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