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UPMC Advantage 2014 Individual & Family Plans Producer Training PowerPoint PPT Presentation


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UPMC Advantage 2014 Individual & Family Plans Producer Training. 2014 Rating Limitations – Inside and Outside Health Insurance Marketplace. Rating Area. Age. Tobacco. (1.5:1). (3:1). Single/Family. Essential Health Benefits.

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UPMC Advantage 2014 Individual & Family Plans Producer Training

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Upmc advantage 2014 individual family plans producer training

UPMC Advantage

2014 Individual & Family Plans

Producer Training


2014 rating limitations inside and outside health insurance marketplace

2014 Rating Limitations – Inside and Outside Health Insurance Marketplace

Rating Area

Age

Tobacco

(1.5:1)

(3:1)

Single/Family


Essential health benefits

Essential Health Benefits


Actuarial value inside and outside health insurance marketplace

Actuarial Value – Inside and Outside Health Insurance Marketplace

Bronze

Gold

Silver

Platinum

Actuarial Value requirements in the ACA will require product changes in 2014.


Explanation of out of pocket maximum

Explanation of Out-of-Pocket Maximum

  • 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 EHBs

    • Expenses 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


Upmc advantage plans for 2014

UPMC Advantage Plans for 2014

9 portfolios of plans


New for 2014 for all individual and family plans

New for 2014 for ALL Individual and Family Plans

  • HMO plans: PCP referral required

  • E-visits: Half the cost of primary care visit

  • Podiatry is covered, but requires Prior Authorization

  • Acupuncture, 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 plan

  • Pediatric dental and vision for children under 19 are included


Upmc advantage 2014 individual family plans producer training

Dental Benefit

  • 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


  • Upmc advantage 2014 individual family plans producer training

    Pediatric Dental Coverage

    PPO Plan

    100/80/50/50

    Benefit CoverageIn-NetworkOut-of-Network

    Class I 100%80%

    Class II80%60%

    Class III50%30%

    Class IV50%50%

    Annual DeductibleIn-NetworkOut-of-Network

    Single Child $50 $75

    Two or More Children $150 $200

    Applies to AllNo, Waived on Class I

    BenefitsBenefits and Orthodontia

    • Orthodontia deductible is tied in with the bundled medical plan

    • HMO Plan

    • 100/60/50/50

    • Benefit Coverage In-Network

    • Class I100%

    • Class II60%

    • Class III50%

    • Class IV$3,450

    • Out-of-PocketMaximums

    • Annual Out-of-Pocket Maximum is tied in with the bundled medical plan and applies to all covered services for medically necessary treatment


    Orthodontic medical necessity requirements

    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.


    Upmc advantage 2014 individual family plans producer training

    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


    Essential health benefit vision coverage

    Essential Health Benefit – Vision Coverage


    Secure plan features

    “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


    Secure plan

    Secure Plan


    Enhanced plan features

    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

    Enhanced Plan Features


    Enhanced plans

    Enhanced Plans


    Value plan features

    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

    Embedded Family Deductibles and Out-Of-Pocket Amounts

    Value Plan Features


    Value plans

    Value Plans

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


    Goals plan features

    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

    Embedded Family Deductibles and Out-Of-Pocket Amounts

    Goals Plan Features


    Goals plan

    Goals Plan

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


    How a health incentive account hia works

    How a Health Incentive Account (HIA) Works

    • Members earn HIA funds by completing healthy activities

    • Each activity has a dollar value

      • Example: Flu shot=$50 in HIA funds

    • The money members earn is placed into HIA

    • HIA funds can be used to pay deductible, coinsurance, and pharmacy copayment expenses


    Examples of hia activities

    Examples of HIA activities

    150+ activities available at www.upmchealthplan.com


    Premium plan features

    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


    Premium plans

    Premium Plans


    Premium savings plan features

    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


    Premium savings plans

    Premium Savings Plans

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


    Essential plan features

    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

    Embedded Family Deductibles and Out-Of-Pocket Amounts

    Essential Plan Features


    Essential bronze plan

    Essential Bronze Plan


    Value plus plan features

    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

    Embedded Family Deductibles and Out-Of-Pocket Amounts

    Value Plus Plan Features


    Value plus plans

    Value Plus Plans


    Inside advantage for individuals plan features

    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


    Inside advantage for individuals plans

    Inside Advantage for Individuals Plans


    Individuals purchasing through the marketplace eligible for help paying for coverage

    Premium Tax Credits

    For consumers with incomes between 100%-400% FPL

    Help consumers pay for coverage

    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


    Premium subsidies and oop limits

    Premium Subsidies and OOP Limits


    Individual exchange marketplace products

    Individual Exchange Marketplace Products

    Overview of Plans Offered in Each Region

    Plans Offered in Select Area

    PPPO Plans

    PHMO Plans with Full Network

    PHMO Plans with “Select” Network (5 County)

    Plans Offered in Full Area

    (All but Select Plans)

    PPPO Plans

    PHMO Plans with Full Network

    Plans Offered in Centre County

    (No HMO Network)

    PPPO Plans with Full Network


    Select network

    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


    Hmo referral process

    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 MyHealthOnLine

      • 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


    Upmc advantage 2014 individual family plans producer training

    2013-2014 Transition for Individual Members

    • 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.


    Visit www upmchealthplan com to learn more

    Visit www.upmchealthplan.com to learn more!


    Plan selector tool

    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


    Plan selector tool1

    Plan Selector Tool


    Plan selector tool2

    Plan Selector Tool


    Upmc advantage 2014 individual family plans producer training

    U.S. Steel Tower

    600 Grant Street

    Pittsburgh, PA 15219

    www.upmchealthplan.com


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