31.11.12.04

.04 Uniform Cost-Sharing Arrangements In General.

A. For each delivery system identified in §§B and C of this regulation, a carrier shall apply the uniform cost-sharing arrangements specified.

B. Preferred Provider—Credit Fund Delivery System.

(1) Covered services are divided into three categories, designated as Categories I, II, and III, based on the type of service to be provided, as follows:

(a) Category I includes the services listed in Regulation .03A(1), (9)—(12), (15)—(18), (20), (22), (23), (25), (26), (29), (31), and (33)—(35) of this chapter;

(b) Category II includes the services listed in Regulation .03A(2)—(8), (13), (14), (19), (21), (24), (28), (30), and (32) of this chapter; and

(c) Category III includes the services listed in Regulation .03A(27) of this chapter.

(2) Credit Fund.

(a) The carrier shall provide a fund which shall cover:

(i) For a person enrolled under individual coverage, $250 of Category I services; and

(ii) For a person enrolled under other than individual coverage, $500 of Category I services.

(b) The fund in §B(2)(a) of this regulation shall be renewed each contract year.

(3) Required Deductibles.

(a) Except as provided in §B(3)(b) of this regulation, services covered under Categories I and II shall be subject to a contract year deductible of:

(i) $1,000 for a person enrolled under individual coverage; and

(ii) $2,000 for a person enrolled under other than individual coverage.

(b) A carrier may not apply the deductible for Category I services until the fund in §B(2)(a) of this regulation has been exhausted.

(4) Services covered under Categories I and II for which coinsurance is applicable shall require coinsurance by the covered person of 30 percent for in-network services and 50 percent for out-of-network services.

(5) All Categories I and II covered services combined are subject to an annual maximum of $10,000 per covered person without regard to whether the person is enrolled under individual coverage or other than individual coverage.

C. Preferred Provider—Capped Benefit Delivery System.

(1) Covered services shall be divided into six groups, designated as Groups A, B, C, D, E, and F, based on the type of services to be provided, as follows:

(a) Group A includes the services listed in Regulation .03A(1), (2)(a), (3)(a), (4)(a), (5)(a), (7)(a), (9)—(12), (13), (14)(a), (15), (17), (18), (19)(a), (20), (21)(a), (22), (23)—(25), (26)(a), (28)(a), (29), (30)(a), (31), and (33)—(35) of this chapter;

(b) Group B includes the services listed in Regulation .03A(6), (8), and (16) of this chapter;

(c) Group C includes the services listed in Regulation .03A(2)(b), (4)(b), (7)(b), (14)(b), (19)(b), (21)(b), (26)(b), (28)(b), (30)(b), and (32) of this chapter;

(d) Group D includes the services listed in Regulation .03A(3)(b) of this chapter;

(e) Group E includes the services listed in Regulation .03A(3)(c) and (5)(b)of this chapter; and

(f) Group F includes the services listed in Regulation .03A(27) of this chapter.

(2) Services covered under Group A shall require coinsurance by the covered person of 0 percent for in-network services and 50 percent for out-of-network services up to the specific annual maximum set out in Regulation .05 of this chapter for the specific type of Group A service.

(3) Services covered under Group B shall require 0 percent coinsurance by the covered person up to the specific annual maximum set out in Regulation .05 of this chapter for the specific type of Group B service.

(4) Services covered under Group C shall require payment by the covered person of all charges less up to $1,000 per day for an in-network provider and less $700 per day for an out-of-network provider for a period of up to 30 days per covered person per contract year.

(5) Services covered under Group D shall require coinsurance by the covered person of 30 percent for in-network services and 50 percent for out-of-network services up to a maximum of $10,000 per covered person per contract year.

(6) Services covered under Group E shall require the covered person to pay, for in-network services, 100 percent of the rate negotiated between the carrier and the provider. Out-of-network services are not covered.

(7) Services covered under Group F shall be covered as set out in Regulation .05 of this chapter.