Monthly Archives: April 2016 publishes health plan and provider network schemas

Some good news on healthcare standards

I have been working with the Google semantic web group for many months to design several schemas that represent healthcare provider networks and health insurance plan coverage.  The good news is that these schemas have been officially published for use with  This is the first step towards a wider adoption for a more consistent designation for this type of information.  The schemas are:

Health Insurance Plan: List of health plans and their corresponding network of providers and drug formularies
Health Plan Network: Defines a network of providers within an health plan.
Health Plan Cost Sharing Specification: List of costs to be paid by the covered beneficiary.
Health Plan Formulary: Lists of drugs covered by health plan.

Now for the background…

In November 2015, the US health agency Centers for Medicare & Medicaid Services (CMS) enacted a new regulatory requirement for health insurers who list plans on insurance marketplaces. They must now publish a machine-readable version of their provider network directory and health plan coverage, publish it to a specified JSON standard, and update it at least monthly. Many major health insurance companies across the US have already started to publish their health plan coverage, provider directories and drug formularies to this standard.

The official schema is kept in a GitHub Repository:  This format makes it possible to see how which changes were made and when.  It also has an issues section to facilitate ongoing discussion about the optimal adoption of the standard.  There’s a website that goes into a more detailed explanation on the background of this effort:

This website also includes the “Machine-readable URL PUF” seed file” to the actual data that have been published by insurance company.  This file contains URLs that can be crawled to aggregate the latest plan and provider data.

In terms of adoption, U.S. health plans that participate in insurance markeplaces have published: *

  • 39 states
  • 398 health plans
  • ~26,000 URLs describing insurance coverage, provider networks, drug formularies

* Updated November 2016

A group of companies representing the provider, payer and consumer segments of healthcare convened to discuss the standard throughout 2015.  The considerations that went into formation of the standard can be found at: