October 30, 2018
On Oct. 24, 2018, Ins. Commissioner Wade published Bulletin HC-124 to eliminate the maximum copayment amounts for specified categories of benefits for health insurance plans with the exception of those cost sharing maximums set by statute, and instead use the federal Actuarial Value (AV) calculator. The bulletin rescinds HC-109 issued on Feb. 5, 2016.
The transition from benefit-by-benefit maximums to the use of the AV calculator is intended to allow more flexibility in developing innovative plan designs to meet a wider range of consumer needs while assuring that consumers still receive significant cost sharing benefits that meet ACA standards.
Going forward, the calculation of the maximum cost sharing allowed will require the use of the most recent CMS/CCIIO published AV calculator. The enrollee cost sharing amount shall never exceed 50 percent for the plan benefits provided (for both in- or out-of-network benefits) and there’s no restriction on the differential of the coinsurance level between in- and out-of-network benefits. The individual and small group market will continue to meet the standards of the ACA Metal Tiers.
Self-insured plans should familiarize themselves with the AV calculator to ensure compliance with actuarial value going forward. Employers with fully-insured plans don’t need to take any action.