Medical

Supported benefits and grammar for medical health plans

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) can be referenced.

This page is organized into sections to cover all data for medical health plans, including it's metadata and benefits. All sections are included on a single page to enable cmd+f searching based on schema keys or conventional terminology.

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.

Carrier and Issuer Data

Metadata Field	API Schema Key	Data Type	Example	Notes
Carrier Info - ID	carrier.id	string	"d31dc8f5-00bd-422d-bcb3-44caa4227b38"	Unique identifier for the carrier, consistent across Ideon's Quote and Select data.
Carrier Info - Name	carrier.name Previously used field: carrier_name	string	"Cigna Healthcare"	The carrier's brand or marketing name.
Carrier Info - Logo URL	carrier.logo_url	string	"https://d1hm12jr612u3r.cloudfront.net/images/logos/353/thumb.png?1724342730"	Carrier logos are presented in thumb size by default. To access a higher resolution image, replace "thumb" in the URL with "medium".
Carrier Info - Issuer ID	carrier.issuer_id Previously used field: hios_issuer_id	string	"40064"	The 5-digit HIOS Issuer ID of the licensed carrier offering the plan.
Carrier Disclaimers	carrier_disclaimers	string	"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."	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.

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.

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.

• 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

Metadata Field	API Schema Key	Data Type	Example	Notes
SBC - Summary of Benefits and Coverage	plan_documents[type="summary_of_benefits_and_coverage"].url	string	"https://d2ed110nmrd591.cloudfront.net/blobs/op3EnjSm5higG5YtyJpfZq58.pdf"	SBCs are included in the plan_documents array, when available. If an SBC is not available for a plan, the SBC object will not be included in the plan_documents array. If both the SBC and SOB are not available for a plan, the plan_documents array will be included in the response as an empty array - [].
SOB - Summary of Benefits (or Schedule of Benefits)	plan_documents[type="summary_of_benefits"].url	string	"https://d2ed110nmrd591.cloudfront.net/blobs/3bjCTpvZGiDDeifmfZT8RuKJ.pdf"	SOBs are included in the plan_documents array, when available. If an SOB is not available for a plan, the SOB object will not be included in the plan_documents array.
Drug Formulary URL	drug_formulary_url	string	"https://www.sutterhealthplan.org/pharmacy"	Drug Formulary URLs are included based on availability in carrier source data. The drug_forumlary_url field in the API schema will return null if not available.
Provider Directory URL	networks[].provider_directory_url	string	"https://ambetter.superiorhealthplan.com/findadoc"	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 provider_directory_url field will not be rendered in the API response schema.

Plan Identifiers

Metadata Field	API Schema Key	Data Type	Example	Notes
HIOS ID	identifiers[type="hios_id"].value Previously used field: id	string	"43283NC0020046"	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.
Carrier-specific Identifiers	identifiers[type="contract_id","package_code"].value	string	"DX98-K35S"	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 type can be included for a single plan. More information can be found in the Carrier Identifiers Section.

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.

-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 for Individual Medical Quoting.

-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 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.

Riders

Metadata Field	API Schema Key	Data Type	Example	Notes
Abortion Rider	abortion_rider	boolean	true, false, or null	True 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 null will be passed.
Age 29 Rider	age29_rider	boolean	true or false	Specific to New York. Indicates whether or not the age 29 rider is excluded, meaning a true value means the age 29 rider is not included. False indicates that dependents up to age 29 are eligible.
Domestic Partner Rider Excluded	dp_rider	boolean	true or false	Specific to New York. Indicates whether or not the domestic partner rider is excluded, meaning a true value means the domestic partner rider is not included. False indicates that domestic partners are eligible for coverage.
Family Planning Rider Excluded	fp_rider	boolean	true or false	Specific to New York. Indicates whether or not the family planning rider is excluded, meaning a true value means the family planning rider is not included. False indicates that family planning coverage is included.
Skilled Nursing Facility 365	skilled_nursing_facility_365	enum	"unlimited"	Specific to New York. Valid values are unlimited or unknown. A value of unlimited indicates 365-day coverage at a SNF.
Infertility Treatment Rider	infertility_treatment_rider	boolean	true, false, or null	True indicates that covered options are available for infertility treatments. If carrier documentation does not include any infertility treatment rider information, then null will be passed.

CMS Fields

Metadata Field	API Schema Key	Data Type	Example	Notes
Standardized Plan	standardized_plan	boolean	true or false	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 CMS.
CMS Star Ratings	ratings[]	string	"4"	CMS Star Ratings are sourced from the CMS PUF for Individual market plans. Ratings can range from 1 to 5; a null value indicates that the plan was not rated. If ratings data for a plan is not available through the CMS PUF, the ratings key will be included in the response schema as an empty array. Additional information can be found through CMS. Valid types for CMS star ratings include: cms_quality_ratings_overall cms_quality_ratings_medical_care cms_quality_ratings_member_experience cms_quality_ratings_plan_administration

Miscellaneous Metadata

Metadata Field	API Schema Key	Data Type	Example	Notes
Plan Name	name	string	"Premier Blue Copay 50/50 $4500"	The name of the plan as detailed in carrier documentation.
Display Name	display_name	string	"Premier Blue Copay 50/50 $4500"	In the vast majority of cases, display_name mirrors the name. If a plan's marketing name differs from the legally filed name and sbc_name, it will be returned as the display_name.
SBC Name	sbc_name	string	"Premier Blue Copay 50/50 $4500"	The name of the plan as given in the header of the SBC.
Metal Level	level	enum	"silver"	Valid values are platinum, gold, silver, bronze, expanded_bronze, or catastrophic. Metal levels are categorized by the plan's actuarial value.
Plan Type	plan_type	enum	"PPO"	Valid values are EPO, HMO, PPO, POS, or Indemnity.
Actuarial Value (AV)	actuarial_value	float	70.06	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.
Estimated Actuarial Value	estimated_actuarial_value	float	70.06	The Estimated AV is calculated by Ideon, using CMS's filings on calculation methodology for AV. This value should only be used if the actuarial_value is not available for a plan.
Data Source	source	enum	"carrier"	Valid values are carrier, cms, and state. A value of carrier 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 cms or state are entirely built from data sourced through public filings: federal or state, respectively. For information on carriers that Ideon maintains a direct relationship with for data sourcing, please reference Planwatch.
Market Availability	plan_market	enum	"on_market"	Both the plan_market and a combination of on_market and off_market fields deliver the same information: whether the plan is available on the public marketplace, off of it, or both. Valid values are: on_market - the plan is available only on the public marketplace off_market - the plan is available only off the public marketplace both_markets - the plan is available both on and off the public marketplace
Market Availability	on_market	boolean	true or false	Indicates whether or not the plan is available on the public marketplace.
Market Availability	off_market	boolean	true or false	Indicates whether or not the plan is available off the public marketplace.
Mail Order RX	mail_order_rx	float	2.0	Represents the cost of home delivery prescriptions, equalling the cost of home delivery divided by retail cost.
Embedded Deductible	embedded_deductible	enum	"embedded"	Valid values are embedded, non_embedded, or unknown. An unknown or null value indicates carrier documentation does not include a clear definition, typically occurring with $0 deductibles.
Gated	gated	boolean	true, false, or null	Indicates whether or not the plan requires referrals to see a specialist.
HSA Eligible	hsa_eligible	boolean	true, false, or null	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 CMS.
Essential Health Benefits Percentage	essential_health_benefits_percentage	float	100.0	Internally-calculated field that represents the percentage of CMS-defined essential health benefits are covered by the plan. Additional information can be found through CMS.
Plan Ancestors	plan_ancestors[]	array of objects	{ "id": "67138CA0700018", "year": 2024 }	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.
Telemedicine	telemedicine	boolean	true, false, or null	Indicates whether or not the plan includes options for virtual healthcare.
Adult Dental	adult_dental	boolean	true, false, or null	Indicates whether or not the plan includes options for adult dental care.
Chiropractic Services	chiropractic_services	boolean	true, false, or null	Indicates whether or not the plan includes options for chiropractic care.
Network	networks[]	array of objects	{ "id": 102126, "name": "AMBETTER PPO IFP" }	While the networks key is returned as an array, Ideon currently returns only a single provider-network for each plan. The id represents the unique network identifier, internal to Ideon.
Quoted via Carrier's API	quoted_via_carrier_api	boolean	true or false	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.
Plan Calendar	plan_calendar	string	"calendar_year"	Valid values are calendar_year or plan_year. A calendar_year value is typical of Individual market plans, where coverage begins on January 1st. A plan_year value indicates plan coverage will last for a 12-month period from the effective date of coverage.
Last Updated Timestamp	updated_at	string	"2024-11-21T21:34:37.850Z"	The ISO 8601 UTC timestamp indicating when the plan's benefit data was last updated by Ideon.

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.

Benefit Field	API Schema Key	Location in SBC (format: Header | Row)	Definition
Individual Medical Deductible	individual_medical_deductible	Important Questions | What is the overall deductible?	The amount an individual needs to spend on covered medical services before the plan’s coverage will go into effect.
Family Medical Deductible	family_medical_deductible	Important Questions | What is the overall deductible?	The amount a family needs to spend on covered medical services before the plan’s coverage will go into effect.
Individual Drug Deductible	individual_drug_deductible	Important Questions | Are there other deductibles for specific services?	The amount an individual needs to spend on covered prescription drugs before the plan’s coverage will go into effect.
Family Drug Deductible	family_drug_deductible	Important Questions | Are there other deductibles for specific services?	The amount a family needs to spend on covered prescription drugs before the plan’s coverage will go into effect.
Individual Medical MOOP	individual_medical_moop	Important Questions | What is the out-of-pocket limit for this plan?	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.
Family Medical MOOP	family_medical_moop	Important Questions | What is the out-of-pocket limit for this plan?	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.
Individual Drug MOOP	individual_drug_moop	Important Questions | What is the out-of-pocket limit for this plan?	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.
Family Drug MOOP	family_drug_moop	Important Questions | What is the out-of-pocket limit for this plan?	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.

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.

Grammar Format	Structure	Example	Notes
Standard Deductible or MOOP	$X	$5,000
Drug Included in Medical	Included in Medical	Included in Medical	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.
Unlimited MOOP	Unlimited	Unlimited	This indicates that there is no maximum out of pocket amount for the associated field and tier. This is used for out_of_network 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.
Not Covered Deductible	Not Covered	Not Covered	Deductibles can be presented as not covered for out_of_network 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.

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.

"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.

Cost Share Format	Structure	Example	Notes
Standard Copay	$X	$25	A $0 copay indicates the carrier documentation presents the benefit as a $0 copay or a 0% coinsurance.
Standard Coinsurance	X%	20%	If two coinsurances are documented for the same benefit and tier, the higher value is captured.
Cost Share with Deductible	$X after deductible X% after deductible	$25 after deductible 20% after deductible	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.
Copay plus Coinsurance	$X plus Y%	$25 plus 20%	Enrollees are responsible for a copay plus a coinsurance for the billed service.
Copay Range	$X - $Y	$25 - $100	When multiple or a range of copays are shown for a benefit in a single tier, Ideon typically presents the range format in this row.
Varying Cost Share by Visit	first X visit(s) Y then Z	first 3 visit(s) $25 then 20% after deductible	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.
Varying Cost Share by Day	first X day(s) Y then Z	first 5 day(s) $250 then $0	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.
Allowances	X after Y allowance	100% after $150 allowance	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.
Not Covered	Not Covered	Not Covered	This denotes a benefit that is not covered by a plan - the enrollee is responsible for all costs.
Unknown	null	null	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.

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.

Limit Format	Structure	Example	Notes
Standard Limit	X {measured service}(s) per {time period}	20 visit(s) per year	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.
Condition-Based Limit	X {measured service}(s) per condition per {time period}	20 visit(s) per condition per benefit period	Condition-based limits add the "per condition" qualifier to the standard limit.
Waived if Admitted	waived if admitted	waived if admitted	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.
Documentation Reference	see carrier documentation for more information	see carrier documentation for more information	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.
No Limit Included	null	null	If no limit is included for the benefit, the limit string will return null.

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.

• 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.

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.

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

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.

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.

Benefit Field	API Schema Key	Unit(s)	Location in SBC (format: Header | Row)
Generic Drugs	generic_drugs	Implied: per fill Alternative: per script	Common Medical Event | If you need drugs to treat your illness or condition Services You May Need | Generic drugs
Non-Preferred Generic Drugs	nonpreferred_generic_drug_share	Implied: per fill Alternative: per script	Common Medical Event | If you need drugs to treat your illness or condition Services You May Need | Generic drugs
Preferred Brand Drugs	preferred_brand_drugs	Implied: per fill Alternative: per script	Common Medical Event | If you need drugs to treat your illness or condition Services You May Need | Preferred brand drugs
Non-Preferred Brand Drugs	non_preferred_brand_drugs	Implied: per fill Alternative: per script	Common Medical Event | If you need drugs to treat your illness or condition Services You May Need | Non-preferred brand drugs
Specialty Drugs	specialty_drugs	Implied: per fill Alternative: per script	Common Medical Event | If you need drugs to treat your illness or condition Services You May Need | Specialty drugs
Non-Preferred Specialty Drugs	nonpreferred_specialty_drug_share	Implied: per fill Alternative: per script	Common Medical Event | If you need drugs to treat your illness or condition Services You May Need | Specialty drugs

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.