Maximum Copays and Filing Issues

STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-94 MARCH 10,2014 TO: ALL INSURANCE COMPANIES, FRATERJ'JAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE INDIVIDUAL AND GROUP HEALTH IJ'JSURANCE POLICIES IN·CONNECTICUT SUBJECT: MAXIMUM COPAYS AND FILING ISSUES The purpose ofthis bulletin is to provide guidance as to maximum copay amounts and to address some recent inquiries regarding specific filing issues. Copays The Insurance Department ("Department") received requests from some carriers to update the maximum copays that would be approved for health insurance policies sold in Connecticut. The Department requested that the carriers submit a claims distribution showing number of claims and total dollars spent at incremental claims levels for each category of service. Data was received on a limited number of service categories and from a limited number of carriers. The following chart indicates the revised maximum copay amounts based on the Department's analysis of data submitted. Revised Limit Previous Limit PCP Office Visit $ 40 $ 30 Specialist Office Visit 50 45 Urgent Care 75 75 . Emergency Room 200 150 Inpatient Admission 500/day up to $2000 500/day up to $2000 Outpatient Surgery/Services 500 500 Generic Drug 5 40 Brand Drug 60 40 In the future, the Insurance Department intends to send out periodic data calls to carriers offering health insurance policies in the state to review and update current copay limits. Prescription Drug Tiers With respect to prescription drug coverage, carriers are free-to set their formularies within any requirements set by the Affordable Care Act. The policy or certificate must, however, include language to cover any FDA approved drug if medically necessary. Generic only plans are not www.ct.gov/cid P.O. Box 816 • Hartford, CT 06142-0816 An Equal Opportunity Employer permitted. Carriers can detennine the structure of any tiered cost-sharing within the confines ofthe copay limits above or a minimum coinsurance level of 50% coverage. If a carrier opts to offer tiers that mix generic and brand name drugs, the copay for that tier should not exceed the generic copay of $5. Coinsurance levels of 50-100% may be applied in lieu of copays, but should be one set amount for any given tier. This applies to both indemnity carriers and health care centers. Health care centers are defined as providing services as compared to indemnity carriers that reimburse for services, so have not been pennitted to use coinsurance except for out of network services. Health care centers may also offer coinsurance options for goods that are provided as benefits such as drugs, eyeglasses or durable medical equipment whether in or out of network. End-Stage Renal Disease The Insurance Department met with dialysis vendors who were concerned that policies issued in the state did not cover services for end-stage renal disease or coordinate with Medicare. Form filings were inconsistent in addressing coverage and coordination with Medicare specifically related to end-stage renal disease. Policies should include language regarding benefit coverage and coordination with Medicare for end- stage renal disease. Language dealing with coordination of benefits should be consistent with Medicare payer rules and Regulations of State Connecticut Agencies §38a-480. Questions Please contact the Insurance Department Life and Health Division at cid.lh@ct.gov with any questions. v-, . = Thomas B. Leonardi Insurance Commissioner