UPMC Advantage 2014 Individual & Family Plans Producer Training

2014 Rating Limitations – Inside and Outside Health Insurance Marketplace

Essential Health Benefits

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

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 Explanation of Out-of-Pocket Maximum

UPMC Advantage Plans for 2014 On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) Off Marketplace only Essential (HMO) Value Plus (HMO) Inside Advantage for Individuals (PPO) 9 portfolios of plans 6

HMO plans: PCP referral required E-visits: Half the cost of primary care visit Podiatry is covered, but requires Prior Authorization Acupuncture, Private Duty Nursing, and Bariatric Surgery are not covered. 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 are included New for 2014 for ALL Individual and Family Plans 7

8 Dental benefits are available in both an HMO and PPO plan and is pre-determined by a member’s county of residence Regardless of which type of medical product you have; the HMO and/or PPO dental benefit will be based on county of residence 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 a product of UPMC Advantage and administered by Dominion Dental Services Dental Benefit

9 PPO Plan 100/80/50/50 Benefit Coverage In-Network Out-of-Network Class I 100%80% Class II80%60% Class III50%30% Class IV50%50% Annual Deductible In-Network Out-of-Network Single Child $50 $75 Two or More Children $150 $200 Applies to All No, Waived on Class I Benefits Benefits and Orthodontia Orthodontia deductible is tied in with the bundled medical plan Pediatric Dental Coverage HMO Plan 100/60/50/50 Benefit Coverage In-Network Class I100% Class II60% Class III50% Class IV$3,450 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

10 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.

11 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 12

“Catastrophic Plan” available to consumers under the age of 30 before plan year begins Low premium with higher out-of- pocket costs $6,350 deductible Three visits to primary care physician not subject to deductible; $30 copayment Designed for people who want “just in case” coverage Embedded Family Deductibles and Out-Of-Pocket Amounts Secure Plan Features On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) 13

14 Secure Plan Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Retail prescription drugs SecureHMO Individual: $6,350 Family: $12, % You pay $0 after deductible; first 3 PCP visits are $30 per visit not subject to deductible $0 after deductible

Available in Bronze, Silver, and Gold metallic levels Primary care and specialist visits covered with a fixed copayment of $10/$40 (Silver and Gold levels only)  Many services not subject to deductible, such as prescription drugs, PCP and specialist visits, and emergency care  90%/10% plans  Embedded Family Deductibles and Out-Of-Pocket Amounts On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) Enhanced Plan Features 15

16 Enhanced Plans Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Retail prescription drugs Enhanced Bronze HMO Individual: $5,000 Family: $10,000 Individual: $6,350 Family: $12,700 90% 10% after deductible $8-$38-$76-50% (up to $500); subject to deductible Enhanced SilverHMO Individual: $3,000 Family: $6,000 Individual: $6,350 Family: $12,700 $10$40 $175$8-$45-$90-50% (up to $500) Enhanced GoldHMO Individual: $1,000 Family: $2,000 Individual: $3,000 Family: $6,000

 Available in Silver and Gold metallic levels  PCP visits at no cost to member  Cost-share for medical services is a fixed copayment rather than coinsurance  Many services not subject to deductible, such as prescription drugs, primary care physician (PCP) and specialist visits, and emergency care  Embedded Family Deductibles and Out-Of-Pocket Amounts Value Plan Features On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) 17

18 Value Plans Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care (Cost-share waived if admitted to the hospital) Hospital Stay Value SilverHMO Individual: $4,500 Family: $9,000 Individual: $6,350 Family: $12, %$0$35$175 $150 after deductible per admission Value GoldHMO Individual: $1,000 Family: $2,000 Individual: $3,000 Family: $6,000 Pharmacy: $8-$45-$90-50% (up to $500)

 Available in Gold metallic level  Health Incentive Account: Ability to earn reward dollars for completing healthy activities  Individuals can earn up to $400 and families up to $800 to help pay for deductible, coinsurance, and pharmacy copayments  Embedded Family Deductibles and Out-Of- Pocket Amounts Goals Plan Features On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) 19

20 Goals Plan *Members can earn up to $400 individual/$800 family to help pay for deductible, coinsurance, and pharmacy copayments. Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Retail prescription drugs Goals Gold HMO Individual: $1,000 Family: $2,000 Individual: $3,000 Family: $6,000 80%$15$40$175 $8-$45- $90-50% (up to $500)

How a Health Incentive Account (HIA) Works Members earn HIA funds by completing healthy activities Each activity has a dollar value –Example: Flu shot=$50 in HIA funds The money members earn is placed into HIA HIA funds can be used to pay deductible, coinsurance, and pharmacy copayment expenses

Examples of HIA activities 150+ activities available at

Available in Bronze, Silver, and Gold metallic levels No referrals required to see specialists Primary care and specialist visits covered with a fixed copayment ( Silver and Gold levels only ) 90%/10% plans Embedded Family Deductibles and Out-Of-Pocket Amounts Premium Plan Features On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) 23

24 Premium Plans Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Retail prescription drugs Premium BronzePPO Individual: $5,000 Family: $10,000 Individual: $6,350 Family: $12,700 10%10% after deductible You pay 10% after deductible $8-$38-$76-50% (up to $500) after deductible Individual: $6,500 Family: $13,000 Individual: $10,000 Family: $20,000 50%50% after deductible Premium SilverPPO Individual: $3,000 Family: $6,000 Individual: $6,350 Family: $12,700 10%$10$40 $175 $8-$45-$90-50% (up to $500) Individual: $6,000 Family: $12,000 Individual: $10,000 Family: $20,000 50%50% after deductible Premium GoldPPO Individual: $1,000 Family: $2,000 Individual: $3,000 Family: $6,000 10%$10$40 $175 Individual: $3,000 Family: $6,000 Individual: $10,000 Family: $20,000 50% You pay 50% after deductible

 Available in Silver and Gold metallic levels  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 tax-free!  Aggregate Family Deductibles and Out-Of- Pocket Amounts Premium Savings Plan Features On and Off Marketplace Secure (HMO) Enhanced (HMO) Value (HMO) Goals (HMO) Premium (PPO) Premium Savings (PPO) 25

26 Premium Savings Plans Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Premium Savings SilverPPO Individual: $1,750 Family: $3,500 Individual: $6,350 Family: $12,700 10%10% after deductible Individual: $3,500 Family: $7,000 Individual: $10,000 Family: $20,000 50%50% after deductible Premium Savings GoldPPO Individual: $1,250 Family: $2,500 Individual: $1,750 Family: $3,500 10%10% after deductible Individual: $2,000 Family: $4,000 Individual: $10,000 Family: $20,000 50%50% after deductible Pharmacy: $8-$45-$90-50% (up to $500); subject to plan deductible

 Available in Bronze metallic level  Low premium with higher out-of- pocket costs  $6,250 deductible  Three visits to primary care physician not subject to deductible; $10 copayment  Designed for people who want “just in case” coverage Similar to the Secure plan, but available to consumers of any age Embedded Family Deductibles and Out-Of-Pocket Amounts Essential Plan Features Off Marketplace only Essential (HMO) Value Plus (HMO) Inside Advantage for Individuals (PPO) 27

28 Essential Bronze Plan Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Retail prescription drugs Essential BronzeHMO Individual: $6,250 Family: $12,500 Individual: $6,350 Family: $12,700 80% 20% after deductible; first 3 PCP visits are $10 per visit not subject to deductible. 20% after deductible $175 after deductible $15 copayment for generic drugs; not subject to deductible $35-$50-50% (up to $500); subject to deductible

 Available in Gold and Platinum metallic levels  100% coinsurance after deductible  Many services not subject to deductible, such as prescription drugs, primary care physician (PCP) and specialist visits, and emergency care  Embedded Family Deductibles and Out-Of-Pocket Amounts Value Plus Plan Features Off Marketplace only Essential (HMO) Value Plus (HMO) Inside Advantage for Individuals (PPO) 29

30 Value Plus Plans Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care Retail prescription drugs Value Plus GoldHMO Individual: $1,000 Family: $2,000 Individual: $3,500 Family: $7, % $15 $35$175 $15-$35-$50-50% (up to $500) Value Plus Platinum HMO Individual: $250 Family: $500 Individual: $750 Family: $1,500

 Available in Silver, Gold, and Platinum metallic levels  Available only in Erie and surrounding counties of Clarion, Crawford, Elk, Forest, McKean, Mercer, Potter, Venango, and Warren  There are three levels of hospital coverage:  Level one facilities, which include Kane Community Hospital, Warren General Hospital, UPMC Hamot, UPMC Northwest, UPMC Horizon, and any UPMC-owned facility, offer the lowest out- of-pocket costs  Level two: All other contracted hospitals  Level three: Out-of-network  Embedded Deductible and Out-Of- Pocket Amounts Inside Advantage for Individuals Plan Features Off Marketplace only Essential (HMO) Value Plus (HMO) Inside Advantage for Individuals (PPO) 31

32 Inside Advantage for Individuals Plans Plan Name Network Annual deductible Annual out-of-pocket maximum Plan Payment Level Provider Office Visit (for illness or injury) Specialist Office Visit Emergency Care (Cost-share waived if admitted to the hospital) Retail prescription drugs Inside Advantage Silver PPO Individual: $4,000 Family: $8,000 Individual: $6,350 Family: $12, % $20$40 $175 $8-$38-$76-50% (up to $500) Individual: $6,000 Family: $12,000 Individual: $6,350 Family: $12,700 80% Individual: $8,000 Family: $16,000 Individual: $10,000 Family: $20,000 60%You pay 40% after deductible Inside Advantage Gold PPO Individual: $1,500 Family: $3,000 Individual: $3,000 Family: $6, % $20$40 $175 Individual: $3,000 Family: $6,000 Individual: $6,000 Family: $12,000 80% Individual: $6,000 Family: $12,000 Individual: $10,000 Family: $20,000 60%You pay 40% after deductible Inside Advantage Platinum PPO Individual: $500 Family: $1,000 Individual: $1,000 Family: $2, % $20$40 $175 Individual: $1,000 Family: $2,000 Individual: $2,000 Family: $4,000 80% Individual: $3,000 Family: $6,000 Individual: $10,000 Family: $20,000 60%You pay 40% after deductible

33 1.Premium Tax Credits For consumers with incomes between 100%-400% FPL Help consumers pay for coverage 2.Cost Share Subsidies For consumers with incomes between 100%-250% FPL Lower the cost shares/out-of-pocket expenses Individuals Purchasing Through the Marketplace Eligible for Help Paying for Coverage

34 Premium Subsidies and OOP Limits

Individual Exchange Marketplace Products  PPO Plans  HMO Plans with Full Network  HMO Plans with “Select” Network (5 County)  PPO Plans  HMO Plans with Full Network  PPO Plans with Full Network Overview of Plans Offered in Each Region Plans Offered in Select Area Plans Offered in Full Area (All but Select Plans) Plans Offered in Centre County (No HMO Network) 35

Select Network 36 Counties: Allegheny, Beaver, Butler, Washington, Westmoreland Providers: All UPMC, Excela, Heritage Valley, Butler Memorial, Washington Hospital For HMO plan offerings, UPMC Health Plan also offers a Select network Customers and members can view provider listing on our Provider Search Page Select network plans offer consumers cost savings of ~8% on monthly premiums versus the 28-county network

HMO Referral Process The member’s PCP or any designated PCP can request a referral Referrals are entered by the PCP in the Provider OnLine portal -Members can access the referral information in MyHealth OnLine -PCPs can also print the referral for the member -Note: The member DOES NOT need to have a printed copy Referrals will last for 90 days Referrals will not be required for Pediatric Specialist, OBGYN, and Mental Health Professionals Members under age 21 will not require a referral 37

UPMC Health Plan will allow current Individual Advantage members to retain their current coverage through December Current membership would simply need to continue to pay their premiums on a monthly basis through December 2014 to retain their coverage — no further action is required. Accumulators, deductible, and OOP limits will reset upon the member’s anniversary date in Members with February-December anniversaries will have a shorter benefit period in Premiums associates with these plans will reflect the rate filing from April 2013 (6.5% increase), which will remain in effect through Transition for Individual Members 38

Visit to learn more! 39

Plan Selector Tool Consumers will input their ZIP code, age, and tobacco status Can answer questions regarding health care preferences to view plans that are suited for them

41 Plan Selector Tool

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