Stream: Da+Vinci+PDex+Plan-Net
Topic: Insurance Plan.Coverage
Chetana Nayyar (Feb 23 2021 at 19:15):
Currently the resource maturity is 0 within FHIR r4. There is a coverage section provided within insuranceplan when there already exist a separate Coverage resource. How are we using this information since InsurancePlan provides Payer plan related details. On the contrary the Covergae provides information once the plan has already been subscribed. So is this specifically placed to keep a link between these two resources?
Lin Zhang (Feb 24 2021 at 00:20):
The relationship/boundary between them is confusing to me.
Saul Kravitz (Mar 02 2021 at 19:49):
Hi @Chetana Nayyar and @Lin Zhang ....
Within the Plan-Net IG, InsurancePlan.coverage is not required (min cardinality >0) nor MS.
So, no client would expect to find it populated.
Lin Zhang (Mar 02 2021 at 23:58):
@Saul Kravitz Thanks.
Chetana Nayyar (Mar 03 2021 at 04:39):
Saul Kravitz said:
Hi Chetana Nayyar and Lin Zhang ....
Within the Plan-Net IG, InsurancePlan.coverage is not required (min cardinality >0) nor MS.
So, no client would expect to find it populated.
Thanks @Saul Kravitz
My question was more from the business usecase where for ex. patient wishes to look for the drug formulary cost sharing information. Currently the Coverage resource doesnt has any field to provide these details.
Even to list these drug formulary details from the payer side it is a lIst resource which is used on the US Drug Formulary IG.
So can you help how can such a use case be resolved?
Saul Kravitz (Mar 03 2021 at 14:53):
@Chetana Nayyar Your point is well taken. There is no good answer today. I think further evolution of both the Formulary and Plan-Net IGs is required to support the business use case you describe. I suggest creating issues against both IGs so that this is taken into account for STU2.
Chetana Nayyar (Mar 04 2021 at 06:38):
@Saul Kravitz can you please help in creating these tickets since I dont have an account for creating these JIRA tickets
Saul Kravitz (Mar 04 2021 at 19:41):
I started to write up the ticket, but not sure I get your point @Chetana Nayyar
Does this capture it?
Currently, the Formulary CoveragePlan profile describes cost sharing and co-insurance for the tiers of a drug insurance
plan. The representation is immature (a bunch of extensions to the List resource). The InsurancePlan profile within the
Plan-Net IG has a coverage backbone element that is theoretically used to describe coverage, but this is very
different from what is in the Formulary IG.
For the shopping scenario one might expect to find the description of the plan in Provider Directory, but the cost
sharing is in the associated Formulary. The Coverage resource doesn't provide the information.
Seems like work is required to provide a consistent and accessible representation for Drug Coverage including
copayments and coinsurance.
Chetana Nayyar (Mar 05 2021 at 12:31):
@Saul Kravitz
The one you have provided will be another scenario. Currently I had raised the concern as per below understanding:
The Coverage resource currently holds the plan details the patient has opted for. In association to the plan the drug formulary cost sharing information if a patient wishes to see there is currently no way.
So hope I was able to clarify my point.
Saul Kravitz (Mar 05 2021 at 13:14):
Let me try again, to see if I understand:
The member authenticates to the PatientAccess API, and retrieves their current Coverage resource.
The Coverage resource doesn't include the cost sharing information for their drug plan.
How can a client navigate from the drug plan info in the Coverage resource to the appropriate CoveragePlan(List) resource in the Drug Formulary?
Chetana Nayyar (Mar 22 2021 at 05:45):
Saul Kravitz6:44 PM
Let me try again, to see if I understand:
The member authenticates to the PatientAccess API, and retrieves their current Coverage resource.
The Coverage resource doesn't include the cost sharing information for their drug plan. -------- Yes that is the ask.
How can a client navigate from the drug plan info in the Coverage resource to the appropriate CoveragePlan(List) resource in the Drug Formulary? ---- Currently there is no drug information available on the Coverage resource, hence that itself is the ask. How to retrieve the drug information related to the Coverage.
Saul Kravitz (Mar 22 2021 at 13:33):
@Chetana Nayyar - Excellent question. May require discussion on the Friday PDEX call. I don't have an off-the-cuff answer.
Richard (Apr 23 2021 at 15:15):
Another question on Drug formulary (and forgive me if this has been answered somewhere else), but does the mandate require that we provide the Drug Formulary both as part of the Patient Access API and for the public facing API for shopping? I'm clear its required for Patient Access but i don't think i've seen a definitive answer as to whether its mandatory for the public facing APIs as well. Can someone please clarify for me? Thanks.
Saul Kravitz (Apr 23 2021 at 17:01):
Best asked on the Formulary thread, but....
Shopping use case is not required.
Last updated: Apr 12 2022 at 19:14 UTC
