All plans are represented as Benefits, which are composed of features, thresholds, and tiers:

• Features: Represents a property of the benefit (and could be something for which a claim could be filed against)
• Thresholds: Marks a boundary. These could be financial or time-based. They mark a change in the logic used to determine the impact an individual incurs for a given event. (e.g., deductibles).
• Tiers: Represents a grouping of feature items and threshold items, such as networks of care (e.g., in-network).

The Benefit Post includes all these entities, while the Snapshot Post contains detailed rates and benefit amounts for employees and their dependents. These entities are all required keys, but some benefits will not need a Tier or Threshold. The API supports passing an empty Tier and/or Threshold array in these cases.

Depending on the benefit type, different Features, Thresholds, and Tiers will be required to create a benefit. While some values are not required, they are used to provide more accurate recommendations. These are defined in the table below.

(F) - Feature
(Th) - Threshold
(T) - Tier

Rule Templates

To handle complex cost-sharing rules and attributes, the API leverages pre-built Rule Templates. These templates apply to both Features and Thresholds in the Benefit Post. Integrators only need to supply a few key inputs, and our system automatically converts them into JSON rules with the appropriate values and display outputs—perfectly suited for user-facing products. This eliminates the need for manual construction of JSON rules, significantly simplifying the integration process. These templates can be found by hitting the /get-templates endpoint.

For example, copays can now be represented both before and after an employee meets their deductible using a provided rule template. If you require a specific template that isn’t currently available, please reach out to our team.

Below are a few examples of Rule Templates used to represent these scenarios:

Coinsurance Coverage

This template accepts one input for coinsuranceCoverage. This template should be used when a feature has a coinsurance amount of x%. The example below will show to an employee as “40% coinsurance”.

{            
  "templateName": "coinsurance_coverage",
  "inputValues": {
    "coinsuranceCoverage": 40
   }
}

Copay Coinsurance Deductible

This template accepts 2 inputs: one for copay and one for coinsurance. This template assumes that a deductible will apply until the deductible is met. This template should be used when a feature has a copay amount of $x and a coinsurance amount of x%. The example below will show to an employee as “$20 copay then 20% coinsurance after deductible is met”

{
  "templateName": "copay_coinsurance_deductible",
  "inputValues": {
    "coinsuranceCoverage": 20,
      "copay": 20
}

Custom Display

This template accepts 2 inputs: one for amount and one for customDisplay. This template should be used when a feature has an amount not defined by any other template. This template will allow partners to add a short line of text after the amount. The example below will show to an employee as “$150 Lifetime Maximum”

{
  "templateName": "customDisplay",
  "inputValues": {
    "amount": 150,
    "customDisplay": "Lifetime Maximum"
}