# Health insurers (CMS-9115)

> Claims, coverage, and clinical history from health insurers, shared by the member through the Patient Access APIs required by CMS-9115.

Web page: https://www.flexpa.com/networks/health-insurers

## For people and teams

A health plan sees the care it paid for, from every doctor, pharmacy, and hospital. One sign-in to a member account can share that history across all of them.

### What comes back

- Claims with financial adjudication: what was billed, what the plan paid, and what the member owed.
- Insurance coverage, including plan details, member ID, and coverage period.
- Pharmacy claims that show which prescriptions were filled, not only which were written.
- Clinical details such as diagnoses and procedures. Notes and lab results are sometimes included.

### How people connect

1. Search for the health plan by name.
2. Choose the plan type when support depends on it: employer, Medicare Advantage, Marketplace, bought directly from the insurer, or Medicaid. Some plans also ask for the state.
3. Sign in with the member account at the health plan and approve sharing.

### Good to know

- Claims arrive within 24 hours of adjudication, which typically comes 5 to 30 days after the visit.
- Each sign-in shares one plan member. To share a dependent’s records, connect again for that member.

## For agents

- **Source:** Health insurer Patient Access APIs (CMS-9115-F)
- **Patient sign-in:** The member’s own health plan account
- **Find the plan:** `directory.search_endpoints`, then `directory.check_lob_support` for the plan type, at https://api.flexpa.com/mcp (no authentication)
- **Launch:** Flexpa Consent authorization URL. `flexpa_endpoint_id` skips plan search; with it, `flexpa_line_of_business` skips the plan type question. Or `flexpa_search_mode=true` with `flexpa_default_filter=PAYER`.
- **FHIR R4:** `ExplanationOfBenefit` and `Coverage`, plus the clinical resources the plan provides
- **Freshness:** Within 24 hours of claims adjudication

### Records tools

After the patient authorizes through Flexpa Consent, read their records with these tools at `https://api.flexpa.com/mcp/consent`. They need a patient access token.

- `get_coverage`: Plan, member ID, and coverage period
- `get_claims`: Recent claims, filterable to pharmacy, professional, or institutional
- `get_financial_summary`: Totals billed, paid by insurance, and owed by the patient

### Notes for agents

- Blue Cross Blue Shield is a federation of independent companies. Ask which state before searching.
- Each authorization covers one plan member. A dependent’s records need a separate authorization for that member.
- A `masked` data-absent reason means the plan withheld that element as sensitive. Handle missing fields as normal.

## Scale and context

### Enrollment reached, by plan type

The share of enrollment in each government program plan type held by health insurers whose Patient Access API Flexpa connects to.

| Plan type | Enrollment | Enrollment reached | Share |
|---|---:|---:|---:|
| Original Medicare | 27,790,912 | 27,790,912 | 100% |
| Medicare Advantage | 39,329,575 | 37,235,685 | 94.7% |
| Medicaid | 76,008,956 | 70,815,486 | 93.2% |
| CHIP | 3,597,128 | 3,474,701 | 96.6% |
| Dual eligibles | 6,433,822 | 6,243,619 | 97% |
| ACA Marketplace | 23,371,417 | 22,327,806 | 95.5% |
| **All shown** | 176,531,810 | 167,888,209 | 95.1% |

Scope:

- Counts enrollments, not unique people, from the payer enrollment data behind Flexpa’s coverage summary.
- An insurer counts when its endpoint in the Endpoint Directory is connected, or connected with intermittent issues, and supports that plan type. This measures which insurers Flexpa reaches, not whether a given member’s sign-in succeeds.
- Employer and other commercial plans are not shown.

Sources:

- Flexpa network coverage summary (2026-11-12): https://api.flexpa.com/network/coverage-summary
- Flexpa Endpoint Directory (2026-11-12): https://www.flexpa.com/docs/network/directory

## Docs

- [Health insurers](https://www.flexpa.com/docs/network#health-insurers)
- [Endpoint Directory](https://www.flexpa.com/docs/network/directory)
- [Line of business support](https://www.flexpa.com/docs/network/directory-tools#directorycheck_lob_support)
- [Authorization URL parameters](https://www.flexpa.com/docs/consent#build-authorization-url)
- [Claims tools for agents](https://www.flexpa.com/docs/guides/agents#get_claims)

## Other networks

- [Medical record systems (ONC (g)(10))](https://www.flexpa.com/networks/medical-record-systems.md)
- [Nationwide exchanges (TEFCA IAS)](https://www.flexpa.com/networks/nationwide-exchanges.md)
- [The Flexpa network](https://www.flexpa.com/network.md)