2 Actuarial Value – Inside and Outside Health Insurance Marketplace BronzeSilverGoldPlatinumActuarial Value60%70%80%90%Monthly premiumsLowestModerateHighestOffer Essential Health BenefitsYesMust Offer in Health Insurance MarketplaceNoAt least 1 planIn 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, 2014Must 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.
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 ExchangeMedicaid benchmark and benchmark-equivalent and Basic Health ProgramsEHBs for Pediatric Services in Pennsylvania are defined by a different benchmark plan than medicalDental – FEDVIP (MetLife – High Option)Vision – FEDVIP (BlueVision – High Option)Options for the Dental Essential Health Benefits PackageEmbedded into medical plans and become part of a single risk pool in the medical filingOffer a stand alone plan that is solely to cover the EHB package as an add-on to a member’s medical planRegardless 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 BenefitAll monies paid for dental services roll up to the aggregate Out-of-Pocket (OOP) MaximumThere is a separate sub-deductible for Class II and Class III servicesOrthodontia benefit is tied to the medical deductibleSee Orthodontia Requirements for Medical Necessity in PennsylvaniaDental Benefits are covered through UPMC Dental AdvantageOut-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
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 feeSalzmann 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 BenefitAll monies paid for vision services roll up to the aggregate Out-of-Pocket (OOP) MaximumPediatric 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
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 coverageIncludes medical, pharmacy, mental health, pediatric dental EHBs, and pediatric vision EHBsExpenses include deductibles, copayments, and coinsuranceOut-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 2014Groups and Health Plans with a single vendor to administer claims must implement a unified OOP maximumThere is a Safe Harbor for Groups and Health Plans that have multiple vendorsGroups with multiple vendors can satisfy the OOP requirement by having a medical OOP max of $6,350 and a pharmacy OOP max of $6,350Pediatric 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 AdvantagePPOEPOHMOUPMC Consumer Advantage for Small BusinessUPMC Inside Advantage for Small BusinessUPMC 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 applyingPreventive care is covered at 100 percentAll benefits are covered 100% after deductible with exception of the first 3 PCP visits and e-visits
19 Consumer-Driven Health Plans HSA/HRA employer contributions count toward Actuarial ValueOptions include funded HRA and HSA plans and High Deductible Health PlansPPO Gold $1,250/100% $20/$40PPO Gold HRA $2,000/100% $20/$40/$3,000- fundedPPO Gold HSA HealthyU $1,500/90% - fundedPlan TypePPOMetal LevelGoldHRA/HSA FundingNo$1,000$125Deductible$1,250$2,000$1,500Coinsurance100%90%OOP Max$2,500$3,000ER$15090% ADPCP$20Specialist$40Advanced Radiology100% AD
20 Pharmacy Options Pharmacy Option Metal Level $8/$38/$76/$95 All metal levels$15/$30/$50/$95$5/$28/$56/$100Platinum and Gold PPO only
21 U.S. Steel Tower600 Grant StreetPittsburgh, PA 15219