Md. Code Regs. 31.11.06.04

Current through Register Vol. 52, No. 1, January 10, 2025

Section 31.11.06.04 - Uniform Cost-Sharing Arrangements - In General

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:

(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;

(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.

Md. Code Regs. 31.11.06.04

Regulation .04F amended effective May 18, 1998 (25:10 Md. R. 746)
Regulations .04 amended effective May 3, 1999 (26:9 Md. R. 731)
Regulation .04 amended effective April 10, 2006 (33:7 Md. R. 676)
Regulation .04B, F amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)
Regulation .04F amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 15, 2004 (31:5 Md. R. 452); April 9, 2007 (34:7 Md. R. 700); March 24, 2008 (35:6 Md. R. 702)
Regulation .04F amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)