Revised Statutory Plans Required BY CONN. GEN. STAT. §38a-568

CT state seal STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-97-14-2 JUNE 26,2014 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE SMALL GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT RE: REVISED 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 HMO version of the statutory plan must be revised to be in compliance with Regulations of Connecticut State Agencies §38a-l 92 et. seq. This regulation sets a minimum $1500 deductible for health care centers. Increasing the $1000 deductible to $1500 for the HMO version of the statutory plan produces an actuarial value of 80.2%, so remains within the required range for a gold plan. This bulletin rescinds Bulletin HC-97 that was issued on June 9, 2014. The revised approved schedules of benefits are attached as Exhibits I and II. The statutory plan for indemnity plans remains unchanged. A copy of the output from the actuarial value calculator is also attached as Exhibit III. 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 with any que tions. Deputy Insurance Commissioner's signature Deputy Insurance Commissioner www.ct.gov/cid P.O. Box 816 • Hartford. cr 06142-0816 An Equal Opportunity Employer EXHIBIT I CSEHRP Indemnity Gold Plan Plan Overview In-Network Out-of-Network Member Pays Member Pays Medical Deductible $1,000 Individual $3,000 Family $2,000 $6,000 (copavs are not applied 10 deductible} Prescription Drug Deductible $0 Individual $350 Family $0 $700 (copays are not applied to deductible) Out-of-Pocket Maximum Individual $3,000 $6,000 $6,000 Family $12,000 Physiciau Oflice Visits Preventive Care/Screenings/Immunizations $0 30% coinsurance Primary Care (injury or illness) $20 copay 30% coinsurance** Specialist $45 copay 30% coinsurance** Emeraencv/Uraent Care Urgent Care Center or Facility $75 copay 30% coinsurance** Emergency Room $150 copay $150 copay Ambulance $0 $0 Hospital Services Inpatient $500 copay per day to a max imum 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 day calendar year maximum $1.000 per admission* Mental Health. Substance Abuse & Behavioral Health Care Mental Health. Substance Abuse & Covered same as any other illness Covered same as any Behavioral Health Services other illness Hospice Care 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 Advanced Radiology (CTIPET Scan. MRI) calendar year maximum of$375 for MRI and CT scans; 30% coinsurance** $400 for PET scans *After in-network medical deductible is met **After out-of-network deductible is met n it G0 Id PIan I demruty Plan 0 erview In-Network Out-of-Network Member Pays Member Pays Outpatient Services Non-Advanced Radiology (X-ray, $45 copay 30% coinsurance** Diagnostic) Laboratory Services $30 copay 30% coinsurance** Rehabilitative & Habilitative Therapy $30 copay 30% coinsurance** (Physical, Speech, Occupational) combined 40 visit calendar year maximum Chiropractic Care $45 copay 30% coinsurance** 20 visit calendar maximum Other Services Durable Medical Equipment 30% coinsurance 30% coinsurance** Prosthetics 30% coinsurance 30% coinsurance** Diabetic Supplies & Equipment 30% coinsurance 30% coinsurance** Prescription Drugs Generic Drugs $5 cooav 30% coinsurance** ** Preferred Brand Drugs $25 copay 30% coinsurance**** Non-Preferred Brand Drugs $50 copay 30% coinsurance**** Specialty Drugs $60 couav 30% coinsurance**** P di my (f hOld I.' iatric-'0 I Services or c I ren un der age 19) 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** medically necessary only Pediatric Vision Care Routine Eye 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 discount *After in-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 0 erview In-Network Medical Deductible Member Pays Individual $1,500 Family $3,000 (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 $6,000 Physician Office Visits Preventive Care/Screenings/Immunizations $0 Primary Care (injury or illness) $20 copay Specialist $45 copay Emeraencv/Urzent Care Urgent Care Center or Facility $75 copay Emergency Room $150 copav 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,OOO per admission* 90 day calendar year maximum Mental Health, Substance Abuse & Behavioral Health Care Mental Health, Substance Abuse & Covered same as any other illness Behavioral Health Services Hosnice Care Hospice Services $0 Outpatient Services Home Health Care SO 100 visit calendar year 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-Netwo rk Member Pays Outpatient Services Non-Advanced Radiology (X-ray, Diagnostic) $45 copay Laboratory Services $30 cona y 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% coinsurance Prosthetics 30% coinsurance Diabetic Supplies & Equipment 30% coinsurance Prescription Drugs Generic Drugs $5 copay Preferred Brand Drugs $25 copay Non-Preferred Brand Drugs $50 conav Specialty Drugs $60 copay Pediatric-Only Services (for children under age 19) Pediatric Dental Cure Diagnostic & Preventive (Oral Exam, Cleaning, X-ray) $0 Basic Restorative (Filling, Simple Extraction) $45 copay Major Restorative (Endodontic, Crown) $45 copay Orthodontia Services medicallv necessary onlv $45 copay Pediatric Vision Care Routine Eve Exam $45 copav Prescription Eye Glasses one pair offrames & lenses per calendar year lenses: $0 collection frames: $0 non-collection frames: Members choosing to upgrade from a collection frame to a non-collection frame will be given a credit equal to the cost of the collection frame and will be entitled to a negotiated discount *After in-network medical deductible is met User Inputs for Plan Parameters Use Integrated Medical and Drug Deductible? Apply Inpatient Copay per Day? Apply Skilled Nursing Facility Copay per Day? Use Separate OOP Maximum for Medical and Drug Spending? Indicate if Plan Meets CSR Standard? Desired Metal Tier,....,...!:L-======-' Deductible ($) Coinsurance (%, Insurer's Cost Share) OOP Maximum ($) OOP Maximum if Separate ($) HSA/HRA Options HSA/HRA Employer Contribution? D Text: Annual contribution amount checkbox ---" Tier 1 Plan Benefit Design I Combined Tier 1 Click Here for Important Instructions trI Subject to Copay, if Type of Benefit Deductible? seoarate I~ f-'. Medical I DAII r-r ~ ~ ~ .......... :=-'JI Emergency Room Services D $150.00 la All Inpatient Hospital Services (inc. MHSA) o $500.00 Primary Care Visit to Treat an Injury or Illness (exc. Preventive, and X-rays) D $20.00 Specialist Visit D D - $45.00 Mental/Behavioral Health and Substance Abuse Disorder Outpatient D D $58 .00 Services - Imaging (CT/PETScans, MRls) D D $75.00 Rehabilitative Speech Therapy o D D D Rehabilitative Occupational and Rehabilitative Physical Therapy Preventive Care/Screening/Immunization background Laboratory Outpatient and Professional Services o D X-rays and Diagnostic Imaging D D $30.00 $30.00 $30.00 $45.00 Skilled Nursi ~g Facility • o D $500.00 . b ac kground Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Drugs Generics Preferred Brand Drugs Non-Preferred Brand Drugs - - -'='--­- ----­ Specialty Drugs (i.e. high-cost) D - -­D - o All 0 0 D D - D D o All D D 0 D $5.00 $25.00 $50.00 $60.00 - 1­ Output Status/Error Messages: Calculation Successful. Actuarial Value: 80 .2% Metal Tier: Gold Options for Additional Benefit Design Limits: Set a Maximum on Specialty Rx Coinsurance Payments? Specialty Rx Coinsurance Maximum: D Set a Maximum Number of Days for Charging an IP Capay? # Days (1-10) : D 2 Begin Primary Care Cost-Sharing After a Set Number of Visits? # Visits (1-10): D Begin Primary Care Deductible/Coinsurance After a Set Number of Copays? # Copays (1-10): D