2014 Small Group Products
Producer Training
Actuarial Value – Inside and Outside
Health Insurance Marketplace
Silver
Gold
60%
70%
80%
90%
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
Bronze
Actuarial Value
Monthly premiums
Actuarial Value requirements in the ACA will require product changes in 2014.
Platinum
Essential Health Benefits
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.
4
Dental Benefit
• 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
Out-of-Pocket Maximums
Annual Out-of-Pocket Maximum is tied in with the bundled medical plan and
applies to all covered services for medically necessary treatment
5
Pediatric Dental Coverage
6
complete something similar to the Orthodontic
Decision Checklist
(ODC) Requirements
to determine medical
Orthodontic
Medical Necessity
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
7 will not meet medical necessity. As a reminder,
all orthodontic services for members require
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
8
Essential Health Benefit – Vision Coverage
9
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
•
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
vendors
– Groups with multiple vendors can satisfy the OOP requirement by having a
medical OOP max of $6,350 and a pharmacy OOP max of $6,350
– Pediatric dental and pediatric vision can also have a separate OOP max if
administered by a separate vendor
2014 Portfolio for Small Group
• UPMC Small Business Advantage
– PPO
– EPO
– HMO
• UPMC Consumer Advantage for Small Business
• UPMC Inside Advantage for Small Business
• UPMC HealthyU for Small Business
11
New Product Design - HMO
• 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.
12
New Benefit Design - First 3 Plan
• The First 3 visits to the PCP are covered without the deductible applying
• Preventive care is covered at 100 percent
• All benefits are covered 100% after deductible with exception of the first
3 PCP visits and e-visits
13
Platinum Plans
Product Type
Metal Level
Deductible
Coinsurance
Hospital
Copay
OOP Max
ER
PCP
Specialist
Advanced
Radiology
14
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%/$2
0/$40/$1,000
OOP
PPO Platinum
$750/100%/$1
0/$40/$1,250
OOP
PPO
HMO
PPO
PPO
PPO
Platinum
Platinum
Platinum
Platinum
Platinum
$0
N/A
$0
$250
$750
100%
N/A
100%
100%
100%
N/A
$300
N/A
N/A
N/A
$1,250
$750
$1,250
$1,000
$1,250
$100
$175
$100
$100
$100
$10
$5
$15
$20
$10
$25
$35
$30
$40
$40
$150
$150
$150
$150
$150
Gold Plans
Plan Type
Actuarial
Value
Deductible
Coinsurance
OOP Max
ER
PCP
Specialist
Advanced
Radiology
15
PPO Gold
$1,250/100%/$
10/$40/$5,000
OOP
HMO Gold
$1,000/100%/$
10/$25/$3,000
OOP
PPO Gold
$1,500/100%/$
20/$40/$4,000
OOP
HealthyU
Gold
$1,250/90%/
$2,250
PPO Gold
$2,000/100%/$
10/$40/$4,000
OOP
PPO
HMO
PPO
HealthyU
PPO
Gold
Gold
Gold
Gold
Gold
$1,250
$1,000
$1,500
$1,250
$2,000
100%
100%
100%
90%
100%
$5,000
$3,000
$4,000
$2,250
$4,000
$150
$175
$150
90% AD
$150
$10
$10
$20
90% AD
$10
$40
$25
$40
90% AD
$40
100% AD
100% AD
100% AD
90% AD
100% AD
Silver Plans
Plan Type
Metal Level
Deductible
Coinsurance
Advanced
Radiology
OOP Max
ER
PCP
Specialist
16
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
PPO
HSA
PPO
HealthyU
Silver
Silver
Silver
Silver
$2,000
$2,000
$3,000
$2,250
80%
100%
80%
85%
80% AD
100% AD
80% AD
85% AD
$6,350
$6,350
$6,350
$6,350
$175
100% AD
$175
85% AD
$20
100% AD
$20
85% AD
$40
100% AD
$40
85% AD
Bronze Plans
Plan Type
Metal Level
Deductible
Coinsurance
OOP Max
ER
PCP
Specialist
Advanced Radiology
17
EPO Bronze
$4,500/80%/$6,350
OOP
EPO Bronze
$3,500/70%/$6,350
OOP
EPO Bronze
$5,500/100%/$6,350
OOP
EPO
EPO
EPO
Bronze
Bronze
Bronze
$4,500
$3,500
$5,500
80%
70%
100%
$6,350
$6,350
$6,350
80% AD
70% AD
100% AD
80% AD
70% AD
100% AD
80% AD
70% AD
100% AD
80% AD
70% AD
100% AD
Inside Advantage Plans
Plan Type
Actuarial Value
Deductible
Coinsurance
OOP Max
ER
PCP
Specialist
Advanced
Radiology
18
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
PPO
PPO
PPO
PPO
Platinum
Platinum
Gold
Silver
$250
$1,250
$2,000
$5,000
100%
100%
100%
100%
$1,000
$1,250
$3,000
$6,350
$100
$100
$100
$100
$20
$20
$20
$20
$40
$40
$40
$40
100% AD
100% AD
100% AD
100% AD
Consumer-Driven Health Plans
• HSA/HRA employer contributions count toward Actuarial Value
– Options include funded HRA and HSA plans and High Deductible 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
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
HRA/HSA Funding
19
Pharmacy Options
20
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
U.S. Steel Tower
600 Grant Street
Pittsburgh, PA 15219
www.upmchealthplan.com