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UPMC Advantage 2014 Individual & Family Plans Producer Training

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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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slide1

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

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
slide8

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
slide9

Pediatric Dental Coverage

PPO Plan

100/80/50/50

Benefit CoverageIn-NetworkOut-of-Network

Class I 100% 80%

Class II 80% 60%

Class III 50% 30%

Class IV 50% 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 II 60%
  • Class III 50%
  • 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.
slide11

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
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
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
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 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
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
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
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
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
slide38

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.
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

slide43

U.S. Steel Tower

600 Grant Street

Pittsburgh, PA 15219

www.upmchealthplan.com

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