HL7 Terminology (THO)
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This page is part of the HL7 Terminology (v6.0.1: Release) based on FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

ValueSet: ActHealthInsuranceTypeCode

Official URL: http://terminology.hl7.org/ValueSet/v3-ActHealthInsuranceTypeCode Version: 3.0.0
Active as of 2014-03-26 Responsible: Health Level Seven International Computable Name: ActHealthInsuranceTypeCode
Other Identifiers: OID:2.16.840.1.113883.1.11.19857

Copyright/Legal: This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html

Definition: Set of codes indicating the type of health insurance policy that covers health services provided to covered parties. A health insurance policy is a written contract for insurance between the insurance company and the policyholder, and contains pertinent facts about the policy owner (the policy holder), the health insurance coverage, the insured subscribers and dependents, and the insurer. Health insurance is typically administered in accordance with a plan, which specifies (1) the type of health services and health conditions that will be covered under what circumstances (e.g., exclusion of a pre-existing condition, service must be deemed medically necessary; service must not be experimental; service must provided in accordance with a protocol; drug must be on a formulary; service must be prior authorized; or be a referral from a primary care provider); (2) the type and affiliation of providers (e.g., only allopathic physicians, only in network, only providers employed by an HMO); (3) financial participations required of covered parties (e.g., co-pays, coinsurance, deductibles, out-of-pocket); and (4) the manner in which services will be paid (e.g., under indemnity or fee-for-service health plans, the covered party typically pays out-of-pocket and then file a claim for reimbursement, while health plans that have contractual relationships with providers, i.e., network providers, typically do not allow the providers to bill the covered party for the cost of the service until after filing a claim with the payer and receiving reimbursement).

References

This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

Logical Definition (CLD)

Generated Narrative: ValueSet v3-ActHealthInsuranceTypeCode

Language: en

This value set includes codes based on the following rules:

 

Expansion

Generated Narrative: ValueSet

Language: en

Expansion based on codesystem ActCode v9.0.0 (CodeSystem)

This value set contains 15 concepts

CodeSystemDisplayDefinition
  EHCPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodeextended healthcare

Private insurance policy that provides coverage in addition to other policies (e.g. in addition to a Public Healthcare insurance policy).

  HSAPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodehealth spending account

Insurance policy that provides for an allotment of funds replenished on a periodic (e.g. annual) basis. The use of the funds under this policy is at the discretion of the covered party.

  _ActHealthInsuranceTypeCodehttp://terminology.hl7.org/CodeSystem/v3-ActCodeActHealthInsuranceTypeCode

Definition: Set of codes indicating the type of health insurance policy that covers health services provided to covered parties. A health insurance policy is a written contract for insurance between the insurance company and the policyholder, and contains pertinent facts about the policy owner (the policy holder), the health insurance coverage, the insured subscribers and dependents, and the insurer. Health insurance is typically administered in accordance with a plan, which specifies (1) the type of health services and health conditions that will be covered under what circumstances (e.g., exclusion of a pre-existing condition, service must be deemed medically necessary; service must not be experimental; service must provided in accordance with a protocol; drug must be on a formulary; service must be prior authorized; or be a referral from a primary care provider); (2) the type and affiliation of providers (e.g., only allopathic physicians, only in network, only providers employed by an HMO); (3) financial participations required of covered parties (e.g., co-pays, coinsurance, deductibles, out-of-pocket); and (4) the manner in which services will be paid (e.g., under indemnity or fee-for-service health plans, the covered party typically pays out-of-pocket and then file a claim for reimbursement, while health plans that have contractual relationships with providers, i.e., network providers, typically do not allow the providers to bill the covered party for the cost of the service until after filing a claim with the payer and receiving reimbursement).

  DENTALhttp://terminology.hl7.org/CodeSystem/v3-ActCodedental care policy

Definition: A health insurance policy that that covers benefits for dental services.

  DISEASEhttp://terminology.hl7.org/CodeSystem/v3-ActCodedisease specific policy

Definition: A health insurance policy that covers benefits for healthcare services provided for named conditions under the policy, e.g., cancer, diabetes, or HIV-AIDS.

  DRUGPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodedrug policy

Definition: A health insurance policy that covers benefits for prescription drugs, pharmaceuticals, and supplies.

  HIPhttp://terminology.hl7.org/CodeSystem/v3-ActCodehealth insurance plan policy

Definition: A health insurance policy that covers healthcare benefits by protecting covered parties from medical expenses arising from health conditions, sickness, or accidental injury as well as preventive care. Health insurance policies explicitly exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy.

Discussion: Health insurance policies are offered by health insurance plans that typically reimburse providers for covered services on a fee-for-service basis, that is, a fee that is the allowable amount that a provider may charge. This is in contrast to managed care plans, which typically prepay providers a per-member/per-month amount or capitation as reimbursement for all covered services rendered. Health insurance plans include indemnity and healthcare services plans.

  LTChttp://terminology.hl7.org/CodeSystem/v3-ActCodelong term care policy

Definition: An insurance policy that covers benefits for long-term care services people need when they no longer can care for themselves. This may be due to an accident, disability, prolonged illness or the simple process of aging. Long-term care services assist with activities of daily living including:

  • Help at home with day-to-day activities, such as cooking, cleaning, bathing and dressing
  • Care in the community, such as in an adult day care facility
  • Supervised care provided in an assisted living facility
  • Skilled care provided in a nursing home
  MCPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodemanaged care policy

Definition: Government mandated program providing coverage, disability income, and vocational rehabilitation for injuries sustained in the work place or in the course of employment. Employers may either self-fund the program, purchase commercial coverage, or pay a premium to a government entity that administers the program. Employees may be required to pay premiums toward the cost of coverage as well.

Managed care policies specifically exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy.

Discussion: Managed care policies are offered by managed care plans that contract with selected providers or health care organizations to provide comprehensive health care at a discount to covered parties and coordinate the financing and delivery of health care. Managed care uses medical protocols and procedures agreed on by the medical profession to be cost effective, also known as medical practice guidelines. Providers are typically reimbursed for covered services by a capitated amount on a per member per month basis that may reflect difference in the health status and level of services anticipated to be needed by the member.

  POShttp://terminology.hl7.org/CodeSystem/v3-ActCodepoint of service policy

Definition: A policy for a health plan that has features of both an HMO and a FFS plan. Like an HMO, a POS plan encourages the use its HMO network to maintain discounted fees with participating providers, but recognizes that sometimes covered parties want to choose their own provider. The POS plan allows a covered party to use providers who are not part of the HMO network (non-participating providers). However, there is a greater cost associated with choosing these non-network providers. A covered party will usually pay deductibles and coinsurances that are substantially higher than the payments when he or she uses a plan provider. Use of non-participating providers often requires the covered party to pay the provider directly and then to file a claim for reimbursement, like in an FFS plan.

  HMOhttp://terminology.hl7.org/CodeSystem/v3-ActCodehealth maintenance organization policy

Definition: A policy for a health plan that provides coverage for health care only through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Eligibility to enroll in an HMO is determined by where a covered party lives or works.

  PPOhttp://terminology.hl7.org/CodeSystem/v3-ActCodepreferred provider organization policy

Definition: A network-based, managed care plan that allows a covered party to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverage and lower deductibles.

  MENTPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodemental health policy

Definition: A health insurance policy that covers benefits for mental health services and prescriptions.

  SUBPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodesubstance use policy

Definition: A health insurance policy that covers benefits for substance use services.

  VISPOLhttp://terminology.hl7.org/CodeSystem/v3-ActCodevision care policy

Definition: Set of codes for a policy that provides coverage for health care expenses arising from vision services.

A health insurance policy that covers benefits for vision care services, prescriptions, and products.


Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code

History

DateActionCustodianAuthorComment
2023-11-14reviseTSMGMarc DuteauAdd standard copyright and contact to internal content; up-476
2022-10-18reviseTSMGMarc DuteauFixing missing metadata; up-349
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26