API Schema Key</th><th width="141.6292724609375">Unit(s)</th><th>Location in SBC (format: Header | Row)</th></tr></thead><tbody><tr><td>Generic Drugs</td><td>generic_drugs</td><td><p>Implied: per fill</p><p><em>Alternative: per script</em></p></td><td><p>Common Medical Event | <em>If you need drugs to treat your illness or condition</em></p><p>Services You May Need | <em>Generic drugs</em></p></td></tr><tr><td>Non-Preferred Generic Drugs</td><td>nonpreferred_generic_drug_share</td><td><p>Implied: per fill</p><p><em>Alternative: per script</em></p></td><td><p>Common Medical Event | <em>If you need drugs to treat your illness or condition</em></p><p>Services You May Need | <em>Generic drugs</em></p></td></tr><tr><td>Preferred Brand Drugs</td><td>preferred_brand_drugs</td><td><p>Implied: per fill</p><p><em>Alternative: per script</em></p></td><td><p>Common Medical Event | <em>If you need drugs to treat your illness or condition</em></p><p>Services You May Need | <em>Preferred brand drugs</em></p></td></tr><tr><td>Non-Preferred Brand Drugs</td><td>non_preferred_brand_drugs</td><td><p>Implied: per fill</p><p><em>Alternative: per script</em></p></td><td><p>Common Medical Event | <em>If you need drugs to treat your illness or condition</em></p><p>Services You May Need | <em>Non-preferred brand drugs</em></p></td></tr><tr><td>Specialty Drugs</td><td>specialty_drugs</td><td><p>Implied: per fill</p><p><em>Alternative: per script</em></p></td><td><p>Common Medical Event | <em>If you need drugs to treat your illness or condition</em></p><p>Services You May Need | <em>Specialty drugs</em></p></td></tr><tr><td>Non-Preferred Specialty Drugs</td><td>nonpreferred_specialty_drug_share</td><td><p>Implied: per fill</p><p><em>Alternative: per script</em></p></td><td><p>Common Medical Event | <em>If you need drugs to treat your illness or condition</em></p><p>Services You May Need | <em>Specialty drugs</em></p></td></tr></tbody></table>

### Plan Coinsurance

Ideon utilizes an internal algorithm to calculate a high-level plan coinsurance, published in our API schema as `plan_coinsurance`. Plan coinsurance is represented with `in_network`, `out_of_network`, and additional tiers as necessary. The grammar used is structured as a percentage, such as `20%`. Plan coinsurance is calculated separately for each in-network and out-of-network tier supported by the plan, based on the cost shares of the benefits within that tier.

To calculate plan coinsurance, the values for most coinsurance-based cost share are counted for frequency. When performing this count, $0 copays are treated as a 0% coinsurance. Over 20 of the primary, non-drug benefits are included in the count. The calculation selects the most-frequent coinsurance across those benefits to assign as the plan coinsurance, subject to minimums and further logic to handle various edge cases.


---

# Agent Instructions: Querying This Documentation

If you need additional information that is not directly available in this page, you can query the documentation dynamically by asking a question.

Perform an HTTP GET request on the current page URL with the `ask` query parameter:

```
GET https://ideonapi.gitbook.io/quote-and-select/additional-information-and-workflows/benefit-grammar-guides/medical.md?ask=<question>
```

The question should be specific, self-contained, and written in natural language.
The response will contain a direct answer to the question and relevant excerpts and sources from the documentation.

Use this mechanism when the answer is not explicitly present in the current page, you need clarification or additional context, or you want to retrieve related documentation sections.