UPMC Advantage
Individual & Family Plans for 2015
Today’s Agenda
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Overview
2015 Plans
New Business Applications
Renewals
Completing Renewals in IKA I&F
UPMC Individual Advantage Rate Change
Public Shopping Tool Overview
Producer Commissions
Overview
Pennsylvania Marketplace Enrollment: 318,077
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2015 Rating Limitations – Inside and Outside Health
Insurance Marketplace
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Essential Health Benefits
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Actuarial Value – Inside and Outside Health Insurance
Marketplace
Silver
Gold
60%
70%
80%
90%
Lowest
Moderate
Moderate
Highest
Offer Essential 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
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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 EHB,
and pediatric vision EHB
– Expenses include deductibles, copayments, and coinsurance
– Out of pocket maximums in 2015:
• $6,600 for individuals and $13,200 for families
• $6,450 for individuals and $12,900 for families on Qualified High
Deductible plans
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2015 Plans
Choose a Network. Choose a Plan.
We are offering the same 9 plans in 3 different networks. Potential
members should first choose a network based on their residence and
provider needs, then choose a plan that best suits their medical needs.
• THREE networks
– Premium (PPO)
– Select (EPO)
– Partner (EPO)
• NINE plans
(Plan names: Metal Level Deductible/PCP – Network)
– Two Bronze
– Four Silver (One HSA)
– Two Gold
– One Platinum
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UPMC Advantage Networks for 2015
UPMC Premium Network
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29-county network for our
PPO plans
Broadest of all networks
Includes all UPMC
providers and UPMCowned facilities as well as
many independent
providers and facilities
Members can go outside
the network but will pay a
greater share of the cost if
they do
UPMC Advantage Networks for 2015
UPMC Select Network
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Covers the five-county region of
Allegheny, Beaver, Butler,
Washington, and Westmoreland
Includes all UPMC providers
and UPMC-owned facilities as
well as our community partners:
– Heritage Valley Hospital
– Butler Memorial Hospital
– Monongahela Valley
Hospital
– Excela Health
– Washington Health System
UPMC Advantage Networks for 2015
UPMC Partner Network
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Only offered to people who live in
Allegheny or Erie county. Plans
offered in this network are the least
expensive.
Includes only UPMC providers and
UPMC-owned facilities.
– In Erie, there are a select
number of independent providers
and facilities that are included.
Although individuals who reside in
Erie and Allegheny are the only
ones who can purchase in this
network, they can receive care from
any UPMC provider or UPMC-owned
facility in the 28-county service
area.
2015 Individual and Family Plans
Catastrophic
$6,600/$0 – Premium
Network
Silver $0/$50 –
Premium Network
Silver $1,750/$30 –
Premium Network
Silver $3,250/$10 –
Premium Network
Gold $500/$15 –
Premium Network
Gold $750/$10 –
Premium Network
Platinum $250/$20 –
Premium Network
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Silver HSA $2,000/20%
- Select Network
Silver $0/$50 –
Select Network
Silver $1,750/$30 –
Select Network
Silver $3,250/$10 –
Select Network
Gold $500/$15 –
Select Network
Partner Network
EPO
Silver HSA
$2,000/20% Premium Network
Bronze $6,000/$25 –
Select Network
Select Network
EPO
Premium Network
PPO
Bronze $5,500/$40 –
Premium Network
Bronze $6,000/$25 –
Premium Network
Bronze $5,500/$40 –
Partner Network
Bronze $5,500/$40 –
Select Network
Bronze $6,000/$25 –
Partner Network
Silver HSA $2,000/20%
– Partner Network
Silver $0/$50 – Partner
Network
Silver $1,750/$30 –
Partner Network
Silver $3,250/$10 –
Partner Network
Gold $500/$15 –
Partner Network
Gold $750/$10 –
Select Network
Gold $750/$10 –
Partner Network
Platinum $250/$20 –
Select Network
Platinum $250/$20 –
Partner Network
Individual and Family Plans
• E-visits (UPMC AnywhereCare): Half the cost of a primary care visit
• 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 is included
• All plans have embedded deductibles with the exception of the Silver
HSA plan, which is aggregate
• Podiatry and acupuncture covered, but require prior authorization
• Private duty nursing and bariatric surgery are not covered
• New for 2015: Alternative medicine discounts via MyHealth Community
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Aggregate vs. Embedded
• Aggregate plans have a single deductible and single outof-pocket (OOP) that the entire family must meet, either by a
combination of claims or by one person in the family.
– Individual plans have an individual deductible and OOP max.
• Embedded plans have an individual deductible and OOP
limit within their family deductible and OOP limit. They are
met when one person in the family reaches the individual
limit, or when a combination of family members’ claims
reaches the family limit.
– Embedded plans are considered more family-friendly because they
limit an individual’s exposure within a family plan.
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Catastrophic Plan Features
Catastrophic $6,600/$0
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2015 Plans
Bronze $5,500/$40
Bronze $6,000/$25
Silver HSA $2,000/20%
Silver $0/$50
Silver $1,750/$30
Silver $3,250/$10
Gold $500/$15
Gold $750/$10
Platinum $250/$20
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Available to consumers under the
age of 30 before the plan year
begins
Low premium with higher out-ofpocket costs
$6,600 deductible
Three visits to primary care
physician not subject to deductible;
$30 copayment
Designed for people who want
“just-in-case” coverage
Bronze Plan Features
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Low monthly premiums
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Higher cost-shares at
the points of services
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Primary care visits not
subject to deductible
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Generic prescriptions not
subject to deductible
Silver HSA Plan Features
• 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 taxfree
• 80/20 plan & $2,000 deductible
• Cost-share reduction plans
available for individuals based
on income level and household
size
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Silver $0/20% Plan Features
• This plan does NOT have a
deductible and only has
copayments; does not have
coinsurance
• Higher copayments for ER and
hospital
• $600 ER
• $1,000 Outpatient
• $4,000 Inpatient
• Intended for individuals who want
predictable copayments and are
relatively healthy
• Cost-share reduction plans
available for individuals based on
income level and household size
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Silver Plan Features
• Benefits that are NOT subject to
deductible:
• PCP
• Specialist
• Lab
• PT/OT
• RX
Gld$500/$15
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• Cost-share reduction plans
available for individuals based
on income level and household
size
Gold and Platinum Plan Features
• Richest plans out of all metal
levels
• Lower cost-shares
• Higher premiums than the
Bronze and Silver Plans
• May be attractive to individuals
coming off group plans since
these are similar to group
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Individuals Purchasing Through the Marketplace Are Eligible
for Help Paying for Coverage
Advanced Premium Tax Credits (APTC)
For consumers with incomes between 100% and 400% FPL
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Helps consumers pay their premiums
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Members who qualify can choose to have these funds reimbursed to them when they
file their tax returns OR the federal government can pay the insurance company
directly each month to lower their monthly bills
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Individuals Purchasing Through the Marketplace Are Eligible
for Help Paying for Coverage
Cost-Share Subsidies
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For consumers with incomes between 100% and 250% FPL
Lowers the cost-shares/out-of-pocket expense
Individuals with incomes between 100 and 250% FPL may be eligible for both a
cost- share reduction plan and a Premium Tax Credit
Silver $1,750/$30 Cost-Share Reduction (CSR) Options
FPL
CSR variation
150%-100%
94%
Individual: $75
Family: $150
200%-150%
87%
Individual: $500
Family: $1,000
250%-200%
73%
Individual: $1,750
Family: $3,500
251% +
Base 70%
Individual: $1,750
Family: $3,500
Annual out-ofpocket maximum
Individual: $1,000
Family: $2,000
Individual: $2,250
Family: $4,500
Individual: $4,800
Family: $9,600
Individual: $6,600
Family: $13,200
Plan payment level
20%
20%
20%
20%
Provider office visit
(for illness or injury)
$5
$15
$30
$30
Specialist office
visit
$10
$30
$80
$80
Emergency care
20% after deductible
20% after deductible
20% after deductible
20% after deductible
Retail prescription
drugs
$2-$10-$25-50%
(up to $500)
$4-$25-$45-50%
(up to $500)
$8-$45-$90-50%
(up to $500)
$8-$45-$90-50%
(up to $500)
Annual deductible
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How Can Consumers Learn More and Apply?
• Contact insurance agent/producer
- If subsidy-eligible  www.healthcare.gov (enter NPN) or Web-based
entity
- If not subsidy-eligible  IKA I&F platform
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New Business Applications
IKA Individual & Family (I&F)
New Business Application in IKA I&F
• Same look and feel; follows same easy application flow
• Several new enhancements and additions
• New cut-off date: Members can apply up to the end of the month for an
effective date of the 1st of the following month
– Example: Can apply on 12/31/14 for a 1/1/15 effective date.
– However, please note that if an application is not accepted until Dec. 31, our claims
system will not be updated in time to use their benefits on Jan. 1.
• Change to Confirmation of Enrollment letter: Only one letter will be
generated per application group
– Total family premium will be included instead of individual premiums
– All members on the policy will be listed on letter
• All the changes also apply to the renewal flow
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Enhanced Filters on Select Plans Page
• Network
• Metallic
Level
• Coinsurance
• Plan Type
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Electronic Plan Document Question
• Added to Personal Details/About You page.
• Please encourage applicants to select this option. Instead of receiving
their policy documents in the mail, they will access them electronically
via MyHealth OnLine.
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New: 5 Questions Added to Optional Page
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Details for Optional Questions
• Each Yes/No question asks for additional details
• Can be completed for each applicant
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E-Signature Page
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Only the subscriber signature is required regardless of the number of applicants
Individual and Family
Renewals
2015 Renewals for Marketplace Plans
• Since the ACA-compliant plans are based on
the calendar year, all members enrolled in
2014 plans will renew coverage on
January 1, 2015.
• The annual renewal period is:
– On-Exchange: November 15 - December 15
– Off-Exchange: November 15 - December 31
• We are not offering the 2014 plans in 2015;
however, we are automatically enrolling
members into a new 2015 plan.
• Members are mapped into a 2015 plan within
the same metal level.
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What are Marketplace (subsidy-eligible) members’ options at
renewal?
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Do nothing. If members like the plan we have mapped them into, all they have
to do is keep paying their monthly premium.
Members who are covered in the Marketplace in 2014 and are subsidy-eligible needed to consent that
CMS would be able to communicate with the IRS for 2015. Since issuers have no way of knowing if a
consumer granted this permission, all consumers are encouraged to visit Healthcare.gov to review
their application and select the plan that best suits their needs.
2.
Shop for a new plan. If members do not like the plan we have mapped them
into or if they would like to see what other options are available to them, they
can shop for and enroll in a new plan.
On Marketplace:
• If members want to change plans, they must do so by December 15.
• Plan changes during the renewal process will be completed through Healthcare.gov.
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How do Marketplace Members Renew?
Members have four options to complete renewal:
1. Log in to Healthcare.gov.
Here they can view the details of their new plan and shop for and enroll in a different 2015 plan
option, including other carriers.
2. Create an account at www.UPMCHealthPlan.com.
UPMC Health Plan will offer direct enrollment functionality, allowing consumers to complete the
application through our site.
3. Call UPMC Health Plan Account Management.
An account manager can assist them with the renewal process and talk to them about the 2015
plan options.
4. Contact their producer/insurance agent.
Producers/insurance agents can utilize the private exchange platform - Go Health.
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2015 Renewals: Off-Exchange ACA Plans
• All members will be auto-enrolled into a new 2015 ACA plan at
renewal, with the exception of members enrolled in Essential
Bronze (NAH16) and Enhanced Silver (NAH32).
– These members will continue in those plans for 2015, and all benefits will
reset on Jan. 1, 2015.
– We want to encourage these members to shop for a new 2015 plan.
• The 2014 plan will end on Dec. 31, 2014, and the new 2015 plan
will automatically begin on Jan. 1, 2015.
• If a member is registered for auto-deduction, the new monthly
premium will be deducted in December for January’s coverage.
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Logging in to MyHealth OnLine
Members should log in to MyHealth OnLine to be directed to IKA:
Coverage and Benefits  Make Changes  Coverage Changes
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How will we notify members?
• We will mail letters to all subscribers
prior to November 15.
• Subscribers will also receive an
email.
– The email will be generated from IKA I&F
– A PDF of the renewal letter will be
attached.
• If a member has not logged in to
complete renewal by December
2015, the subscriber will receive a
reminder email.
• A Producer Update will be emailed
when the renewals are available to
view in IKA I&F.
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Completing Renewals
in IKA I&F
Renewal Search
• Select Renewal Search from the I&F drop-down menu.
• All members due for renewal will be listed on this page.
• The new 2015 plan and renewal letter is listed for each group.
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Beginning Renewal: Member Dashboard
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Click “Edit Renewal Now” button to begin the renewal.
All member maintenance functions will also be available, but any changes may affect the
renewal rates.
All members will be moved to “completed status” because they will already have been
enrolled in the new 2015 plan.
Editing Renewal Application
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A member can make changes to the renewal application up to December 31.
If a member has already completed renewal, select the “Edit Renewal” link
under the member maintenance actions list.
Renewal Member Verification
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Verify information for all members on policy.
Can choose not to renew coverage by selecting “Waived.”
Can also add dependents (effective date will be 1/1/15).
Can modify Tobacco Use and ZIP code/County.
Select Plans for Renewal
• Both current and new
plan information is
listed for easy
comparison of rates
and benefits.
• Can shop for and
enroll in a different
plan in the same
manner as
completing a new
application.
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Select Dental Plans for Renewal
• Dental buy-up plans will
remain the same in
2015.
• Members will remain in
the current plan, if
applicable. (Rate may
increase if a member
moves age bands.)
• Members can change,
add, or drop buy-up
dental coverage at
renewal.
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Cart Summary
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The original mapped plan will always appear in the cart summary.
If a member wants to change plans at renewal, he must check the box next to
the new plan(s).
Enrollment and Premium Summary
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There is no premium screen. We will continue to use the payment information
we have on file if enrolled for auto-deduction.
There is no additional step for member acceptance. From here, the member will
be asked to sign the renewal application and the renewal will be complete.
UPMC Individual Advantage
Rate Change
UPMC Individual Advantage Rate Change
• Members can remain in their medically underwritten plans at least
through the end of 2015.
• The PID has approved a rate increase for all Individual Advantage
plans (Value, Savings, and Goals), which will be applied to all
members effective January 1, 2015.
• Members will receive a letter and email in November informing
them of the rate change.
• Benefits will still reset upon their 12-month policy anniversary
date in 2015.
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Shopping for a 2015 ACA-Compliant Plan
• Individual Advantage members can easily shop for and switch to a 2015
ACA plan.
• Start by clicking on the Shop Now button in the blue banner on the top of
member dashboard.
• They will be able to see all the 2015 plan options and systematically
switch to a new 2015 plan via IKA I&F.
• Members will retain the same member ID.
• The option to change to a new plan will be available to members during
the open enrollment period (11/15/14-2/15/15).
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2015 Individual & Family
Public Shopping Tool Overview
Revised Homepage on November 15
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New Learning Landing Page –
Accessed From “Get the Facts”
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11/7 – 11/14: Window Shopping
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New Dashboard – For Returning Users Only
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Orients returning user to what they have done and next steps.
Content is dynamic, based on the status we receive from the FFM.
Example: This user has an estimated tax credit but did not go to the FFM. Basic
census information is included here because the user did not go to the FFM where that
information is required.
New – Tax Credit Calculation Screen
• Replaces the “likely to qualify” screen.
• Users who have completed the FFM tax credit verification process will not see this screen;
they will see the dashboard.
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New – Plan Display and Enhanced Filters
Networks based
on ZIP code
entered
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Plan and Rate Displays Per Network
Shoppers will see two rates if
they qualify for a tax credit. This
rate will indicate (est.) for
estimate if they have not verified
the amount on the FFM.
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Existing - Off-Exchange Purchase (via IKA) - Cart
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If user selected “Add to cart” or Skip Tax Credit
Off-Exchange purchase via IKA
Profile created if haven’t already done so
New - Exchange Purchase Experience
(FFM Direct) - Cart
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User clicked on “use tax credit” button next to the rate.
This user has not been to the FFM to apply/verify their tax credit (user has an estimated
tax credit).
Apply for a tax credit takes the user to the profile screen if they have not yet completed
one with instructions on what will happen (screen 16). They will be redirected to the
Marketplace to verify their tax credit.
New - Exchange Purchase Experience (FFM
Direct) - Cart
• User clicks “Use tax credit” on rate page.
• User has verified/applied for tax credit on the FFM and has returned (non
estimated rate).
• User will be purchasing an exchange product with government approved
subsidy applied.
• Purchase will take the user to the attestation screen.
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Responsive Design – Existing
Can view same site:
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Online
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Tablet
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Smartphone
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Producer Commissions
2015 Standard Producer –
Individual Commissions
SELECT AND
PARTNER
NETWORK
PREMIUM
NETWORK
YEAR 1
$18.00
$14.00
YEAR 2
$14.00
$10.00
YEAR 3
$12.00
$8.00
YEAR 4+
$6.00
$5.00
Note: You are not required to write business through a GA.
You can write business directly with UPMC Health Plan.
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Commission Increase Override Schedule
• Standard Producer/Agency Override Schedule
 250-499 members: $1.00 per member override
 500-999 members: $2.00 per member override
 1,000+ members: $4.00 per member override
*Book of business assessment based upon total individual block of
business ending June 30 of every calendar year.
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2015 Resources and Materials
• Producer Update containing 2015 rate sheets and producer
sales brochure will be sent within the next few days.
• “Window Shopping” for 2015 plans begins on 11/7; visit
www.upmchealthplan.com/coverage to learn more.
• Producer OnLine will be updated with 2015 plan documents.
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Appendix
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Key Components – Public I&F Shopping
1. 11/7 – 11/15 single webpage providing products, rates, and the Inside Sales
phone number.
2. New learning homepage: One place where users can go to learn about health
insurance, ACA, etc.
3. Subsidy/tax credit calculation
4. Dynamic links to our FFM direct enrollment experience
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Prospects will start on our site; we will route them to the FFM to verify their
subsidy/tax credit; they will be redirected back to our site for enrollment (plan
selection, plan details, compare/print/email, checkout, and payment)
5. New plan display, incorporating the networks
6. Incorporating rates with and without subsidy/tax credit applied
7. Usability modifications
1. Updating covered individuals
2. Revised filter logic
3. Minor updates to the plan details
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Current Value-Adds in Today’s Experience
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Profile information collected for remarketing
Responsive design (coded specifically for desktop, mobile, and tablet)
Ability to continue to IKA for “on exchange” purchases
Ability to compare up to three plans
Print, email, and save results
Return to where the user left off
Hesitation screen popup for help if no keyboard or mouse movement by the user
Analytics and tracking
U.S. Steel Tower
600 Grant Street
Pittsburgh, PA 15219
www.upmchealthplan.com