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

2. B. Copayments.

   1. (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. (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.
3. C. A carrier shall apply the covered person's coinsurance amount and emergency services copayments to the deductible and out-of-pocket limit.
4. D. A carrier shall apply the deductible to the out-of-pocket limit.
5. 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.

6. F. For each of the delivery systems identified, the following general cost-sharing requirements apply:

   1. (1) Indemnity:

      1. (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;
      2. (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;

      3. (c) Lifetime maximum of:

         1. (i) For plan years beginning before September 23, 2010, $2 million per covered person; and
         2. (ii) For plan years beginning on or after September 23, 2010, unlimited;
      4. (d) Carrier's coinsurance percentage of 80 percent of allowable charges;

   2. (2) Preferred provider organizations:

      1. (a) Non-health savings account-compatible preferred provider organizations (PPO):

         1. (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;
         2. (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;

      2. (b) PPO-HSA:

         1. (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;
         2. (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;
         3. (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;
      3. (c) A carrier may offer either a PPO-HSA or a non PPO-HSA, or both;

      4. (d) Lifetime maximum of:

         1. (i) For plan years beginning before September 23, 2010, $2 million per covered person; and
         2. (ii) For plan years beginning on or after September 23, 2010, unlimited;
      5. (e) Carrier's coinsurance percentage of 80 percent of allowable charges for in-network services;
      6. (f) Carrier's coinsurance percentage of 60 percent of allowable charges for out-of-network services;

   3. (3) Point-of-service when delivered in conjunction with preferred provider:

      1. (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;
      2. (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;

      3. (c) Lifetime maximum of:

         1. (i) For plan years beginning before September 23, 2010, $2 million per covered person; and
         2. (ii) For plan years beginning on or after September 23, 2010, unlimited;
      4. (d) Carrier's coinsurance percentage of 80 percent of allowable charges for in-network services;
      5. (e) Carrier's coinsurance percentage of 60 percent of allowable charges for out-of-network services;

   4. (4) Health maintenance organization-non-health savings account compatible delivery system:

      1. (a) A covered person shall be responsible for copayments for the following services at the payment level indicated:

         1. (i) Primary care services—$30;
         2. (ii) Specialty care services—$40;
         3. (iii) Physician inpatient hospital visits—$30;
         4. (iv) Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;
         5. (v) Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and
         6. (vi) Inpatient hospital copayment—$1,000 per admission;
      2. (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;
      3. (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;
      4. (d) Under the mandatory POS option, carrier's coinsurance percentage of at least 60 percent of allowable charges for out-of-network services;

   5. (5) High deductible health maintenance organization—non-health savings account compatible delivery system:

      1. (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;
      2. (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;

      3. (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:

         1. (i) Primary care services—$30;
         2. (ii) Specialty care services—$40;
         3. (iii) Physician inpatient hospital visits—$30;
         4. (iv) Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;
         5. (v) Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and
         6. (vi) Inpatient hospital copayment—$1,000 per admission;
      4. (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
      5. (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. (6) HMO-HSA:

      1. (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;
      2. (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;

      3. (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:

         1. (i) Primary care services—$30;
         2. (ii) Specialty care services—$40;
         3. (iii) Physician inpatient hospital visits—$30;
         4. (iv) Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;
         5. (v) Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and
         6. (vi) Inpatient hospital copayment—$1,000 per admission;
      4. (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;
      5. (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. (7) Triple option point-of-service:

      1. (a) For the indemnity portion of the triple option, the general cost-sharing requirements set forth in §F(1) of this regulation shall apply;
      2. (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;
      3. (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;
      4. (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;
      5. (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;
      6. (f) A lifetime maximum may not apply to the health maintenance organization portion of the triple option;

   8. (8) Exclusive provider:

      1. (a) Non-health savings account-compatible exclusive provider organization (EPO):

         1. (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;
         2. (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;

      2. (b) EPO-HSA:

         1. (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;
         2. (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;
         3. (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;
      3. (c) A carrier may offer an EPO or an EPO-HSA, or both;

      4. (d) There shall be a lifetime maximum of:

         1. (i) For plan years beginning before September 23, 2010, $2 million per covered person; and
         2. (ii) For plan years beginning on or after September 23, 2010, unlimited;
      5. (e) There shall be a carrier's coinsurance percentage of 80 percent of allowable charges for covered services;
      6. (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.

Authority: Health-General Article, §§19-103(c)(6), 19-108, and 19-1510; Insurance Article, §§2-108, 2-109, and 15-1207; Annotated Code of Maryland

Effective date: April 25, 1994 (21:8 Md. R. 672)

Regulation .02B amended as an emergency provision effective July 1, 1994 (21:13 Md. R. 1151); amended permanently effective November 7, 1994 (21:22 Md. R. 1876)

Chapter revised effective February 12, 1996 (23:3 Md. R. 167)

Regulation .01 amended effective May 18, 1998 (25:10 Md. R. 746)

Regulation .02B amended as an emergency provision effective February 2, 1996 (23:4 Md. R. 270); emergency status expired August 2, 1996; amended permanently effective October 21, 1996 (23:21 Md. R. 1467)

Regulation .02B amended as an emergency provision effective April 1, 1997 (24:9 Md. R. 653); emergency status extended at 24:21 Md. R. 1444; amended permanently effective September 22, 1997 (24:19 Md. R. 1340)

Regulation .02B amended effective May 18, 1998 (25:10 Md. R. 746)

Regulation .03A amended and H, I adopted as an emergency provision effective April 1, 1997 (24:9 Md. R. 653); emergency status extended at 24:21 Md. R. 1444; amended permanently effective September 22, 1997 (24:19 Md. R. 1340)

Regulation .03A, D amended effective May 18, 1998 (25:10 Md. R. 746)

Regulation .04F amended effective May 18, 1998 (25:10 Md. R. 746)

Regulation .05 amended effective May 18, 1998 (25:10 Md. R. 746)

Regulation .05H amended as an emergency provision effective October 1, 1997 (24:21 Md. R. 1444); amended permanently effective January 12, 1998 (25:1 Md. R. 15)

Regulation .05I amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 937); emergency status extended at 23:18 Md. R. 1313; emergency status expired January 16, 1997

Regulation .05I amended effective March 10, 1997 (24:5 Md. R. 407)

Regulation .08 amended as an emergency provision effective September 30, 1996 (23:21 Md. R. 1464); amended permanently effective March 10, 1997 (24:5 Md. R. 407)

Regulation .08A amended as an emergency provision effective April 25, 1996 (23:10 Md. R. 729); emergency status extended at 23:18 Md. R. 1314; emergency status expired January 16, 1997

Regulation .09A amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 937); emergency status extended at 23:18 Md. R. 1313; emergency status expired January 16, 1997

Regulation .09A amended effective March 10, 1997 (24:5 Md. R. 407)

Regulation .09A amended as an emergency provision effective October 1, 1997 (24:21 Md. R. 1441); amended permanently effective January 12, 1998 (25:1 Md. R. 15)

Regulation .09A amended as an emergency provision effective December 31, 1997 (25:2 Md. R. 73); amended permanently effective April 6, 1998 (25:7 Md. R. 527)

Regulation .09A amended effective May 18, 1998 (25:10 Md. R. 746)

Regulation .12 amended effective May 18, 1998 (25:10 Md. R. 746)

Chapter recodified from COMAR 09.31.05 to COMAR 31.11.06 effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .01 amended effective April 10, 2006 (33:7 Md. R. 675)

Regulation .01C amended effective April 9, 2007 (34:7 Md. R. 700); March 24, 2008 (35:6 Md. R. 702)

Regulation .02B amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489)

Regulation .02B 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 .02B amended effective February 28, 2005 (32:4 Md. R. 412); April 10, 2006 (33:7 Md. R. 676); March 24, 2008 (35:6 Md. R. 702); April 20, 2009 (36:8 Md. R. 598)

Regulation .02B 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)

Regulations .03—.08 amended effective May 3, 1999 (26:9 Md. R. 731)

Regulation .03 amended effective April 10, 2006 (33:7 Md. R. 676)

Regulation .03A amended as an emergency provision effective October 1, 1999 (26:22 Md. R. 1689); emergency status expired February 1, 2000

Regulation .03A amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489); April 20, 2009 (36:8 Md. R. 598)

Regulation .03A-1 adopted effective April 20, 2009 (36:8 Md. R. 598)

Regulation .03E amended effective February 7, 2000 (27:2 Md. R. 148)

Regulation .03-1 adopted as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); adopted permanently effective January 13, 2011 (38:1 Md. R. 13)

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)

Regulation .05 amended effective February 5, 2001 (28:2 Md. R. 106); March 15, 2004 (31:5 Md. R. 452); April 10, 2006 (33:7 Md. R. 676)

Regulation .05E, I amended effective March 24, 2008 (35:6 Md. R. 702)

Regulation .05H amended effective February 7, 2000 (27:2 Md. R. 148)

Regulation .05H 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 .05H 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)

Regulation .05I amended effective May 3, 1999 (26:9 Md. R. 731)

Regulation .06B amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489); April 20, 2009 (36:8 Md. R. 598)

Regulation .06F adopted effective November 16, 2009 (36:23 Md. R. 1819)

Regulation .07 amended effective March 24, 2008 (35:6 Md. R. 702)

Regulation .07A amended effective February 7, 2000 (27:2 Md. R. 148)

Regulation .07C amended effective April 10, 2006 (33:7 Md. R. 676)

Regulation .08 amended effective March 24, 2008 (35:6 Md. R. 702)

Regulation .09 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 .09A amended effective March 18, 2002 (29:5 Md. R. 506); April 20, 2009 (36:8 Md. R. 598)

Regulation .09B amended effective April 10, 2006 (33:7 Md. R. 676)

Regulation .09D adopted as an emergency provision effective October 1, 1999 (26:22 Md. R. 1689); emergency status expired February 1, 2000

Regulation .09D adopted effective February 7, 2000 (27:2 Md. R. 148)

Regulation .09D amended effective February 5, 2001 (28:2 Md. R. 106); April 10, 2006 (33:7 Md. R. 676)

Regulation .09E 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)

Regulation .10D adopted as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); adopted permanently effective August 16, 2004 (31:16 Md. R. 1257)

Regulation .10D repealed effective April 10, 2006 (33:7 Md. R. 676)

Regulation .11A, B 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)

Regulation .11B amended effective November 16, 2009 (36:23 Md. R. 1819)

Regulation .11C amended effective February 28, 2005 (32:4 Md. R. 412); November 16, 2009 (36:23 Md. R. 1819)