UPMC Advantage
2014 Individual & Family Plans
Producer Training
2014 Rating Limitations – Inside and Outside
Health Insurance Marketplace
Essential Health Benefits
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
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
9 portfolios of plans
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings
(PPO)
6
Off Marketplace
only
On and Off
Marketplace
Secure (HMO)
Essential (HMO)
Value Plus (HMO)
Inside Advantage for
Individuals (PPO)
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
7
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
8
Pediatric Dental Coverage
HMO Plan
100/60/50/50
PPO Plan
100/80/50/50
Benefit Coverage In-Network
Class I
100%
Class II
60%
Class III
50%
Class IV
$3,450
Benefit Coverage In-Network Out-of-Network
Class I
100%
80%
Class II
80%
60%
Class III
50%
30%
Class IV
50%
50%
Annual Deductible
Single Child
Two or More Children
Applies to All
Benefits
In-Network
$50
$150
Out-of-Network
$75
$200
No, Waived on Class I
Benefits and Orthodontia
Orthodontia deductible is tied in with the bundled medical plan
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
9
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.
10
Vision Benefit
• All monies paid for vision services roll up to the aggregate Out-ofPocket (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
11
Essential Health Benefit – Vision Coverage
12
Secure Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings
(PPO)
13
• “Catastrophic Plan” available to
consumers under the age of 30
before plan year begins
• Low premium with higher out-ofpocket 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
14
HMO
Individual: Individual:
$6,350
$6,350
Family:
Family:
$12,700
$12,700
Retail prescription drugs
Emergency Care
Specialist Office Visit
Provider Office Visit (for illness or
injury)
Plan Payment Level
Annual out-of-pocket maximum
Annual deductible
Network
Plan Name
Secure Plan
You pay $0
after
deductible;
$0 after
$0 after
$0 after
100% first 3 PCP
visits are $30 deductible deductible deductible
per visit not
subject to
deductible
Enhanced Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings
(PPO)
15
• 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 Gold
16
HMO
HMO
10% after
deductible
10% after
deductible
10% after
deductible
$10
$40
$175
Retail prescription drugs
Individual:
$6,350
Family:
$12,700
Individual:
$3,000
Family:
$6,000
Emergency Care
Individual:
$3,000
Family:
$6,000
Individual:
$1,000
Family:
$2,000
Specialist Office Visit
Individual:
$6,350
Family:
$12,700
Provider Office Visit (for
illness or injury)
HMO
Individual:
$5,000
Family:
$10,000
Plan Payment Level
Annual out-of-pocket
maximum
Enhanced Silver
Annual deductible
Enhanced
Bronze
Network
Plan Name
Enhanced Plans
$8-$38-$76-50% (up to $500);
subject to deductible
90%
$8-$45-$90-50% (up to $500)
Value Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
 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
Premium Savings (PPO)
17
 Available in Silver and Gold
metallic levels
Value Gold
$35
Individual:
Individual:
$4,500 Family: $6,350 Family:
HMO
$9,000
$12,700
Individual:
Individual:
$1,000 Family: $3,000 Family:
HMO
$2,000
$6,000
Pharmacy: $8-$45-$90-50% (up to $500)
18
$175
Hospital Stay
$0
Emergency Care
Specialist Office Visit
100%
(Cost-share waived if admitted
to the hospital)
Provider Office Visit (for
illness or injury)
Annual out-of-pocket
maximum
Annual deductible
Plan Payment Level
Value Silver
Network
Plan Name
Value Plans
$150 after
deductible
per admission
Goals Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (PPO)
19
 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-OfPocket Amounts
$15
Specialist Office Visit
Provider Office Visit (for
illness or injury)
Annual out-of-pocket
maximum
Annual deductible
Plan Payment Level
80%
$40
Retail prescription drugs
HMO
Individual: Individual:
$1,000
$3,000
Family: Family:
$2,000
$6,000
Emergency Care
Goals
Gold
Network
Plan Name
Goals Plan
$175
$8-$45$90-50%
(up to
$500)
*Members can earn up to $400 individual/$800 family to help pay
for deductible, coinsurance, and pharmacy copayments.
20
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
150+ activities available at www.upmchealthplan.com
Premium Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
• No referrals required to see
specialists
• Primary care and specialist visits
covered with a fixed copayment
(Silver and Gold levels only)
• 90%/10% plans
Premium (PPO)
Premium Savings (PPO)
23
• Available in Bronze, Silver, and
Gold metallic levels
• Embedded Family Deductibles and
Out-Of-Pocket Amounts
Premium Gold
24
PPO
PPO
50%
10%
Emergency Care
Retail prescription
drugs
10%
Specialist Office Visit
Individual:
$6,350
Family:
$12,700
Individual:
$10,000
Family:
$20,000
Individual:
$6,350
Family:
$12,700
Individual:
$10,000
Family:
$20,000
Individual:
$3,000
Family:
$6,000
Individual:
$10,000
Family:
$20,000
Provider Office Visit
(for illness or injury)
Individual:
$5,000
Family:
$10,000
Individual:
$6,500
Family:
$13,000
Individual:
$3,000
Family:
$6,000
Individual:
$6,000
Family:
$12,000
Individual:
$1,000
Family:
$2,000
Individual:
$3,000
Family:
$6,000
Plan Payment Level
Annual out-of-pocket
maximum
Premium Silver
PPO
Annual deductible
Premium Bronze
Network
Plan Name
Premium Plans
You pay
10% after
deductible
$8-$38-$76-50% (up to $500)
after deductible
10% after deductible
50% after deductible
$10
$40
$175
50%
50% after deductible
$8-$45-$90-50% (up to $500)
10%
$10
$40
$175
50%
You pay 50% after
deductible
Premium Savings Plan Features
On and Off Marketplace
Secure (HMO)
Enhanced (HMO)
Value (HMO)
Goals (HMO)
Premium (PPO)
Premium Savings (PPO)
25
 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-OfPocket Amounts
Premium Savings Silver
Premium Savings Gold
PPO
PPO
Individual: $1,750 Individual: $6,350
Family: $3,500 Family: $12,700
10%
Individual:
Individual: $3,500
$10,000 Family:
Family: $7,000
$20,000
50%
50% after deductible
Individual: $1,250 Individual: $1,750
Family: $2,500 Family: $3,500
10%
10% after deductible
Individual:
Individual: $2,000
$10,000 Family:
Family: $4,000
$20,000
10% after deductible
10% after
deductible
50%
50% after deductible
Pharmacy: $8-$45-$90-50% (up to $500); subject to plan deductible
26
Emergency Care
Specialist Office Visit
Provider Office Visit (for illness
or injury)
Plan Payment Level
Annual out-of-pocket maximum
Annual deductible
Network
Plan Name
Premium Savings Plans
10% after
deductible
 Available in Bronze metallic level
 Low premium with higher out-ofpocket 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
27
Off Marketplace only
Essential Plan Features
Essential (HMO)
Value Plus (HMO)
Inside Advantage for
Individuals (PPO)
Essential Bronze HMO
28
Individual: Individual:
$6,250
$6,350
Family:
Family:
$12,500
$12,700
80%
20% after
deductible;
first 3 PCP
visits are 20% after
$10 per visit deductible
not subject
to
deductible.
$175
after
deductible
Retail prescription drugs
Emergency Care
Specialist Office Visit
Provider Office Visit (for illness
or injury)
Plan Payment Level
Annual out-of-pocket maximum
Annual deductible
Network
Plan Name
Essential Bronze Plan
$15 copayment for generic
drugs; not subject to deductible
$35-$50-50% (up to $500);
subject to deductible
Value Plus Plan Features
 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
29
Off Marketplace only
 Available in Gold and Platinum
metallic levels
Essential (HMO)
Value Plus (HMO)
Inside Advantage for
Individuals (PPO)
Plan Payment Level
Provider Office Visit (for illness
or injury)
Specialist Office Visit
Emergency Care
Retail prescription drugs
Annual out-of-pocket maximum
Annual deductible
Network
Plan Name
Value Plus Plans
100%
$15
$35
$175
$15-$35-$50-50% (up to
$500)
Individual:
Individual: $3,500
Value Plus Gold HMO $1,000 Family:
Family: $7,000
$2,000
Value Plus
Platinum
30
HMO
Individual:
$250 Family:
$500
Individual: $750
Family: $1,500



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:




31
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 outof-pocket costs
Level two: All other contracted hospitals
Level three: Out-of-network
Embedded Deductible and Out-OfPocket Amounts
Off Marketplace only
Inside Advantage for Individuals Plan Features
Essential (HMO)
Value Plus (HMO)
Inside Advantage for Individuals
(PPO)
Inside Advantage
Silver
PPO
PPO
80%
PPO
Individual:
Individual:
$1,500 Family: $3,000 Family:
$3,000
$6,000
Individual:
Individual:
$3,000 Family: $6,000 Family:
$6,000
$12,000
Individual:
$10,000
Family:
$20,000
Individual:
Individual: $500
$1,000 Family:
Family: $1,000
$2,000
Individual:
Individual:
$1,000 Family: $2,000 Family:
$2,000
$4,000
Individual:
$3,000 Family:
$6,000
32
Individual:
$10,000
Family:
$20,000
Individual:
$10,000
Family:
$20,000
60%
Retail prescription
drugs
$40
Emergency Care
$20
(Cost-share waived if
admitted to the hospital)
Specialist Office Visit
Individual:
Individual:
$6,000 Family: $6,350 Family:
$12,000
$12,700
Provider Office Visit
(for illness or injury)
100%
Individual:
$6,000 Family:
$12,000
Inside Advantage
Platinum
Plan Payment Level
Individual:
Individual:
$4,000 Family: $6,350 Family:
$8,000
$12,700
Individual:
$8,000 Family:
$16,000
Inside Advantage
Gold
Annual out-of-pocket
maximum
Annual deductible
Network
Plan Name
Inside Advantage for Individuals Plans
$175
You pay 40% after deductible
100%
$20
$40
80%
60%
$175
You pay 40% after deductible
100%
$20
$40
80%
60%
$175
You pay 40% after deductible
$8-$38-$76-50% (up to $500)
Individuals Purchasing Through the Marketplace
Eligible for Help Paying for Coverage
1. Premium Tax Credits
•
•
For consumers with incomes between 100%-400% FPL
Help consumers pay for coverage
2. Cost Share Subsidies
•
•
33
For consumers with incomes between 100%-250% FPL
Lower the cost shares/out-of-pocket expenses
Premium Subsidies and OOP Limits
1
Family of 4 (Subscriber is age 40)
Individual (Subscriber is age 40)
%FPL
100
1
2
3
4
34
138
150
160
175
200
240
250
300
350
400
450
Plan
Variation
Annual
Income
Medicaid or
CSR 94% AV1
$11,505
CSR 94% AV
CSR 94% AV
CSR 87% AV
CSR 87% AV
CSR 73% AV
CSR 73% AV
70%
70%
70%
70%
70%
$15,877
$17,258
$18,408
$20,134
$23,010
$27,612
$28,763
$34,515
$40,268
$46,020
$51,773
Weekly Net
Estimated
Proposed
pay after member monthly statutory
premium
OOP Max
taxes2
$184
$20
%FPL
100
$2,250
1
$248
$268
$284
$309
$349
$413
$430
$511
$592
$666
$735
4
3
2
$44
$58
$68
$86
$121
$177
$193
$275
$375
$375
$375
$2,250
$2,250
$2,250
$2,250
$5,200
$5,200
$6,400
$6,400
$6,400
$6,400
$6,400
2
3
4
138
150
160
175
200
240
250
300
350
400
450
Plan
Variation
Medicaid or
CSR 94% AV1
CSR 94% AV
CSR 94% AV
CSR 87% AV
CSR 87% AV
CSR 73% AV
CSR 73% AV
70%
70%
70%
70%
70%
Annual
Income
Weekly Net
pay after
2
taxes
Estimated
family monthly
premium
Proposed
OOP Max
$23,425
$386
$40
$4,500
$32,327
$35,138
$37,480
$40,994
$46,850
$56,220
$58,563
$70,275
$81,988
$93,700
$105,413
$514
$554
$587
$636
$719
$846
$875
$1,017
$1,160
$1,302
$1,444
$89
$117
$139
$176
$246
$361
$393
$560
$649
$1,011
$1,011
$4,500
$4,500
$4,500
$4,500
$10,400
$10,400
$12,800
$12,800
$12,800
$12,800
$12,800
Individual Exchange Marketplace Products
Overview of Plans Offered in Each Region
Plans Offered in Select Area
P PPO
Plans
P HMO Plans with Full Network
P HMO Plans with “Select”
Network (5 County)
Plans Offered in Full Area
(All but Select Plans)
PPO Plans
P HMO Plans with Full Network
P
Plans Offered in Centre County
(No HMO Network)
P PPO Plans with Full Network
35
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
36
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
37
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.
38
Visit www.upmchealthplan.com to learn more!
39
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 Tool
41
Plan Selector Tool
U.S. Steel Tower
600 Grant Street
Pittsburgh, PA 15219
www.upmchealthplan.com