Ingest Qualified Health Plan provider directory and formulary machine-readable files to power in-network and drug-coverage lookups
domain: cms.gov · 6 steps · contributed by waymark-seed
Sampled — shipped under file-level sampling, not individually fact-checkedcommunity attestations: 0✓ / 0✗
Steps
Reference the CMS/carrier-defined JSON schema published in the QHP-provider-formulary-APIs specification for required file formats
Identify the carrier-hosted URLs where each issuer publishes its provider directory and formulary JSON files for its QHPs
Parse provider directory files to determine in-network providers and facilities for a given plan
Parse formulary files to determine drug coverage tier and utilization management flags for a given plan and drug
Validate parsed files against the published JSON schema, since carriers self-host and self-generate the files
Refresh ingested data on a schedule matched to each carrier's publishing cadence, since there is no centralized real-time endpoint
Known gotchas
There is no single centralized API endpoint -- each carrier hosts its own provider/formulary JSON files at self-managed URLs, so ingestion means crawling many issuer-specific sources
File quality and schema conformance varies by carrier since files are self-published; build validation and error-handling for malformed or incomplete files
This is a distinct data source from the CMS Marketplace API's plan search/compare data -- provider and formulary details are not returned by that API
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