February 23, 2016

On Feb. 5, 2016, the Connecticut Insurance Department published Bulletin HC-109 to provide guidance as to the maximum copayment amounts for health insurance plans. The bulletin rescinds Bulletin HC-94, Maximum Copays and Filing Issues, that was issued on Mar. 10, 2014.

As background, in December 2015, the Insurance Department conducted a data call to determine reasonable levels of copayment amounts regarding specified categories of benefits. The maximum copays are set to not exceed 50 percent of the 90 percentile of claims for the category. For the home health care category, 25 percent was used in lieu of 50 percent to reflect the statutory requirement in Conn. Gen. Stat. Section 38a-493 and Section 38a-520 that coinsurance cover at least 75 percent of the charges. The maximum copay for routine radiology does not apply to advance radiology services that are subject to the limits set forth in Conn. Gen. Stat. Section 38a-511 and Section 38a-550.

The following indicates the revised maximum copays and the copays will be effective for all policies issued or renewed on or after Jan. 1, 2017.

Durable Medical Equipment $25
Home Health Care $25
Ambulance $225
Laboratory $10
Routine radiology services $40

The maximum copays for the following categories of benefits were not part of the most recent data call and will remain at the current allowable levels.

PCP Office Visit $40
Specialist Office Visit $50
Urgent Care $75
Emergency Room $200
Inpatient Admission $500/day up to $2000
Outpatient Surgery/Services $500
Generic Drug $5
Brand Drug $60

Plans that use coinsurance may not impose an enrollee cost sharing amount that exceeds 50 percent. This applies both for in and out of network benefits. There is no restriction on the differential of the coinsurance level between in and out of network benefits. The level of coinsurance must be consistent for all services within a service category except for plans utilizing tiered networks.

Bulletin HC-110 »