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2014 Small Group Products Producer Training.

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Presentation on theme: "2014 Small Group Products Producer Training."— Presentation transcript:

1 2014 Small Group Products Producer Training

2 Actuarial Value – Inside and Outside Health Insurance Marketplace
Bronze Silver Gold Platinum Actuarial Value 60% 70% 80% 90% Monthly premiums Lowest Moderate Highest Offer Essential Health Benefits Yes Must Offer in Health Insurance Marketplace No At least 1 plan In addition to offering Essential Health Benefits, all non-grandfathered health insurance in the individual or small group market, inside and outside the Health Insurance Marketplace, must meet specific actuarial values. Applies for policy or plan years beginning on or after January 1, 2014 Must meet one of these levels – recently proposed regulations indicate a de minimis variation of plus or minus two percentage points will be permitted. This regulation has not been finalized. Actuarial Value requirements in the ACA will require product changes in 2014.

3 Essential Health Benefits

4 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.

5 Out-of-Pocket Maximums
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

6 Pediatric Dental Coverage

7 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.

8 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

9 Essential Health Benefit – Vision Coverage

10 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

11 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

12 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.

13 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

14 Platinum Plans 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%/$20/$40/$1,000 OOP PPO Platinum $750/100%/$10/$40/$1,250 OOP Product Type PPO HMO Metal Level Platinum Deductible $0 N/A $250 $750 Coinsurance 100% Hospital Copay $300 OOP Max $1,250 $1,000 ER $100 $175 PCP $10 $5 $15 $20 Specialist $25 $35 $30 $40 Advanced Radiology $150

15 Gold Plans 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 Plan Type PPO HMO HealthyU Actuarial Value Gold Deductible $1,250 $1,000 $1,500 $2,000 Coinsurance 100% 90% OOP Max $5,000 $3,000 $4,000 ER $150 $175 90% AD PCP $10 $20 Specialist $40 $25 Advanced Radiology 100% AD

16 PPO Silver $2,000/80%/$20/$40/$6,350 OOP
Silver Plans 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 Plan Type PPO HSA HealthyU Metal Level Silver Deductible $2,000 $3,000 $2,250 Coinsurance 80% 100% 85% Advanced Radiology 80% AD 100% AD 85% AD OOP Max ER $175 PCP $20 Specialist $40

17 Bronze Plans EPO Bronze $4,500/80%/$6,350 OOP
Plan Type EPO Metal Level Bronze Deductible $4,500 $3,500 $5,500 Coinsurance 80% 70% 100% OOP Max $6,350 ER 80% AD 70% AD 100% AD PCP Specialist Advanced Radiology

18 Inside Advantage Plans
Inside Advantage PPO Platinum $250/100%/$20/$40/$1,000 OOP $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 Plan Type PPO Actuarial Value Platinum Gold Silver Deductible $250 $1,250 $2,000 $5,000 Coinsurance 100% OOP Max $1,000 $3,000 $6,350 ER $100 PCP $20 Specialist $40 Advanced Radiology 100% AD

19 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 Metal Level Gold HRA/HSA Funding No $1,000 $125 Deductible $1,250 $2,000 $1,500 Coinsurance 100% 90% OOP Max $2,500 $3,000 ER $150 90% AD PCP $20 Specialist $40 Advanced Radiology 100% AD

20 Pharmacy Options Pharmacy Option Metal Level $8/$38/$76/$95
All metal levels $15/$30/$50/$95 $5/$28/$56/$100 Platinum and Gold PPO only

21 U.S. Steel Tower 600 Grant Street Pittsburgh, PA 15219

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