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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyConnecticut Cost Sharing Policy Update | OpenPayer
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    CurrentConnecticut Insurance DepartmentPolicy HC-109

    Maximum Cost Sharing

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    This bulletin governs maximum copayments, coinsurance, variable cost sharing, and prescription drug tiering for individual and group health insurance policies delivered or issued in Connecticut.

    Policy Summary
    PayerConnecticut Insurance Department
    PolicyMaximum Cost Sharing
    Policy CodePolicy HC-109
    Change TypeRevised
    Effective DateJan 1, 2017
    Next Review DateN/A
    Key ActionLimit enrollee coinsurance to no more than 50% for both in-network and out-of-network benefits.
    SourceLink
    POLICY UPDATE CHANGES

    The bulletin establishes revised maximum copay amounts for durable medical equipment, home health care, ambulance, laboratory, and routine radiology services.

    This bulletin rescinds Bulletin HC-94, Maximum Copays and Filing Issues.

    The bulletin requires compliance demonstrations and annual actuarial certifications for plans using varying copayments within a service category.

    50%Maximum enrollee coinsurance
    25%Home health care calculation factor
    $25Durable medical equipment copay

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    $225
    Ambulance copay
    $500Outpatient surgery/services copay
    $5Generic prescription drug copay

    Maximum Copayment and Cost-Sharing Requirements

    Revised maximum copay categories

    Maximum copayment limits apply by benefit category for policies issued or renewed on or after January 1, 2017.

    ALL of the following

    • ALL of the following

      • Durable medical equipment copay does not exceed $25≤ $25
      • Home health care copay does not exceed $25≤ $25
      • Ambulance copay does not exceed $225≤ $225
      • Laboratory copay does not exceed $10≤ $10
      • Routine radiology copay does not exceed $40≤ $40

        Does not apply to advanced radiology services, including MRI, PET, and CAT services, which are subject to separate statutory limits.

    Continuing maximum copay categories

    Other benefit categories retain the listed allowable maximum copay levels.

    ALL of the following

    • Primary care physician office visit copay does not exceed $40≤ $40
    • Specialist office visit copay does not exceed $50≤ $50
    • Urgent care copay does not exceed $75≤ $75
    • Emergency room inpatient admission copay does not exceed $200≤ $200

    Operational cost-sharing requirements

    Plans must comply with cost-sharing, variable-copay, parity, and prescription drug requirements.

    ALL of the following

    • Enrollee coinsurance does not exceed 50% for both in-network and out-of-network benefits≤ 50%

    • ONE of

      • Coinsurance is consistent for all services within a service category
      • The plan utilizes a tiered network

        Tiered-network plans are excepted from the within-category consistency requirement.

    • Copayments within a service category are not varied based on service intensity, the enrollee's medical condition, or provider specialty

    Copay and Coinsurance Limits

    Standard maximum copay calculation
    Calculation basis90th percentile of claims for the applicable benefit category
    Maximum factorMust not exceed 50% of the 90th percentile
    Effective dateApplies to policies issued or renewed on or after January 1, 2017
    Home health care maximum copay calculation
    Calculation factor25% for home health care
    Statutory requirementCoinsurance must cover at least 75% of charges
    Statutory references

    Operational Compliance Actions

    Billing Rule

    Apply maximum coinsurance limits

    Limit enrollee coinsurance to no more than 50% for both in-network and out-of-network benefits. Keep the coinsurance level consistent for all services within a service category, except for plans utilizing tiered networks.

    Billing Rule

    Restrict variable copays

    Do not vary copayments within a service category based on the intensity of services, the enrollee’s medical condition, or provider specialty. Office visit copayments may differ between a primary care physician and a specialist, but variations by specialist or service intensity are not permitted.

    Billing Rule

    Prohibit multiple copays in one setting

    Key Terms

    Health care centers
    MeaningEntities that provide services
    DistinctionDistinguished from indemnity carriers that reimburse for services
    Cost sharing contextHealth care centers may offer coinsurance options for covered goods such as drugs, eyeglasses, or durable medical equipment
    Ongoing course of treatment
    MeaningServices received as part of a continuing treatment course
    Copay treatmentA lower copay may be established than the standard copay for the service category
    Examples
    Policy Summary
    PayerConnecticut Insurance Department
    PolicyMaximum Cost Sharing
    Policy CodePolicy HC-109
    Change TypeRevised
    Effective DateJan 1, 2017
    Next Review DateN/A
    Key ActionLimit enrollee coinsurance to no more than 50% for both in-network and out-of-network benefits.
    SourceLink
    On This Page
    Maximum Copayment and Cost-Sharing RequirementsCopay and Coinsurance LimitsOperational Compliance ActionsKey Terms
  1. Outpatient surgery/services copay does not exceed $500≤ $500
  2. Generic drug copay does not exceed $5≤ $5
  3. Brand drug copay does not exceed $60≤ $60

    4. Office visit copayments may differ between primary care physicians and specialists; variations by specialist or by intensity of service are not permitted.

  4. No more than one copay is assessed for specific services received in a single setting

    Applies to office visits, outpatient treatment, inpatient stays, emergency room visits, and similar settings.

  5. Enrollees are not balance billed beyond the applicable copay

    Carriers must pay billed charges or include hold-harmless provisions in provider contracts.

  6. A lower copay may be established for an ongoing course of treatment

    This is permitted as an exception to the standard category copay.

  7. Each plan using varying copayments within a service category provides a mental health parity demonstration addressing the substantially-all and predominant tests and includes a certification signed by a member of the American Academy of Actuaries

    The demonstration and certification must be provided annually after initial approval.

  8. Prescription drug coverage includes any FDA-approved drug when medically necessary
  9. Prescription drug coverage is not generic-only

  10. ONE of

    • For a prescription drug tier mixing generic and brand-name drugs, the tier copay does not exceed the generic copay limit of $5≤ $5
    • If coinsurance is used instead of copays for a prescription drug tier, one coinsurance level applies to that tier and does not exceed 50%≤ 50%
    11. Conn. Gen. Stat. §38a-493 and §38a-520
    Durable medical equipment maximum copay
    Benefit categoryDurable medical equipment
    Maximum copay$25
    Effective dateApplies to policies issued or renewed on or after January 1, 2017
    Home health care maximum copay
    Benefit categoryHome health care
    Maximum copay$25
    Effective dateApplies to policies issued or renewed on or after January 1, 2017
    Ambulance maximum copay
    Benefit categoryAmbulance services
    Maximum copay$225
    Effective dateApplies to policies issued or renewed on or after January 1, 2017
    Laboratory maximum copay
    Benefit categoryLaboratory services
    Maximum copay$10
    Effective dateApplies to policies issued or renewed on or after January 1, 2017
    Routine radiology maximum copay
    Benefit categoryRoutine radiology services
    Maximum copay$40
    ExclusionsDoes not apply to advanced radiology services, including MRI, PET, and CAT, which are subject to separate statutory limits
    Primary care physician office visit maximum copay
    Benefit categoryPrimary care physician office visit
    Maximum copay$40
    StatusRemains at the current allowable level
    Specialist office visit maximum copay
    Benefit categorySpecialist office visit
    Maximum copay$50
    StatusRemains at the current allowable level
    Urgent care maximum copay
    Benefit categoryUrgent care
    Maximum copay$75
    StatusRemains at the current allowable level
    Emergency room inpatient admission maximum copay
    Benefit categoryEmergency room inpatient admission
    Maximum copay$200
    StatusRemains at the current allowable level
    Outpatient surgery/services maximum copay
    Benefit categoryOutpatient surgery and services
    Maximum copay$500
    StatusRemains at the current allowable level
    Generic drug maximum copay
    Benefit categoryGeneric prescription drug
    Maximum copay$5
    Mixed generic and brand tiersThe copay for a tier mixing generic and brand-name drugs should not exceed $5
    Brand drug maximum copay
    Benefit categoryBrand prescription drug
    Maximum copay$60
    Tiering requirementPrescription drug tiers remain subject to the applicable copay and coinsurance limits
    Maximum coinsurance
    In-network benefitsEnrollee cost sharing may not exceed 50%
    Out-of-network benefitsEnrollee cost sharing may not exceed 50%
    Prescription drug tiersCoinsurance may be used instead of copays at one set level for a tier, up to a maximum of 50%

    Assess no more than one copay for specific services received in a single setting. This applies to office visits, outpatient treatment, inpatient stays, emergency room visits, and similar settings.

    Billing Rule

    Prevent balance billing beyond copay

    Pay billed charges or include hold-harmless clauses in provider contracts to ensure enrollees are not balance billed beyond the applicable copay.

    Billing Rule

    Permit reduced ongoing-treatment copays

    For an ongoing course of treatment, a lower copay may be established than the standard copay for the service category.

    • Examples include reduced copays for ongoing allergy shots or chemotherapy treatments.
    Documentation Required

    Document mental health parity compliance

    For each plan that uses varying copayments within a service category, provide a mental health parity compliance demonstration addressing the “substantially all” and “predominant” tests. Include a certification signed by a member of the American Academy of Actuaries and submit the demonstration and certification annually after initial approval.

    Documentation Required

    Maintain required prescription drug coverage

    Ensure the policy or certificate includes coverage for any FDA-approved drug when medically necessary. Generic-only plans are not permitted.

    Billing Rule

    Apply prescription drug tier limits

    For tiers that mix generic and brand-name drugs, set the tier copay no higher than the generic copay limit of $5. If coinsurance is used instead of copays, apply one set level for the tier and do not exceed 50%.

    Ongoing treatments may include allergy shots or chemotherapy
    Tiered cost sharing
    MeaningPrescription drug coverage organized into cost-sharing levels
    Drugs includedA tier may include generic and brand-name drugs
    Applicable limitsTiers are subject to the bulletin’s copay and coinsurance limits