2014 Small Group ProductsProducer Training

Actuarial Value – Inside and Outside Health Insurance Marketplace

Actuarial Value requirements in the ACA will require product changes in 2014.

GoldBronze PlatinumSilver

Actuarial Value 60% 70% 80% 90%

Monthly premiums 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

Essential Health Benefits

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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.

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• 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 MaximumsAnnual Out-of-Pocket Maximum is tied in with the bundled medical plan and

applies to all covered services for medically necessary treatment

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Pediatric Dental Coverage

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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.

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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

Essential Health Benefit – Vision Coverage

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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 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 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 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

Explanation of Out-of-Pocket Maximum

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UPMC Small Business AdvantagePPOEPOHMO

UPMC Consumer Advantage for Small Business

UPMC Inside Advantage for Small Business

UPMC HealthyU for Small Business

2014 Portfolio for Small Group

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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

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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

New Benefit Design - First 3 Plan

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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 TypePPO HMO PPO PPO PPO

Metal LevelPlatinum Platinum Platinum Platinum Platinum

Deductible$0 N/A $0 $250 $750

Coinsurance100% N/A 100% 100% 100%

Hospital Copay N/A $300 N/A N/A N/AOOP Max

$1,250 $750 $1,250 $1,000 $1,250ER

$100 $175 $100 $100 $100 PCP

$10 $5 $15 $20 $10 Specialist

$25 $35 $30 $40 $40 Advanced Radiology $150 $150 $150 $150 $150

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Gold Plans

PPO Gold $1,250/100%/$10/$40/$5,00

0 OOP

HMO Gold $1,000/100%/$10/$25/$3,00

0 OOP

PPO Gold $1,500/100%/$20/$40/$4,00

0 OOP

HealthyU Gold

$1,250/90%/$2,250

PPO Gold $2,000/100%/$10/$40/$4,00

0 OOP

Plan TypePPO HMO PPO HealthyU PPO

Actuarial Value Gold Gold Gold Gold GoldDeductible

$1,250 $1,000 $1,500 $1,250 $2,000 Coinsurance

100% 100% 100% 90% 100%OOP Max

$5,000 $3,000 $4,000 $2,250 $4,000 ER

$150 $175 $150 90% AD $150 PCP

$10 $10 $20 90% AD $10 Specialist

$40 $25 $40 90% AD $40 Advanced Radiology 100% AD 100% AD 100% AD 90% AD 100% AD

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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 TypePPO HSA PPO HealthyU

Metal LevelSilver Silver Silver Silver

Deductible$2,000 $2,000 $3,000 $2,250

Coinsurance80% 100% 80% 85%

Advanced Radiology 80% AD 100% AD 80% AD 85% ADOOP Max

$6,350 $6,350 $6,350 $6,350 ER

$175 100% AD $175 85% ADPCP

$20 100% AD $20 85% ADSpecialist

$40 100% AD $40 85% AD

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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 TypeEPO EPO EPO

Metal LevelBronze Bronze Bronze

Deductible$4,500 $3,500 $5,500

Coinsurance80% 70% 100%

OOP Max$6,350 $6,350 $6,350

ER 80% AD 70% AD 100% AD

PCP80% AD 70% AD 100% AD

Specialist80% AD 70% AD 100% AD

Advanced Radiology80% AD 70% AD 100% AD

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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 TypePPO PPO PPO PPO

Actuarial ValuePlatinum Platinum Gold Silver

Deductible$250 $1,250 $2,000 $5,000

Coinsurance100% 100% 100% 100%

OOP Max$1,000 $1,250 $3,000 $6,350

ER $100 $100 $100 $100

PCP$20 $20 $20 $20

Specialist$40 $40 $40 $40

Advanced Radiology 100% AD 100% AD 100% AD 100% AD

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HSA/HRA employer contributions count toward Actuarial ValueOptions 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 PPO PPO

Metal Level Gold Gold Gold

HRA/HSA Funding No $1,000 $125

Deductible $1,250 $2,000 $1,500

Coinsurance 100% 100% 90%

OOP Max $2,500 $3,000 $2,500

ER $150 $150 90% AD

PCP $20 $20 90% AD

Specialist $40 $40 90% AD

Advanced Radiology 100% AD 100% AD 90% AD

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Pharmacy Options

Pharmacy Option Metal Level

$8/$38/$76/$95 All metal levels

$15/$30/$50/$95 All metal levels

$5/$28/$56/$100 Platinum and Gold PPO only

U.S. Steel Tower600 Grant Street Pittsburgh, PA 15219

www.upmchealthplan.com