Plans and Eligibility

Insurance Plans

By default, the project contains Insurance Plans in the src/main/resources/payers/insurance_plans.csv file. This file defines insurance plans which can be linked to the payers defined in #Payer Data.

The default financial numbers (e.g. premiums and copays) are not necessarily accurate. However, they are based on the sources linked in the Notes column of the file.

You can modify the insurance plans file or have Synthea use an alternative payer file by altering the src/main/resources/synthea.properties file:

# Payers
generate.payers.insurance_companies.default_file = payers/insurance_companies.csv
**generate.payers.insurance_plans.default_file = payers/insurance_plans.csv**
generate.payers.insurance_plans.eligibilities_file = payers/insurance_eligibilities.csv

Insurance Plans File Format

The plans file is a CSV file, with a single row for each plan.

Column Header	Description
Plan ID	The unique ID to use for this plan.
Payer Id	This is the ID of the payer, defined in insurance_companies.csv, that this plan should be linked to.
Name	The name of the plan.
Services Covered	The services covered (i.e. paid for) by this payer. Use * to signify all services. Otherwise, used a quoted comma-separated string. e.g. "wellness,medications,emergency"
Deductible	The amount required out of pocket from patients before the payer will reimburse.
Default Coinsurance	Coinsurance as a percentage. 0.0 - 1.0. Currently unused. Maybe used in future versions.
Default Copay	The amount required out of pocket from patients at each encounter.
Monthly Premium	The monthly fee paid by the patient to have coverage from this insurance plan.
Medicare Supplement	A true/false boolean that defines whether this is a Medicare Supplement Plan.
Eligibility Policy	A String that defines this plan's patient eligibility criteria by linking to an eligibility in the eligibility file. See #Eligibility for more details.
Start Year	The initial year that this plan is available. Inclusive.
End Year	The final year that this plan is available. Inclusive.
Notes	Notes and sources associated with the plan data.

Eligibility

By default, the project contains Insurance Plan Patient Eligibility Criteria in the src/main/resources/payers/insurance_eligibilities.csv file. This file defines patient eligibility criteria which can be linked to previously defined insurance plans, as described in #Insurance Plans.

The default eligibility criteria for Medicare and Medicaid are not necessarily complete. Social Security eligibility is missing conditions not featured in Synthea and Medicare income thresholds are accurate by-age, but are missing parental Medicaid. However, they are based on the sources linked in the Notes column of the file.

You can modify the eligibility criteria file or have Synthea use an alternative eligibility file by altering the src/main/resources/synthea.properties file:

# Payers
generate.payers.insurance_companies.default_file = payers/insurance_companies.csv
generate.payers.insurance_plans.default_file = payers/insurance_plans.csv
**generate.payers.insurance_plans.eligibilities_file = payers/insurance_eligibilities.csv**

Eligibility Criteria File Format

The eligibility file is a CSV file, with a single row for each eligibility criteria.

Any column can be left blank (except Name). Blank eligibility columns will not be used. Multiple previously defined eligibilities can be mixed and matched using the Sub-Eligibilities column. This can be combined with the Logical Operator column to have nested logic.

Column Header	Description
Name	The name of this eligibility criteria. It must be unique and is used to link insurance plans with an eligibility type in ##Insurance Plan file.
Poverty Multiplier	A simple decimal multiplier that defines what income threshold multiple of the federal poverty level is required to be below for the person to be eligible. For instance, if the poverty multiplier is 1.5, and the federal poverty level is $10,000, then anyone making less than $15,000 will be eligible.