Superseded by Bulletin HC-97-14-2

CT state seal STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-97 JUNE 9, 2014 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVlCE CORPORATIONS, MEDICAL SERVlCE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE SMALL GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT RE: REVlSED STATUTORY PLANS REQUIRED BY CONN. GEN. STAT. §38a-568 Conn. Gen. Stat. §38a-568 requires health insurance carriers, including health care centers that transact small employer group health insurance business in this state, to offer plans established by the Board of the Connecticut Small Employer Health Reinsurance Pool (CSEHRP). The CSEHRP Board filed revised major medical and health care center plans that were approved by the Insurance Department on May 30, 2014. The approved schedules of benefits are attached as Exhibits I and II. Carriers must include the appropriate version of the revised plans as part of their small employer form and rate filings for January 1,2015. Questions Please contact the Insurance Department Life and Health Division at cid.lh@ct.gov Anne Melissa Dowling Deputy Insurance Commissioner www.c t.gov/cid P.O. Box 816 • Hartford, CT 06142-0816 An Equal Opportu nity Employer EXHIBIT I CSEHRP Indemnity Gold Plan Plan Overview In-Network Out-of-Network Member Pays Member Pays Medical Deductible Individual $1,000 $3,000 Family $2,000 $6,000 (copays are not applied to deductible) Prescription Drug Deductible Individual $0 $350 Family $0 $700 (copays are not applied to deductible) Out-of-Pocket Maximum Individual $3,000 $6,000 Family $6,000 $12000 Physician Office Visits Preventive Care/Screenings/Immunizations $0 30% coinsurance Primary Care (injury or illness) $20 conav 30% coinsurance** Specialist $45 copay 30% coinsurance"'* Emeruencv/Uruent Care Urgent Care Center or Facilitv $75 copay 30 % coinsurance** Emergency Room $150 copay $150 copay Ambulance $0 $0 Hospital Services Inpatient $500 copay per day to a maximum of 30% coinsurance** $1 000 per admission* Outpatient (performed at hospital or $500 copay* 30% coinsurance** ambulatory facility) Skilled Nursing Facility $500 copay per day to a maximum of 30% coinsurance** 90 da y calendar year maximum $1 000 per admission* Mental Healt h. Substa nce Abuse & Behavioral Health Care Mental Health, Substance Abuse & Covered same as any other illness Covered same as an y Behavioral Health Services other illness Hospice Cure Hospice Services I $0 I 30% coinsurance** Outpatient Services Home Health Care 25% coinsurance 100 visit calendar year maximum $0 subject to a $50 deductible $75 copay per service up to a combined calendar year maximum of $375 for MRI and Advanced Radiology (CTIPET Scan, MRI) 30% coinsurance** CTscans; $400 for PET scans *After in-network medical deductible is met **After out-of-network deductible is met I dernrnty n it 0 G Id PI an Plan Overview In -Network Out-of-Network Member Pays Member Pays 30% coinsurance** Outpaticnt Services Non-Advanced Radiology (X-ray, $45 copay Diagnostic) Laboratory Services Rehabilitative & Habilitative Therapy $30copay $30 copay 30% coinsurance** 30% coinsurance** (Physical, Speech, Occupational) combined 40 visit calendar year maximum Chiropractic Care $45 copay 30% coinsurance** 20 visit calendar maximum 30% coinsurance** 30% coinsurance** Other Servic ' . Durable Medical Equipment Prosthetics 30% coinsurance 30% coinsurance Diabetic Supplies & Equipment Prescri ption Druus Generic Dru zs 30% coinsurance $5 CODav 30% coinsurance** 30% coinsurance**** Preferred Brand Drues $25 copay 30% coinsurance**** Non-Preferred Brand Drugs $50 copav 30% coinsu rance**** Specialty Drugs $60 copay 30% coinsurance**** e iatric- I d 9 P d" lc-Onl v Services ( ~or ch'ldren un er age 1 ) Pediatric Dental Care Diagnostic & Preventive $0 50% coinsurance** (Oral Exam Cleaning, X-ray) Basic Restorative 20% coinsurance 50% coinsurance** (Filling, Simple Extraction) Major Restorative 40% coinsurance 50% coinsurance** (Endodontic, Crown) Orthodontia Services 50% coinsurance 50% coinsurance** medicallv necessarv 0 11Iv Pediatric Vision Care Routine Eve Exam $45 copay 30% coinsurance Prescription Eye Glasses lenses: $0 100% coinsurance one pair offrames & lenses per calendar collection frames: $0 year non-collection frames: Members choosing to upgrade from a collection frame to a noncollection frame will be given a credit equal to the cost of the collection frame and will be entitled to a negotiated discoun t *After III-network medical deductible IS met **After out-of-network medical deductible is met ***After in-network prescription drug deductible is met ****After out-of-network prescription drug deductible is met. EXHIBIT II CSEHRP HMO Gold Plan Plan Overview In-Network Member Pays Medical Deductible Individual $1,000 Family $2,000 (copays are not applied to deductible) Prescription Drug Deductible Individual $0 Family $0 (copays are not applied to deductible) Out-of-Pocket Maximum Individual $3,000 Family $6000 Physician Office Visits Preventive CareiScreeninl!S!lmmunizations $0 Primarv Care (injury or illness) $20 copay Soecialist $45 copay Emergency/Urgent Care Uraent Care Center or Facilitv $75 conav Emeraencv Room $150 copay Ambulance $0 Hospital Services Inpatient $500 copay per day to a maximum of $1,000 per admission* Outpatient (performed at hospital or $500 copay* ambulatory facility) Skilled Nursing Facility $500 copay per day to a maximum of $1,000 per admission* 90 dav calendar year maximum Mental Health, Substance Abuse & Uehavioral Health Care Mental Health, Substance Abuse & Covered same as any other illness Behavioral Health Ser vices Hosnice Care Hospice Services I $0 Outpatient Services Home Health Care $0 100 visit calendar vear maximum $75 copay per service up to a combined calendar year Advanced Radiology (CTIPET Scan, MRI) maximum of $375 for MRI and CT scans; $400 for PET scans *After in-network medical deductible is met HMO Gold Plan Plan Overview In-Network Member Pays Outpatient Services Non-Advanced Radiology (X-ray, Diagnostic) $45 copay Laboratory Services $30 copay Rehabilitative & Habilitative Therapy (Physical, Speech, Occupational) combined 40 visit calendar year maximum $30 copay Chiropractic Care 20 visit calendar maximum $45 copay Other Services Durable Medical Equipment 30% coinsu rance Prosthetics 30% coinsurance Diabetic Supplies & Equipment 30 % coinsurance Prescri ution Druas Generic Druzs $5 copay Preferred Brand Drugs $25 copay Non- Preferred Brand Drugs $50 conav Specialty Druas $60 copay e iatric- ( ~ hild 19) P d" . OnJIY Servrces or c I ren un der aae Pediatric Dental Care Diagnostic & Preventive (Oral Exam Cleaning, X-ray) $0 Basic Restorative $45 copay (Fillina, Simple Extraction) Major Restorative $45 copay (Endodontic, Crow n) Orthodontia Services $45 copay medicallv necessarv 0111)' Pediatric Vision Care Routine Eve Exam $45 copay Prescription Eye Glasses lenses: $0 one pair offrames & lenses per calendar collection frames: $0 year non-collection frames: Members choosing to upgrade from a collection frame to a non-collection frame will be given a credit equal to the cost of the collection frame and will be entitled to a neaotiated discou nt *After in-network medical deductible is met