UPMC Advantage 2014 Individual & Family Plans Producer Training.

UPMC Advantage2014 Individual & Family PlansProducer Training

2014 Rating Limitations – Inside and Outside Health Insurance Marketplace

(1.5:1) (3:1)

Essential Health Benefits

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

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 coinsurance Out-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

Explanation of Out-of-Pocket Maximum

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UPMC Advantage Plans for 2014

On

an

d O

ff

Mar

ketp

lace

Secure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)

Premium Savings (PPO)

Off

Mar

ketp

lace

o

nly

Essential (HMO)

Value Plus (HMO)

Inside Advantage for Individuals (PPO)

9 portfolios of plans

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HMO plans: PCP referral requiredE-visits: Half the cost of primary care visitPodiatry is covered, but requires Prior AuthorizationAcupuncture, Private Duty Nursing, and Bariatric Surgery are not covered. Advantage Choice Formulary

$0 generics for oral cholesterol agents, oral hypertensive agents, non-sedating antihistamines, Proton Pump Inhibitors, and Antibiotics.4 tier formulary Cost-share associated with each Rx tier depends on the medical planPediatric dental and vision for children under 19 are included

New for 2014 for ALL Individual and Family Plans

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• Dental benefits are available in both an HMO and PPO plan and is pre-determined by a member’s county of residence

• Regardless of which type of medical product you have; the HMO and/or PPO dental benefit will be based on county of residence

• 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 a product of UPMC Advantage and

administered by Dominion Dental Services

Dental Benefit

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PPO Plan100/80/50/50

Benefit Coverage In-Network Out-of-NetworkClass I 100% 80%Class II 80% 60%Class III 50% 30%Class IV 50% 50%

Annual Deductible In-Network Out-of-Network Single Child $50 $75 Two or More Children $150 $200 Applies to All No, Waived on Class I

Benefits Benefits and Orthodontia

Orthodontia deductible is tied in with the bundled medical plan

Pediatric Dental Coverage

HMO Plan100/60/50/50

Benefit Coverage In-NetworkClass I 100%Class II 60%Class III 50% Class IV $3,450

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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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.

https://secure.ucci.com/docs/orthodontic-decision-checklist%20.pdf

https://secure.ucci.com/docs/salzmann-evaluation-index.pdf

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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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• “Catastrophic Plan” available to consumers under the age of 30 before plan year begins

• Low premium with higher out-of-pocket costs

• $6,350 deductible• Three visits to primary care

physician not subject to deductible; $30 copayment

• Designed for people who want “just in case” coverage

• Embedded Family Deductibles and Out-Of-Pocket Amounts

Secure Plan Features

On and Off MarketplaceSecure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)


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Secure Plan

Plan Name NetworkAnnual

deductible

Annual out-of-pocket

maximum

Plan Payment Level

Provider Office Visit

(for illness or injury)

Specialist Office Visit

Emergency Care

Retail prescription drugs

Secure HMO

Individual: $6,350 Family: $12,700


100%

You pay $0 after deductible; first 3 PCP visits are $30 per visit not subject to deductible

$0 after deductible

$0 after deductible

$0 after deductible

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Available in Bronze, Silver, and Gold metallic levels

Primary care and specialist visits covered with a fixed copayment of $10/$40 (Silver and Gold levels only)

Many services not subject to deductible, such as prescription drugs, PCP and specialist visits, and emergency care

90%/10% plans

Embedded Family Deductibles and Out-Of-Pocket Amounts

On and Off MarketplaceSecure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)


Enhanced Plan Features

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Enhanced Plans

Plan NameNetwo

rk

Annual deductib

le


maximum

Plan Payment

Level

Provider Office

Visit (for illness or

injury)

Specialist Office

Visit

Emergency Care


Enhanced Bronze HMO



90%

10% after deductible


10% after deductible $8-$38-$76-50% (up to $500);

subject to deductible

Enhanced Silver HMO



$10 $40 $175 $8-$45-$90-50% (up to $500)

Enhanced Gold HMO



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Available in Silver and Gold metallic levels

PCP visits at no cost to member

Cost-share for medical services is a fixed copayment rather than coinsurance

Many services not subject to deductible, such as prescription drugs, primary care physician (PCP) and specialist visits, and emergency care


Value Plan Features

On and Off Marketplace

Secure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)


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Value Plans

Plan NameNetwork

Annual deductible

Annual out-of-pocket maximum

Plan Payment

Level

Provider Office


injury)


Emergency Care

(Cost-share waived if admitted to the hospital)

Hospital Stay

Value Silver HMO

Individual: $4,500 Family:

$9,000


$12,700100% $0 $35 $175

$150 after deductible

per admission

Value Gold HMO


$2,000


$6,000

Pharmacy: $8-$45-$90-50% (up to $500)

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Available in Gold metallic level

Health Incentive Account: Ability to earn reward dollars for completing healthy activities

Individuals can earn up to $400 and families up to $800 to help pay for deductible, coinsurance, and pharmacy copayments


Goals Plan Features


Secure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)


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Goals Plan

*Members can earn up to $400 individual/$800 family to help pay for deductible, coinsurance, and pharmacy copayments.

Plan Name Network

Annual deductibl

e

Annual out-of-pocket maximu

m

Plan Payment

Level

Provider Office


injury)

Specialist Office

Visit

Emergency Care


Goals Gold HMO



80% $15 $40 $175

$8-$45-$90-50%

(up to $500)

How a Health Incentive Account (HIA) Works

Members earn HIA funds by completing healthy activitiesEach activity has a dollar value

Example: Flu shot=$50 in HIA funds

The money members earn is placed into HIAHIA funds can be used to pay deductible, coinsurance, and pharmacy copayment expenses

Examples of HIA activities

150+ activities available at www.upmchealthplan.com

http://www.upmchealthplan.com/

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• Available in Bronze, Silver, and Gold metallic levels

• No referrals required to see specialists

• Primary care and specialist visits covered with a fixed copayment (Silver and Gold levels

only)

• 90%/10% plans

• Embedded Family Deductibles and Out-Of-Pocket Amounts

Premium Plan Features


Secure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)


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Premium Plans

Plan Name Network

Annual deductible


maximum

Plan Payment

Level

Provider Office Visit (for illness or injury)


Emergency Care Retail prescription drugs

Premium Bronze PPO



10% 10% after deductibleYou pay


$8-$38-$76-50% (up to $500) after deductibleIndividual:

$6,500 Family: $13,000


50% 50% after deductible

Premium Silver PPO



10% $10 $40

$175

$8-$45-$90-50% (up to $500)



50% 50% after deductible

Premium Gold PPO



10% $10 $40

$175Individual:

$3,000 Family: $6,000


50%You pay 50% after

deductible

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Available in Silver and Gold metallic levels

Qualified High Deductible plans eligible for health savings account (HSA)

HSA members don’t pay taxes on the money put into their account, or the money spent on medical expenses. Plus, the money in an HSA grows tax-free!

Aggregate Family Deductibles and Out-Of-Pocket Amounts

Premium Savings Plan Features


Secure (HMO)

Enhanced (HMO)

Value (HMO)

Goals (HMO)

Premium (PPO)


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Premium Savings Plans


deductible


maximum

Plan Payment Level




Emergency Care

Premium Savings Silver PPO


Individual: $6,350 Family: $12,700 10% 10% after deductible




$20,00050% 50% after deductible

Premium Savings Gold PPO


Individual: $1,750 Family: $3,500 10% 10% after deductible

10% after deductibleIndividual: $2,000

Family: $4,000


$20,00050% 50% after deductible

Pharmacy: $8-$45-$90-50% (up to $500); subject to plan deductible

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Available in Bronze metallic level Low premium with higher out-of-

pocket costs $6,250 deductible Three visits to primary care

physician not subject to deductible; $10 copayment

Designed for people who want “just in case” coverage

Similar to the Secure plan, but available to consumers of any age


Essential Plan Features

Off Marketplace only

Essential (HMO)

Value Plus (HMO)


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Essential Bronze Plan

Plan NameNetwor

kAnnual

deductible

Annual out-of-pocket maximum

Plan Payment

Level

Provider Office Visit (for illness or injury)


Emergency Care


Essential Bronze HMO



80%

20% after deductible;first 3 PCP visits are

$10 per visit not subject

to deductible.


$175 after

deductible

$15 copayment for generic drugs; not subject to deductible

$35-$50-50% (up to $500);subject to deductible

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Available in Gold and Platinum metallic levels

100% coinsurance after deductible

Many services not subject to deductible, such as prescription drugs, primary care physician (PCP) and specialist visits, and emergency care


Value Plus Plan Features


Essential (HMO)

Value Plus (HMO)


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Value Plus Plans

Plan NameNetwor

kAnnual

deductible


maximum

Plan Payment

Level

Provider Office

Visit (for illness

or injury)

Specialist Office

Visit

Emergency Care


Value Plus Gold HMOIndividual:

$1,000 Family: $2,000


100%

$15 $35 $175 $15-$35-$50-50% (up to $500)

Value Plus Platinum

HMOIndividual:

$250 Family: $500

Individual: $750 Family: $1,500

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Available in Silver, Gold, and Platinum metallic levels

Available only in Erie and surrounding counties of Clarion, Crawford, Elk, Forest, McKean, Mercer, Potter, Venango, and Warren

There are three levels of hospital coverage:

Level one facilities, which include Kane Community Hospital, Warren General Hospital, UPMC Hamot, UPMC Northwest, UPMC Horizon, and any UPMC-owned facility, offer the lowest out-of-pocket costs

Level two: All other contracted hospitals Level three: Out-of-network Embedded Deductible and Out-

Of-Pocket Amounts

Inside Advantage for Individuals Plan Features


Essential (HMO)

Value Plus (HMO)


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Inside Advantage for Individuals Plans


deductible


maximum

Plan Payment Level




Emergency Care (Cost-share waived if admitted to the

hospital)


Inside Advantage Silver

PPO


$8,000


$12,700100%

$20 $40

$175

$8-$38-$76-50% (up to $500)


$12,000


$12,70080%


$16,000


60% You pay 40% after deductible

Inside Advantage Gold

PPO


$3,000


$6,000100%

$20 $40

$175


$6,000


$12,00080%


$12,000



Inside Advantage Platinum

PPO

Individual: $500 Family: $1,000


$2,000100%

$20 $40

$175


$2,000


$4,00080%


$6,000



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1. Premium Tax Credits• For consumers with incomes between 100%-400% FPL• Help consumers pay for coverage

2. Cost Share Subsidies• For consumers with incomes between 100%-250% FPL• Lower the cost shares/out-of-pocket expenses

Individuals Purchasing Through the Marketplace Eligible for Help Paying for Coverage

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Premium Subsidies and OOP Limits

Family of 4 (Subscriber is age 40)

%FPLPlan

VariationAnnual Income

Weekly Net pay after

taxes2

Estimated family monthly

premium

Proposed OOP Max

100Medicaid or

CSR 94% AV1 $23,425 $386 $40 $4,500

138 CSR 94% AV $32,327 $514 $89 $4,500150 CSR 94% AV $35,138 $554 $117 $4,500160 CSR 87% AV $37,480 $587 $139 $4,500175 CSR 87% AV $40,994 $636 $176 $4,500200 CSR 73% AV $46,850 $719 $246 $10,400240 CSR 73% AV $56,220 $846 $361 $10,400250 70% $58,563 $875 $393 $12,800300 70% $70,275 $1,017 $560 $12,800350 70% $81,988 $1,160 $649 $12,800400 70% $93,700 $1,302 $1,011 $12,800450 70% $105,413 $1,444 $1,011 $12,800

3

4

1

2

1 432

Individual (Subscriber is age 40)

%FPLPlan

VariationAnnual Income

Weekly Net pay after

taxes2

Estimated member monthly

premium

Proposed statutory OOP Max

100Medicaid or

CSR 94% AV1 $11,505 $184 $20 $2,250

138 CSR 94% AV $15,877 $248 $44 $2,250150 CSR 94% AV $17,258 $268 $58 $2,250160 CSR 87% AV $18,408 $284 $68 $2,250175 CSR 87% AV $20,134 $309 $86 $2,250200 CSR 73% AV $23,010 $349 $121 $5,200240 CSR 73% AV $27,612 $413 $177 $5,200250 70% $28,763 $430 $193 $6,400300 70% $34,515 $511 $275 $6,400350 70% $40,268 $592 $375 $6,400400 70% $46,020 $666 $375 $6,400450 70% $51,773 $735 $375 $6,400

1

2

3

4

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Individual Exchange Marketplace Products

P PPO PlansP HMO Plans with Full NetworkP HMO Plans with “Select” Network

(5 County)

P PPO PlansP HMO Plans with Full Network

P PPO Plans with Full Network

Overview of Plans Offered in Each Region

Plans Offered in Select Area

Plans Offered in Full Area(All but Select Plans)

Plans Offered in Centre County (No HMO Network)

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Select Network

Counties:

• Allegheny, Beaver, Butler, Washington, Westmoreland

Providers:

• All UPMC, Excela, Heritage Valley, Butler Memorial, Washington Hospital

• For HMO plan offerings, UPMC Health Plan also offers a Select network • Customers and members can view provider listing on our Provider

Search Page• Select network plans offer consumers cost savings of ~8% on monthly

premiums versus the 28-county network

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HMO Referral Process

• The member’s PCP or any designated PCP can request a referral• Referrals are entered by the PCP in the Provider OnLine portal

- Members can access the referral information in MyHealth OnLine

- PCPs can also print the referral for the member- Note: The member DOES NOT need to have a printed

copy• Referrals will last for 90 days• Referrals will not be required for Pediatric Specialist, OBGYN, and

Mental Health Professionals• Members under age 21 will not require a referral

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• UPMC Health Plan will allow current Individual Advantage members to retain their current coverage through December 2014.

• Current membership would simply need to continue to pay their premiums on a monthly basis through December 2014 to retain their coverage — no further action is required.

• Accumulators, deductible, and OOP limits will reset upon the member’s anniversary date in 2014.

• Members with February-December anniversaries will have a shorter benefit period in 2014. Premiums associates with these plans will reflect the rate filing from April 2013 (6.5% increase), which will remain in effect through 2014.

2013-2014 Transition for Individual Members

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Visit www.upmchealthplan.com to learn more!

Plan Selector Tool

Consumers will input their ZIP code, age, and tobacco status Can answer questions regarding health care preferences to view plans that are suited for them

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Plan Selector Tool

Plan Selector Tool

U.S. Steel Tower600 Grant Street Pittsburgh, PA 15219

www.upmchealthplan.com

UPMC Advantage 2014 Individual & Family Plans Producer Training.

Documents

Transcript of UPMC Advantage 2014 Individual & Family Plans Producer Training.