COV / PROPOSED / DRAFT

Care is an event.
Coverage is state.

Coverage State is a proposed contract for resolving who is covered, under which plan, for which benefits, at what time, and through which network—without collapsing person, member, subscriber, dependent, and employee into one identity.

Inspect the draft Discuss the contract

COV / any/coverage.state@1Coverage State

Feed your agents
coverage state—not
portal answers.

Beginning with self-funded plan administration, Coverage State makes time and relationships first-class. It distinguishes what administrative evidence establishes from what remains unknown, conflicting, conditional, or outside the contract.

Proposed family

any/coverage.state@1

proposed / draft

Invoke: coverage.resolve
Accepts: subject_ref + effective_at + intent
Relates: Person + member + subscriber + employment
Resolves: Coverages + benefits + accumulators + network routes
Returns: Determinations + provenance + issues

Membership is a role, not the root object. A subject may have simultaneous primary, secondary, and supplemental coverage.

Draft response domains

JSON

{
  "contract": "any/coverage.state@1",
  "operation": "coverage.resolve",
  "request_id": "…",
  "status": "resolved | partial | unresolved | failed",
  "effective_at": "…",
  "observed_at": "…",
  "result": {
    "subject": { "person_ref": "…", "member_refs": [ "…" ] },
    "relationships": [ "…" ],
    "coverages": [
      {
        "member_ref": "…", "subscriber_ref": "…",
        "coordination_role": "primary | secondary | supplemental",
        "funding": "self_funded",
        "plan_ref": "…", "plan_sponsor_ref": "…",
        "network_refs": [ "…" ]
      }
    ],
    "benefits": [ "…" ],
    "accumulators": [ "…" ],
    "network_routes": [ "…" ],
    "determinations": [ "…" ]
  },
  "evidence": [ "…" ], "provenance": [ "…" ], "issues": [ "…" ]
}

Draft family shape. Breaking changes may occur before activation.

One state / many decisions

Different agents.
Same coverage evidence.

member.agent

Navigate care

Can I receive this care, where can I go, and what might it cost under the evidence available now?

provider.agent

Route payment

Which plan and network apply, where should the claim go, and what payment path does the evidence support?

payer.agent

Review context

Join coverage state to encounter, rate, policy, and adjudication evidence before testing payment correctness.

tpa.member_services.agent

Resolve the caller

Who is calling, how are they related to the subscriber, and what coverage is—or should be—in force?

supplemental.agent

Find the gaps

Identify where primary coverage stops and which supplemental benefits may be relevant, without manufacturing a recommendation.

encounter.lifecyclecoverage.staterate / policy / adjudicationpayment review

// truth boundary Coverage State reports what available administrative evidence indicates was in force at an effective time and when that evidence was observed. It does not guarantee authorization, medical necessity, provider participation at the moment of care, an allowed amount, final member responsibility, or payment.

Draft invariants

Time is part
of the truth.

effective_at

When the requested coverage state is meant to apply.

observed_at

When the source evidence was actually seen by the resolver.

state: unknown

Evidence could not establish the answer. It must never silently become false.

state: conflicting

Authorized sources disagree. The conflict remains explicit and traceable.

“Was the claim paid correctly?” is outside this contract alone. It requires Encounter Lifecycle, Coverage State, and applicable rate, policy, and adjudication evidence.