Regulation .04 Uniform Cost-Sharing Arrangements — In General.
Regulation .04 Uniform Cost-Sharing Arrangements — In General.LinkCopy Citation
A.
For each delivery system identified in §F of this regulation, a carrier shall apply the uniform cost-sharing arrangements specified.
B.
Copayments.
(1)
Except for copayments for emergency services, which a carrier shall apply to the deductible and the out-of-pocket limit, a carrier may not apply the copayments set forth in this chapter to reduce the amount of a deductible or out-of-pocket limit.
(2)
Notwithstanding §B(1) of this regulation, a carrier shall apply all copayments set forth in this chapter to reduce the amount of a deductible or out-of-pocket limit for a HSA-compatible delivery system.
C.
A carrier shall apply the covered person's coinsurance amount and emergency services copayments to the deductible and out-of-pocket limit.
D.
A carrier shall apply the deductible to the out-of-pocket limit.
E.
A carrier may increase deductibles, copayments, coinsurance, or out-of-pocket limits up to 1.5 times the amounts specified in §F of this regulation in accordance with Insurance Article, §15-1208, Annotated Code of Maryland.
F.
For each of the delivery systems identified, the following general cost-sharing requirements apply:
(1)
Indemnity:
(a)
For an employee enrolled under individual coverage, a deductible of $2,500 per year; for an employee enrolled under other than individual coverage, a deductible of $5,000 in aggregate per year;
(b)
For an employee enrolled under individual coverage, out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, out-of-pocket limit of $9,800 in aggregate per year;
(c)
Lifetime maximum of:
(i)
For plan years beginning before September 23, 2010, $2 million per covered person; and
(ii)
For plan years beginning on or after September 23, 2010, unlimited;
(d)
Carrier's coinsurance percentage of 80 percent of allowable charges;
(2)
Preferred provider organizations:
(a)
Non-health savings account-compatible preferred provider organizations (PPO):
(i)
For an employee enrolled under individual coverage, combined in-network and out-of-network deductible of $2,500 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network deductible of $5,000 in aggregate per year;
(ii)
For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $9,800 in aggregate per year;
(b)
PPO-HSA:
(i)
For an employee enrolled under individual coverage, combined in-network, out-of-network, and prescription drug deductible of $2,700 per year; for an employee enrolled under other than individual coverage, combined in-network, out-of-network, and prescription drug deductible of $5,450 in aggregate per year;
(ii)
For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $5,250 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $10,500 in aggregate per year;
(iii)
For the health savings account-compatible preferred provider, carriers may not offer additional benefits to reduce deductibles below the minimum deductibles required by federal law or raise out-of-pocket limits above the maximum out-of-pocket limits required by federal law;
(c)
A carrier may offer either a PPO-HSA or a non PPO-HSA, or both;
(d)
Lifetime maximum of:
(i)
For plan years beginning before September 23, 2010, $2 million per covered person; and
(ii)
For plan years beginning on or after September 23, 2010, unlimited;
(e)
Carrier's coinsurance percentage of 80 percent of allowable charges for in-network services;
(f)
Carrier's coinsurance percentage of 60 percent of allowable charges for out-of-network services;
(3)
Point-of-service when delivered in conjunction with preferred provider:
(a)
For an employee enrolled under individual coverage, a deductible of $2,500 per year; for an employee enrolled under other than individual coverage, a deductible of $5,000 in aggregate per year;
(b)
For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $9,800 in aggregate per year;
(c)
Lifetime maximum of:
(i)
For plan years beginning before September 23, 2010, $2 million per covered person; and
(ii)
For plan years beginning on or after September 23, 2010, unlimited;
(d)
Carrier's coinsurance percentage of 80 percent of allowable charges for in-network services;
(e)
Carrier's coinsurance percentage of 60 percent of allowable charges for out-of-network services;
(4)
Health maintenance organization-non-health savings account compatible delivery system:
(a)
A covered person shall be responsible for copayments for the following services at the payment level indicated:
(i)
Primary care services—$30;
(ii)
Specialty care services—$40;
(iii)
Physician inpatient hospital visits—$30;
(iv)
Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;
(v)
Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and
(vi)
Inpatient hospital copayment—$1,000 per admission;
(b)
For an employee enrolled under individual coverage, the out-of-pocket limit is 200 percent of the total annual premium as specified by a fixed dollar amount in the employee's certificate;
(c)
For an employee enrolled under other than individual coverage, the out-of-pocket limit is 200 percent of the total annual premium in aggregate as specified by a fixed dollar amount in the employee's certificate;
(d)
Under the mandatory POS option, carrier's coinsurance percentage of at least 60 percent of allowable charges for out-of-network services;
(5)
High deductible health maintenance organization—non-health savings account compatible delivery system:
(a)
Except as described in §F(5)(e) of this regulation, for an employee enrolled under individual coverage, combined in-network and out-of-network deductible of $2,500 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network deductible of $5,000 in aggregate per year;
(b)
For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $9,800 in aggregate per year;
(c)
After the deductible described in §F(5)(a) of this regulation is satisfied, the covered person shall be responsible for copayments for the following services at the payment level indicated:
(i)
Primary care services—$30;
(ii)
Specialty care services—$40;
(iii)
Physician inpatient hospital visits—$30;
(iv)
Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;
(v)
Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and
(vi)
Inpatient hospital copayment—$1,000 per admission;
(d)
Under the mandatory POS option, the carrier's coinsurance percentage shall be at least 60 percent of allowable charges for out-of-network services; and
(e)
Well-child care and immunization benefits provided in conjunction with the high deductible health maintenance organization—non-health savings account compatible delivery system shall be subject to a $10 copayment and not subject to the overall deductible;
(6)
HMO-HSA:
(a)
Except as described in §F(6)(e) of this regulation, combined annual deductible for all covered services, including prescription drugs, of $2,700 for an employee enrolled in individual coverage and $5,450 in aggregate for an employee enrolled in other than individual coverage;
(b)
The out-of-pocket limit for all covered services, including prescription drugs, child wellness, and immunization services, shall be subject to the annual out-of-pocket maximum for HSA-compatible delivery systems of $5,250 for employees enrolled as individuals and $10,500 in aggregate for employees enrolled as other than individuals;
(c)
After the deductible described in §F(6)(a) of this regulation is satisfied, the covered person shall be responsible for copayments at the payment level indicated:
(i)
Primary care services—$30;
(ii)
Specialty care services—$40;
(iii)
Physician inpatient hospital visits—$30;
(iv)
Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;
(v)
Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and
(vi)
Inpatient hospital copayment—$1,000 per admission;
(d)
Under the mandatory POS option, the carrier's coinsurance percentage shall be at least 60 percent of allowable charges for out-of-network services;
(e)
Well-child care and immunization benefits provided in conjunction with the HMO-HSA shall be subject to a $10 copayment and not subject to the overall deductible;
(7)
Triple option point-of-service:
(a)
For the indemnity portion of the triple option, the general cost-sharing requirements set forth in §F(1) of this regulation shall apply;
(b)
For the preferred provider portion of the triple option, the general cost-sharing requirements set forth in §F(2)(a), (e)—(g) of this regulation shall apply;
(c)
For the health maintenance organization portion of the triple option, the general cost-sharing requirements set forth in §F(4) of this regulation shall apply;
(d)
For plan years beginning before September 23, 2010, a $2 million lifetime maximum per covered person is applicable to the indemnity and preferred provider portions of the triple option;
(e)
For plan years beginning on or after September 23, 2010, a lifetime maximum may not apply to the indemnity and preferred portions of the triple option;
(f)
A lifetime maximum may not apply to the health maintenance organization portion of the triple option;
(8)
Exclusive provider:
(a)
Non-health savings account-compatible exclusive provider organization (EPO):
(i)
For an employee enrolled under individual coverage, a deductible of $2,500 per year; for an employee enrolled under other than individual coverage, a deductible of $5,000 in aggregate per year;
(ii)
For an employee enrolled under individual coverage, an out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, an out-of-pocket limit of $9,800 in aggregate per year;
(b)
EPO-HSA:
(i)
For an employee enrolled under individual coverage, a deductible of $2,700 per year; for an employee enrolled under other than individual coverage, a deductible of $5,450 in aggregate per year;
(ii)
For an employee enrolled under individual coverage, an out-of-pocket limit of $5,250 per year; for an employee enrolled under other than individual coverage, an out-of-pocket limit of $10,500 in aggregate per year;
(iii)
For the health savings account-compatible exclusive provider organization, carriers may not offer additional benefits to reduce deductibles below the minimum deductibles required by federal law or raise out-of-pocket limits above the maximum out-of-pocket limits required by federal law;
(c)
A carrier may offer an EPO or an EPO-HSA, or both;
(d)
There shall be a lifetime maximum of:
(i)
For plan years beginning before September 23, 2010, $2 million per covered person; and
(ii)
For plan years beginning on or after September 23, 2010, unlimited;
(e)
There shall be a carrier's coinsurance percentage of 80 percent of allowable charges for covered services;
(f)
Under the mandatory out-of-network option described in Regulation .08 of this chapter, there shall be a carrier's coinsurance percentage of at least 60 percent of allowable charges for out-of-network services.