2014 Small Group Products Producer Training
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Transcript of 2014 Small Group Products Producer Training
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2014 Small Group ProductsProducer Training
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Actuarial Value – Inside and Outside Health Insurance Marketplace
Actuarial Value requirements in the ACA will require product changes in 2014.
GoldBronze PlatinumSilver
Actuarial Value 60% 70% 80% 90%
Monthly premiums Lowest Moderate Moderate Highest
Offer Essential Health Benefits
Yes Yes Yes Yes
Must Offer in Health Insurance Marketplace
No At least 1 plan At least 1 plan No
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Essential Health Benefits
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Essential Health Benefits (EHBs)
• The following plans must cover EHBs: Non-grandfathered health insurance plans in the individual and small group markets both
inside and outside the Exchange Medicaid benchmark and benchmark-equivalent and Basic Health Programs
• EHBs for Pediatric Services in Pennsylvania are defined by a different benchmark plan than medical
Dental – FEDVIP (MetLife – High Option) Vision – FEDVIP (BlueVision – High Option)
• Options for the Dental Essential Health Benefits Package Embedded into medical plans and become part of a single risk pool in the medical filing Offer a stand alone plan that is solely to cover the EHB package as an add-on to a
member’s medical plan
Regardless of how it is offered, it is ultimately the health plan who is responsible for reminding the member they must have the dental component for all members under the age of 19.
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• All monies paid for dental services roll up to the aggregate Out-of-Pocket (OOP) Maximum
• There is a separate sub-deductible for Class II and Class III services
• Orthodontia benefit is tied to the medical deductible• See Orthodontia Requirements for Medical Necessity
in Pennsylvania• Dental Benefits are covered through UPMC Dental
Advantage
Dental Benefit
Out-of-Pocket MaximumsAnnual Out-of-Pocket Maximum is tied in with the bundled medical plan and
applies to all covered services for medically necessary treatment
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Pediatric Dental Coverage
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Orthodontic Medical Necessity Requirements
To comply with Essential Health Benefits dental program guidelines for Pennsylvania, UPMC Health Plan recommends that orthodontists complete something similar to the Orthodontic Decision Checklist (ODC) to determine medical necessity for enrolled members. Completing the ODC will help to ensure unnecessary treatment is not performed before the final medical necessity determination is made by UPMC Health Plan.
• All anticipated treatment phases with a total case fee
• Salzmann Index (reflecting a score of 25 or higher)
If one of the questions 2-8 on the ODC is not a “yes” response, most likely the orthodontic case will not meet medical necessity. As a reminder, all orthodontic services for members require prior approval.
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Vision Benefit
• All monies paid for vision services roll up to the aggregate Out-of-Pocket (OOP) Maximum
• Pediatric Benefits include:• Yearly vision exam at no cost (in-network)• Frames and Lenses or Medically Necessary Contacts once
every 12 months (in-network)• Benefits will be covered through UPMC Vision Advantage
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Essential Health Benefit – Vision Coverage
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The ACA requires all non-grandfathered plans effective January 1, 2014, and after to have a single out-of-pocket maximum for all plan coverage
Includes medical, pharmacy, mental health, pediatric dental EHBs, and pediatric vision EHBsExpenses include deductibles, copayments, and coinsuranceOut-of-pocket maximum is tied to the IRS OOP maximum for Qualified High Deductible plans, which is $6,350 for individuals and $12,700 for families in 2014
Groups and Health Plans with a single vendor to administer claims must implement a unified OOP maximum
There is a Safe Harbor for Groups and Health Plans that have multiple vendorsGroups with multiple vendors can satisfy the OOP requirement by having a medical OOP max of $6,350 and a pharmacy OOP max of $6,350Pediatric dental and pediatric vision can also have a separate OOP max if administered by a separate vendor
Explanation of Out-of-Pocket Maximum
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UPMC Small Business AdvantagePPOEPOHMO
UPMC Consumer Advantage for Small Business
UPMC Inside Advantage for Small Business
UPMC HealthyU for Small Business
2014 Portfolio for Small Group
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Members are required to select a PCP; the PCP helps members coordinate their care.Many services are not subject to the deductible, such as prescription drugs, PCP and specialist visits, and emergency care.Members must receive care from network physicians and facilities in order to receive coverage (unless they are traveling outside the service area).Preventive care is covered at 100 percent.The pharmacy benefit includes certain generic drugs at no cost to the member — select contraceptives, oral hypertensive agents, antibiotics, and some preventive medications.
New Product Design - HMO
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The First 3 visits to the PCP are covered without the deductible applyingPreventive care is covered at 100 percentAll benefits are covered 100% after deductible with exception of the first 3 PCP visits and e-visits
New Benefit Design - First 3 Plan
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Platinum Plans
PPO Platinum $0/100%/$10/$25/$1,250 OOP
HMO Platinum
$300/100%/$5/$35/$750 OOP
PPO Platinum $0/100%//$15/$30/$1,250 OOP
PPO Platinum $250/100%/$20/$40/$1,000
OOP
PPO Platinum $750/100%/$10/$40/$1,250
OOP
Product TypePPO HMO PPO PPO PPO
Metal LevelPlatinum Platinum Platinum Platinum Platinum
Deductible$0 N/A $0 $250 $750
Coinsurance100% N/A 100% 100% 100%
Hospital Copay N/A $300 N/A N/A N/AOOP Max
$1,250 $750 $1,250 $1,000 $1,250ER
$100 $175 $100 $100 $100 PCP
$10 $5 $15 $20 $10 Specialist
$25 $35 $30 $40 $40 Advanced Radiology $150 $150 $150 $150 $150
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Gold Plans
PPO Gold $1,250/100%/$10/$40/$5,00
0 OOP
HMO Gold $1,000/100%/$10/$25/$3,00
0 OOP
PPO Gold $1,500/100%/$20/$40/$4,00
0 OOP
HealthyU Gold
$1,250/90%/$2,250
PPO Gold $2,000/100%/$10/$40/$4,00
0 OOP
Plan TypePPO HMO PPO HealthyU PPO
Actuarial Value Gold Gold Gold Gold GoldDeductible
$1,250 $1,000 $1,500 $1,250 $2,000 Coinsurance
100% 100% 100% 90% 100%OOP Max
$5,000 $3,000 $4,000 $2,250 $4,000 ER
$150 $175 $150 90% AD $150 PCP
$10 $10 $20 90% AD $10 Specialist
$40 $25 $40 90% AD $40 Advanced Radiology 100% AD 100% AD 100% AD 90% AD 100% AD
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Silver Plans
PPO Silver $2,000/80%/$20/$
40/$6,350 OOP
PPO Silver $2,000/100%/
$6,350(Qualified HDHP)
PPO Silver $3,000/80%/$20/$40/$6,350 OOP
HealthyU Silver $2,250/85%/$6,350 OOP
Plan TypePPO HSA PPO HealthyU
Metal LevelSilver Silver Silver Silver
Deductible$2,000 $2,000 $3,000 $2,250
Coinsurance80% 100% 80% 85%
Advanced Radiology 80% AD 100% AD 80% AD 85% ADOOP Max
$6,350 $6,350 $6,350 $6,350 ER
$175 100% AD $175 85% ADPCP
$20 100% AD $20 85% ADSpecialist
$40 100% AD $40 85% AD
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Bronze Plans
EPO Bronze $4,500/80%/$6,350
OOP
EPO Bronze $3,500/70%/$6,350
OOP
EPO Bronze $5,500/100%/$6,350
OOP
Plan TypeEPO EPO EPO
Metal LevelBronze Bronze Bronze
Deductible$4,500 $3,500 $5,500
Coinsurance80% 70% 100%
OOP Max$6,350 $6,350 $6,350
ER 80% AD 70% AD 100% AD
PCP80% AD 70% AD 100% AD
Specialist80% AD 70% AD 100% AD
Advanced Radiology80% AD 70% AD 100% AD
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Inside Advantage Plans
Inside Advantage PPO
Platinum$250/100%/
$20/$40/$1,000 OOP
Inside Advantage PPO Platinum $1250/100%/
$20/$40/$1,250 OOP
Inside Advantage PPO Gold
$2,000/100%/$20/$40/$3,000
OOP
Inside Advantage PPO
$5,000/100%/$20/$40/$6,350
OOP
Plan TypePPO PPO PPO PPO
Actuarial ValuePlatinum Platinum Gold Silver
Deductible$250 $1,250 $2,000 $5,000
Coinsurance100% 100% 100% 100%
OOP Max$1,000 $1,250 $3,000 $6,350
ER $100 $100 $100 $100
PCP$20 $20 $20 $20
Specialist$40 $40 $40 $40
Advanced Radiology 100% AD 100% AD 100% AD 100% AD
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HSA/HRA employer contributions count toward Actuarial ValueOptions include funded HRA and HSA plans and High Deductible Health Plans
Consumer-Driven Health Plans
PPO Gold $1,250/100%
$20/$40
PPO Gold HRA $2,000/100%
$20/$40/$3,000 - funded
PPO Gold HSA HealthyU
$1,500/90% - funded
Plan Type PPO PPO PPO
Metal Level Gold Gold Gold
HRA/HSA Funding No $1,000 $125
Deductible $1,250 $2,000 $1,500
Coinsurance 100% 100% 90%
OOP Max $2,500 $3,000 $2,500
ER $150 $150 90% AD
PCP $20 $20 90% AD
Specialist $40 $40 90% AD
Advanced Radiology 100% AD 100% AD 90% AD
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Pharmacy Options
Pharmacy Option Metal Level
$8/$38/$76/$95 All metal levels
$15/$30/$50/$95 All metal levels
$5/$28/$56/$100 Platinum and Gold PPO only
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U.S. Steel Tower600 Grant Street Pittsburgh, PA 15219
www.upmchealthplan.com