upmc advantage 2014 individual & family plans producer training
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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
6
UPMC Advantage Plans for 2014
On
and
Off
Mar
ketp
lace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (PPO)
Off
Mar
ketp
lace
on
ly
Essential (HMO)
Value Plus (HMO)
Inside Advantage for Individuals (PPO)
9 portfolios of plans
7
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.
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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)
Premium Savings (PPO)
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Secure Plan
Plan Name Network Annual 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
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 levelsPrimary 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)
Premium Savings (PPO)
Enhanced Plan Features
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Enhanced Plans
Plan Name Network
Annual deductib
le
Annual out-of-pocket
maximum
Plan Payment
Level
Provider Office
Visit (for illness or
injury)
Specialist Office
Visit
Emergency Care
Retail prescription drugs
Enhanced Bronze HMO
Individual: $5,000 Family: $10,000
Individual: $6,350 Family: $12,700
90%
10% after deductible
10% after deductible
10% after deductible $8-$38-$76-50% (up to $500);
subject to deductible
Enhanced Silver HMO
Individual: $3,000 Family: $6,000
Individual: $6,350 Family: $12,700
$10 $40 $175 $8-$45-$90-50% (up to $500)
Enhanced Gold HMO
Individual: $1,000 Family: $2,000
Individual: $3,000 Family: $6,000
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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
Embedded Family Deductibles and Out-Of-Pocket Amounts
Value Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (PPO)
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Value Plans
Plan Name Network
Annual deductible
Annual out-of-pocket maximum
Plan Payment
Level
Provider Office
Visit (for illness or
injury)
Specialist Office Visit
Emergency Care
(Cost-share waived if admitted to the hospital)
Hospital Stay
Value Silver HMO
Individual: $4,500 Family:
$9,000
Individual: $6,350 Family:
$12,700100% $0 $35 $175
$150 after deductible
per admission
Value Gold HMO
Individual: $1,000 Family:
$2,000
Individual: $3,000 Family:
$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
Embedded Family Deductibles and Out-Of-Pocket Amounts
Goals Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (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
maximum
Plan Payment
Level
Provider Office
Visit (for illness or
injury)
Specialist Office
Visit
Emergency Care
Retail prescription drugs
Goals Gold HMO
Individual: $1,000 Family: $2,000
Individual: $3,000 Family: $6,000
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 fundsThe 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
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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
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (PPO)
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Premium Plans
Plan Name Network
Annual deductible
Annual out-of-pocket
maximum
Plan Payment
Level
Provider Office Visit (for illness or injury)
Specialist Office Visit
Emergency Care Retail prescription drugs
Premium Bronze PPO
Individual: $5,000 Family: $10,000
Individual: $6,350 Family: $12,700
10% 10% after deductibleYou pay
10% after deductible
$8-$38-$76-50% (up to $500) after deductibleIndividual:
$6,500 Family: $13,000
Individual: $10,000 Family: $20,000
50% 50% after deductible
Premium Silver PPO
Individual: $3,000 Family: $6,000
Individual: $6,350 Family: $12,700
10% $10 $40
$175
$8-$45-$90-50% (up to $500)
Individual: $6,000 Family: $12,000
Individual: $10,000 Family: $20,000
50% 50% after deductible
Premium Gold PPO
Individual: $1,000 Family: $2,000
Individual: $3,000 Family: $6,000
10% $10 $40
$175Individual: $3,000 Family: $6,000
Individual: $10,000 Family: $20,000
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
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (PPO)
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Premium Savings Plans
Plan Name Network Annual deductible
Annual out-of-pocket
maximumPlan Payment
Level
Provider Office Visit
(for illness or injury)
Specialist Office Visit
Emergency Care
Premium Savings Silver PPO
Individual: $1,750 Family: $3,500
Individual: $6,350 Family: $12,700 10% 10% after deductible
10% after deductibleIndividual: $3,500
Family: $7,000
Individual: $10,000 Family:
$20,00050% 50% after deductible
Premium Savings Gold PPO
Individual: $1,250 Family: $2,500
Individual: $1,750 Family: $3,500 10% 10% after deductible
10% after deductibleIndividual: $2,000
Family: $4,000
Individual: $10,000 Family:
$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 ageEmbedded Family Deductibles and Out-Of-Pocket Amounts
Essential Plan Features
Off Marketplace only
Essential (HMO)
Value Plus (HMO)
Inside Advantage for Individuals (PPO)
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Essential Bronze Plan
Plan Name Network
Annual deductible
Annual out-of-pocket maximum
Plan Payment
Level
Provider Office Visit (for illness or injury)
Specialist Office Visit
Emergency Care Retail prescription drugs
Essential Bronze HMO
Individual: $6,250 Family: $12,500
Individual: $6,350 Family: $12,700
80%
20% after deductible;first 3 PCP visits are
$10 per visit not subject
to deductible.
20% after 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
Embedded Family Deductibles and Out-Of-Pocket Amounts
Value Plus Plan Features
Off Marketplace only
Essential (HMO)
Value Plus (HMO)
Inside Advantage for Individuals (PPO)
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Value Plus Plans
Plan Name Network
Annual deductible
Annual out-of-pocket
maximum
Plan Payment
Level
Provider Office
Visit (for illness
or injury)
Specialist Office
Visit
Emergency Care
Retail prescription drugs
Value Plus Gold HMOIndividual:
$1,000 Family: $2,000
Individual: $3,500 Family: $7,000
100%
$15 $35 $175 $15-$35-$50-50% (up to $500)
Value Plus Platinum HMO
Individual: $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
Off Marketplace only
Essential (HMO)
Value Plus (HMO)
Inside Advantage for Individuals (PPO)
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Inside Advantage for Individuals Plans
Plan Name Network Annual deductible
Annual out-of-pocket
maximumPlan Payment
Level
Provider Office Visit
(for illness or injury)
Specialist Office Visit
Emergency Care (Cost-share waived if admitted to the
hospital)
Retail prescription drugs
Inside Advantage Silver PPO
Individual: $4,000 Family:
$8,000
Individual: $6,350 Family:
$12,700100%
$20 $40
$175
$8-$38-$76-50% (up to $500)
Individual: $6,000 Family:
$12,000
Individual: $6,350 Family:
$12,70080%
Individual: $8,000 Family:
$16,000
Individual: $10,000 Family: $20,000
60% You pay 40% after deductible
Inside Advantage Gold PPO
Individual: $1,500 Family:
$3,000
Individual: $3,000 Family:
$6,000100%
$20 $40
$175
Individual: $3,000 Family:
$6,000
Individual: $6,000 Family:
$12,00080%
Individual: $6,000 Family:
$12,000
Individual: $10,000 Family: $20,000
60% You pay 40% after deductible
Inside Advantage Platinum PPO
Individual: $500 Family: $1,000
Individual: $1,000 Family:
$2,000100%
$20 $40
$175
Individual: $1,000 Family:
$2,000
Individual: $2,000 Family:
$4,00080%
Individual: $3,000 Family:
$6,000
Individual: $10,000 Family: $20,000
60% You pay 40% after deductible
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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)
%FPL Plan Variation
Annual 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)
%FPL Plan Variation
Annual 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, WestmorelandProviders:
• 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