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Medical Benefits API
Show what a Medicare Advantage or ACA Marketplace plan covers and what a member pays, from the plan files CMS publishes.
One of haau3's two Benefits services. See Benefits
GETapi.haau3.com/v1/fhir/r4/InsurancePlan
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Request
GET /v1/fhir/r4/InsurancePlan/H2406-013-000Response
{
"resourceType": "InsurancePlan",
"id": "H2406-013-000",
"type": [{ "coding": [{
"code": "mediadv",
"display": "Medicare Advantage" }] }],
"name": "AARP Medicare Advantage from UHC FL-0021 (PPO)",
"period": { "start": "2027", "end": "2027" },
"plan": [{
"specificCost": [{
"category": { "coding": [{
"code": "specialist-visit",
"display": "Specialist Visit" }] },
"benefit": [{ "cost": [{
"type": { "text": "Copayment" },
"value": {
"value": 65,
"unit": "USD",
"comparator": "<=" },
"applicability": { "coding": [{
"code": "in-network" }] }
}] }]
}]
}]
}What a plan covers, and what a member pays.
The implementation guide’s two example plans: a Medicare Advantage PPO, and a Marketplace gold plan with two in-network tiers. Each service reads as a plain name first, with SBC’s and CMS’s words and codes beneath, and a cost the files do not state says why.
A readable view of the example. The API returns the FHIR JSON.
AARP Medicare Advantage from UHC FL-0021 (PPO)
H2406-013-000- Program
- Medicare Advantagemediadv
- Plan type
- Local PPOPreferred Provider Organization (PPO)PPO
- Issuer
- UnitedHealthcareCARE IMPROVEMENT PLUS SOUTH CENTRAL INSURANCE CO.H2406
- Plan year
- 2027
- Sold in
- FL
- CMS release
- ma-2027-2026-10-01
Premium
- Monthly premium$0
- Part B premium reductionNoneNo amount
Deductibles
- Individual DeductibleOut of network, for medical care$1,000
Out-of-pocket maximums
- Individual Out-of-Pocket MaximumIn network, for medical care$7,150
- Individual Out-of-Pocket MaximumOut of network, for medical care: noneNo amount
- Individual Out-of-Pocket MaximumIn and out of network combined, for medical care$10,750
What a member pays for care
ServiceIn networkOut of network
- Primary carePrimary Care Visitprimary-care-visitPrimary Care Physician Services7aIn network$0CopaymentOut of network$45Copayment
- SpecialistSpecialist Visitspecialist-visitPhysician Specialist Services7dIn networkup to $65Copayment$0 to $65Out of network$100Copayment
- Urgent careUrgent Careurgent-careUrgently Needed Services4bIn networkup to $50CopaymentOne price in and out of network$0 to $50Out of networkup to $50CopaymentOne price in and out of network$0 to $50
- Emergency roomEmergency Room Careemergency-room-careEmergency Services4a
Limits and terms
- Copay waived if admitted to the hospital within 24 hours
In network$130CopaymentOne price in and out of networkOut of network$130CopaymentOne price in and out of network - Inpatient hospitalHospital Inpatient Carehospital-inpatientInpatient Hospital-Acute1a
Limits and terms
- Benefit period (in network): Per Admission or Per Stay
In network$550 a day, days 1 to 5Copayment$0 a day, days 6 to 90Copayment$0 a stayCopaymentOut of network40% a stayCoinsurance - Outpatient hospitalHospital Outpatient Carehospital-outpatientOutpatient Hospital Services9a1In networkup to $550Copayment$0 to $550Out of network40%Coinsurance
- Surgery center or facility feeFacility Feefacility-feeAmbulatory Surgical Center (ASC) Services9bIn networkup to $500Copayment$0 to $500Out of network40%Coinsurance
- ImagingImaging (CT/PET/MRI)imagingDiagnostic Radiological Services8b1In networkup to $320Copayment$0 to $320Out of network40%Coinsurance
- TherapyRehabilitation ServicesrehabilitationPhysical Therapy and Speech-Language Pathology Services7iIn network$65CopaymentOut of network$100Copayment
- Mental health, outpatientMental/Behavioral Health Outpatient Servicesmental-health-outpatientIndividual Sessions for Mental Health Specialty Services7e1In networkup to $25Copayment$0 to $25Out of network$40Copayment
- AmbulanceEmergency Medical Transportationemergency-medical-transportGround Ambulance Services10a1In network$380CopaymentOut of network$380Copayment
- Skilled nursingSkilled Nursing Careskilled-nursingSkilled Nursing Facility (SNF)2
Limits and terms
- Benefit period (in network): Original Medicare
In network$0 a day, days 1 to 20Copayment$221 a day, days 21 to 100CopaymentOut of network$250 a day, days 1 to 100Copayment$0 a stayCopayment - Preventive carePreventive Care/Screening/Immunizationpreventive-careMedicare-covered Zero Dollar Preventive Services14a
Limits and terms
- The public files state the cost for preventive care, screenings and immunizations, not which services or visits a plan counts as preventive.
In network$0CopaymentNo cost sharing, as the plan attests for Original Medicare's preventive servicesOut of networkup to 40%Coinsurance0% to 40%
Also carried
SBC’s benefit categories have no code for these, so they are carried in an extension shaped the same way.
ServiceIn networkOut of network
- LabLab Services8a2In network$0CopaymentOut of network$0Copayment
- Hospital observationObservation Services9a2In network$550 a dayCopaymentOut of network40%Coinsurance
- Home healthHome Health Services6In network$0CopaymentOut of network50%Coinsurance
Extra benefits
Whether the plan covers each, as CMS’s files say. Not in the CMS data never means not covered.
Extra benefitCoverage
- Hearing aidsPrescription Hearing Aids18bCoverageCovered with a limit
- Dental cleaningsProphylaxis (Cleaning)16b4CoverageCovered with a limit
- Fillings and other restorative dentalRestorative Services16c1CoverageNot covered
- EyeglassesEyeglasses (lenses and frames)17b2CoverageCovered with a limit
- Routine eye examRoutine Eye Exams17a1CoverageCovered with a limit
- Over-the-counter allowanceOver-the-Counter (OTC) Items13bCoverageNot covered
- Fitness benefitFitness Benefit14c4CoverageCovered
- Rides to medical appointmentsTransportation Services10bCoverageNot covered
- MealsMeal Benefit13cCoverageNot covered
- Routine hearing examRoutine Hearing Exams18a1CoverageCovered with a limit
Plan facts
- Special needs plan
- No
- Only an employer or union group can enroll
- No
- Covers Part B services only
- No
- Files cost data in CMS’s public files
- Yes
- Covers care out of network
- Yes
- Has a point-of-service option
- No
Contacts
- General Questions
- (866)627-7806AARPMedicarePlans.com
- Provider directory
- AARPMedicarePlans.com
CMS files
- https://www.cms.gov/files/zip/pbp-benefits-2027.zip2026-10-01SHA-256 6d8430e2ecb51acf3cc8547f12dd73506aa73f0dccf034cc3c3393868576ff47
What it does
- Medicare Advantage plans, and ACA Marketplace plans sold through HealthCare.gov
- Deductibles, out-of-pocket maximums and the cost of core services, in and out of network
- Read a plan by its CMS or HIOS id, or search by id, name, state or county
- Find the plans sold in a county that a person can buy on their own, apart from those sold only to employer and union groups
- Check up to 20 providers against a Medicare Advantage plan's network in the CMS National Provider Directory
- Every plan names the CMS release it was read from
- A cost the files do not state carries a code saying why, and is never written as $0
- Conforms to the Summary of Benefits and Coverage profile of the CARIN Digital Insurance Card guide (in ballot)
Built on
FHIR R4CARIN SBC profile (ballot)CMS plan files
Look up a Medicare Advantage or ACA Marketplace plan by its id, or find one by name, state or county. You get back what it covers and what a member pays: deductibles and out-of-pocket maximums, and the cost of core services such as a primary care visit, an emergency room visit or a hospital stay, in network and out of network. Every plan is a standard FHIR InsurancePlan and names the CMS release it was read from. Medical Benefits serves the medical plan-design part of Real-Time Benefits, a CMS Health Tech Ecosystem use case.
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