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2014 Small Group Products Producer Training. Actuarial Value – Inside and Outside Health Insurance Marketplace Actuarial Value requirements in the ACA.

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Presentation on theme: "2014 Small Group Products Producer Training. Actuarial Value – Inside and Outside Health Insurance Marketplace Actuarial Value requirements in the ACA."— Presentation transcript:

1 2014 Small Group Products Producer Training

2 Actuarial Value – Inside and Outside Health Insurance Marketplace Actuarial Value requirements in the ACA will require product changes in Gold Bronze Platinum Silver Actuarial Value60%70%80%90% Monthly premiumsLowestModerate Highest Offer Essential Health Benefits Yes Must Offer in Health Insurance Marketplace NoAt least 1 plan No

3 Essential Health Benefits

4 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 members 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 5 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 Dental Benefit 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 6 Pediatric Dental Coverage

7 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.Orthodontic Decision Checklist (ODC) All anticipated treatment phases with a total case fee Salzmann Index (reflecting a score of 25 or higher)Salzmann Index 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 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 9

10 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 Explanation of Out-of-Pocket Maximum

11 11 UPMC Small Business Advantage –PPO –EPO –HMO UPMC Consumer Advantage for Small Business UPMC Inside Advantage for Small Business UPMC HealthyU for Small Business 2014 Portfolio for Small Group

12 12 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. New Product Design - HMO

13 13 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 New Benefit Design - First 3 Plan

14 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%/$2 0/$40/$1,000 OOP PPO Platinum $750/100%/$1 0/$40/$1,250 OOP Product Type PPOHMOPPO Metal Level Platinum Deductible $0N/A$0$250$750 Coinsurance 100%N/A100% Hospital Copay N/A$300N/A OOP Max $1,250$750$1,250$1,000$1,250 ER $100$175$100 PCP $10$5$15$20$10 Specialist $25$35$30$40 Advanced Radiology $150

15 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 PPOHMOPPOHealthyUPPO Actuarial Value Gold Deductible $1,250$1,000$1,500 $1,250$2,000 Coinsurance 100% 90%100% OOP Max $5,000$3,000$4,000$2,250$4,000 ER $150$175$15090% AD$150 PCP $10 $2090% AD$10 Specialist $40$25$4090% AD$40 Advanced Radiology 100% AD 90% AD100% AD

16 16 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 PPOHSAPPOHealthyU Metal Level Silver Deductible $2,000 $3,000$2,250 Coinsurance 80%100%80%85% Advanced Radiology 80% AD100% AD80% AD85% AD OOP Max $6,350 ER $175100% AD$17585% AD PCP $20100% AD$2085% AD Specialist $40100% AD$4085% AD

17 17 Bronze Plans EPO Bronze $4,500/80%/$6,350 OOP EPO Bronze $3,500/70%/$6,350 OOP EPO Bronze $5,500/100%/$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% AD70% AD100% AD PCP 80% AD70% AD100% AD Specialist 80% AD70% AD100% AD Advanced Radiology 80% AD70% AD100% AD

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

19 19 HSA/HRA employer contributions count toward Actuarial Value –Options include funded HRA and HSA plans and High Deductible Health Plans Consumer-Driven 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$2,500 ER $150 90% AD PCP $20 90% AD Specialist $40 90% AD Advanced Radiology 100% AD 90% AD

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

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


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