1. UPMC Advantage
Individual & Family Plans for 2015

2. Today’s Agenda Overview 2015 Plans New Business Applications Renewals
Completing Renewals in IKA I&F
UPMC Individual Advantage Rate Change
Public Shopping Tool Overview
Producer Commissions

3. Overview

4. Pennsylvania Marketplace Enrollment: 318,077

5. Rating Area Tobacco Age
2015 Rating Limitations – Inside and Outside Health Insurance Marketplace
Rating Area
Tobacco
Age
(1.5:1)
(3:1)
Single/Family 5

6. Essential Health Benefits

7. 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 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.

8. 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 EHB, and pediatric vision EHB
Expenses include deductibles, copayments, and coinsurance
Out of pocket maximums in 2015:
$6,600 for individuals and $13,200 for families
$6,450 for individuals and $12,900 for families on Qualified High Deductible plans

9. 2015 Plans

10. Choose a Network. Choose a Plan.
We are offering the same 9 plans in 3 different networks. Potential members should first choose a network based on their residence and provider needs, then choose a plan that best suits their medical needs.
THREE networks
Premium (PPO)
Select (EPO)
Partner (EPO)
NINE plans
(Plan names: Metal Level Deductible/PCP – Network)
Two Bronze
Four Silver (One HSA)
Two Gold
One Platinum

11. UPMC Advantage Networks for 2015
UPMC Premium Network
29-county network for our PPO plans
Broadest of all networks
Includes all UPMC providers and UPMC-owned facilities as well as many independent providers and facilities
Members can go outside the network but will pay a greater share of the cost if they do

12. UPMC Advantage Networks for 2015
UPMC Select Network
Covers the five-county region of Allegheny, Beaver, Butler, Washington, and Westmoreland
Includes all UPMC providers and UPMC-owned facilities as well as our community partners:
Heritage Valley Hospital
Butler Memorial Hospital
Monongahela Valley Hospital
Excela Health
Washington Health System

13. UPMC Advantage Networks for 2015
UPMC Partner Network
Only offered to people who live in Allegheny or Erie county. Plans offered in this network are the least expensive.
Includes only UPMC providers and UPMC-owned facilities.
In Erie, there are a select number of independent providers and facilities that are included.
Although individuals who reside in Erie and Allegheny are the only ones who can purchase in this network, they can receive care from any UPMC provider or UPMC-owned facility in the 28-county service area.

14. 2015 Individual and Family Plans
Partner Network EPO
Bronze $5,500/$40 – Partner Network
Bronze $6,000/$25 – Partner Network
Silver HSA $2,000/20% – Partner Network
Silver $0/$50 – Partner Network
Silver $1,750/$30 – Partner Network
Silver $3,250/$10 – Partner Network
Gold $500/$15 – Partner Network
Gold $750/$10 – Partner Network
Platinum $250/$20 – Partner Network
Premium Network PPO
Catastrophic $6,600/$0 – Premium Network
Bronze $5,500/$40 – Premium Network
Bronze $6,000/$25 – Premium Network
Silver HSA $2,000/20% - Premium Network
Silver $0/$50 – Premium Network
Silver $1,750/$30 – Premium Network
Silver $3,250/$10 – Premium Network
Gold $500/$15 – Premium Network
Gold $750/$10 – Premium Network
Platinum $250/$20 – Premium Network
Select Network EPO
Bronze $5,500/$40 – Select Network
Bronze $6,000/$25 – Select Network
Silver HSA $2,000/20% - Select Network
Silver $0/$50 –
Select Network
Silver $1,750/$30 – Select Network
Silver $3,250/$10 – Select Network
Gold $500/$15 – Select Network
Gold $750/$10 – Select Network
Platinum $250/$20 – Select Network

15. Individual and Family Plans
E-visits (UPMC AnywhereCare): Half the cost of a primary care visit
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 is included
All plans have embedded deductibles with the exception of the Silver HSA plan, which is aggregate
Podiatry and acupuncture covered, but require prior authorization
Private duty nursing and bariatric surgery are not covered
New for 2015: Alternative medicine discounts via MyHealth Community

16. Aggregate vs. Embedded
Aggregate plans have a single deductible and single out-of-pocket (OOP) that the entire family must meet, either by a combination of claims or by one person in the family.
Individual plans have an individual deductible and OOP max.
Embedded plans have an individual deductible and OOP limit within their family deductible and OOP limit. They are met when one person in the family reaches the individual limit, or when a combination of family members’ claims reaches the family limit.
Embedded plans are considered more family-friendly because they limit an individual’s exposure within a family plan.

17. Catastrophic Plan Features
2015 Plans
Catastrophic $6,600/$0
Bronze $5,500/$40
Bronze $6,000/$25
Silver HSA $2,000/20%
Silver $0/$50
Silver $1,750/$30
Silver $3,250/$10
Gold $500/$15
Gold $750/$10
Platinum $250/$20
Available to consumers under the age of 30 before the plan year begins
Low premium with higher out-of-pocket costs
$6,600 deductible
Three visits to primary care physician not subject to deductible; $30 copayment
Designed for people who want “just-in-case” coverage

18. Bronze Plan Features Low monthly premiums
Higher cost-shares at the points of services
Primary care visits not subject to deductible
Generic prescriptions not subject to deductible

19. Silver HSA Plan Features
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
80/20 plan & $2,000 deductible
Cost-share reduction plans available for individuals based on income level and household size

20. Silver $0/20% Plan Features
This plan does NOT have a deductible and only has copayments; does not have coinsurance
Higher copayments for ER and hospital
$600 ER
$1,000 Outpatient
$4,000 Inpatient
Intended for individuals who want predictable copayments and are relatively healthy
Cost-share reduction plans available for individuals based on income level and household size

21. Silver Plan Features Benefits that are NOT subject to deductible: PCP
Specialist
Lab
PT/OT RX
Cost-share reduction plans available for individuals based on income level and household size
Gld$500/$15

22. Gold and Platinum Plan Features
Richest plans out of all metal
levels
Lower cost-shares
Higher premiums than the Bronze and Silver Plans
May be attractive to individuals
coming off group plans since
these are similar to group

23. Advanced Premium Tax Credits (APTC)
Individuals Purchasing Through the Marketplace Are Eligible for Help Paying for Coverage
Advanced Premium Tax Credits (APTC)
For consumers with incomes between 100% and 400% FPL
Helps consumers pay their premiums
Members who qualify can choose to have these funds reimbursed to them when they file their tax returns OR the federal government can pay the insurance company directly each month to lower their monthly bills

24. Individuals Purchasing Through the Marketplace Are Eligible for Help Paying for Coverage
Cost-Share Subsidies
For consumers with incomes between 100% and 250% FPL
Lowers the cost-shares/out-of-pocket expense
Individuals with incomes between 100 and 250% FPL may be eligible for both a cost- share reduction plan and a Premium Tax Credit

25. Silver $1,750/$30 Cost-Share Reduction (CSR) Options
FPL
150%-100%
200%-150%
250%-200%
251% +
CSR variation
94%
87%
73%
Base 70%
Annual deductible
Individual: $75
Family: $150
Individual: $500
Family: $1,000
Individual: $1,750
Family: $3,500
Annual out-of-pocket maximum
Individual: $1,000
Family: $2,000
Individual: $2,250
Family: $4,500
Individual: $4,800
Family: $9,600
Individual: $6,600
Family: $13,200
Plan payment level
20%
Provider office visit (for illness or injury) $5
$15
$30
Specialist office visit
$10
$80
Emergency care
20% after deductible
Retail prescription drugs
$2-$10-$25-50%
(up to $500)
$4-$25-$45-50%
$8-$45-$90-50%

26. How Can Consumers Learn More and Apply?
Contact insurance agent/producer
If subsidy-eligible  (enter NPN) or Web-based entity
If not subsidy-eligible  IKA I&F platform

27. New Business Applications IKA Individual & Family (I&F)

28. New Business Application in IKA I&F
Same look and feel; follows same easy application flow
Several new enhancements and additions
New cut-off date: Members can apply up to the end of the month for an effective date of the 1st of the following month
Example: Can apply on 12/31/14 for a 1/1/15 effective date.
However, please note that if an application is not accepted until Dec. 31, our claims system will not be updated in time to use their benefits on Jan. 1.
Change to Confirmation of Enrollment letter: Only one letter will be generated per application group
Total family premium will be included instead of individual premiums
All members on the policy will be listed on letter
All the changes also apply to the renewal flow

29. Enhanced Filters on Select Plans Page
Network
Metallic Level
Coinsurance
Plan Type

30. Electronic Plan Document Question
Added to Personal Details/About You page.
Please encourage applicants to select this option. Instead of receiving their policy documents in the mail, they will access them electronically via MyHealth OnLine.

31. New: 5 Questions Added to Optional Page

32. Details for Optional Questions
Each Yes/No question asks for additional details
Can be completed for each applicant

33. E-Signature Page
Only the subscriber signature is required regardless of the number of applicants

34. Individual and Family
Renewals

35. 2015 Renewals for Marketplace Plans
Since the ACA-compliant plans are based on the calendar year, all members enrolled in 2014 plans will renew coverage on January 1, 2015.
The annual renewal period is:
On-Exchange: November 15 - December 15
Off-Exchange: November 15 - December 31
We are not offering the 2014 plans in 2015; however, we are automatically enrolling members into a new 2015 plan.
Members are mapped into a 2015 plan within the same metal level.

36. What are Marketplace (subsidy-eligible) members’ options at renewal?
Do nothing. If members like the plan we have mapped them into, all they have to do is keep paying their monthly premium.
Members who are covered in the Marketplace in 2014 and are subsidy-eligible needed to consent that CMS would be able to communicate with the IRS for Since issuers have no way of knowing if a consumer granted this permission, all consumers are encouraged to visit Healthcare.gov to review their application and select the plan that best suits their needs.
2. Shop for a new plan. If members do not like the plan we have mapped them into or if they would like to see what other options are available to them, they can shop for and enroll in a new plan.
On Marketplace:
If members want to change plans, they must do so by December 15.
Plan changes during the renewal process will be completed through Healthcare.gov.

37. How do Marketplace Members Renew?
Members have four options to complete renewal:
1. Log in to Healthcare.gov.
Here they can view the details of their new plan and shop for and enroll in a different 2015 plan option, including other carriers.
2. Create an account at
UPMC Health Plan will offer direct enrollment functionality, allowing consumers to complete the application through our site.
3. Call UPMC Health Plan Account Management.
An account manager can assist them with the renewal process and talk to them about the 2015 plan options.
4. Contact their producer/insurance agent.
Producers/insurance agents can utilize the private exchange platform - Go Health.

38. 2015 Renewals: Off-Exchange ACA Plans
All members will be auto-enrolled into a new 2015 ACA plan at renewal, with the exception of members enrolled in Essential Bronze (NAH16) and Enhanced Silver (NAH32).
These members will continue in those plans for 2015, and all benefits will reset on Jan. 1, 2015.
We want to encourage these members to shop for a new 2015 plan.
The 2014 plan will end on Dec. 31, 2014, and the new 2015 plan will automatically begin on Jan. 1, 2015.
If a member is registered for auto-deduction, the new monthly premium will be deducted in December for January’s coverage.

39. Logging in to MyHealth OnLine
Members should log in to MyHealth OnLine to be directed to IKA: Coverage and Benefits  Make Changes  Coverage Changes

40. How will we notify members?
We will mail letters to all subscribers prior to November 15.
Subscribers will also receive an .
The will be generated from IKA I&F
A PDF of the renewal letter will be attached.
If a member has not logged in to complete renewal by December 2015, the subscriber will receive a reminder .
A Producer Update will be ed when the renewals are available to view in IKA I&F.

41. Completing Renewals
in IKA I&F

42. Renewal Search Select Renewal Search from the I&F drop-down menu.
All members due for renewal will be listed on this page.
The new 2015 plan and renewal letter is listed for each group.

43. Beginning Renewal: Member Dashboard
Click “Edit Renewal Now” button to begin the renewal.
All member maintenance functions will also be available, but any changes may affect the renewal rates.
All members will be moved to “completed status” because they will already have been enrolled in the new 2015 plan.

44. Editing Renewal Application
A member can make changes to the renewal application up to December 31.
If a member has already completed renewal, select the “Edit Renewal” link under the member maintenance actions list.

45. Renewal Member Verification
Verify information for all members on policy.
Can choose not to renew coverage by selecting “Waived.”
Can also add dependents (effective date will be 1/1/15).
Can modify Tobacco Use and ZIP code/County.

46. Select Plans for Renewal
Both current and new plan information is listed for easy comparison of rates and benefits.
Can shop for and enroll in a different plan in the same manner as completing a new application.

47. Select Dental Plans for Renewal
Dental buy-up plans will remain the same in 2015.
Members will remain in the current plan, if applicable. (Rate may increase if a member moves age bands.)
Members can change, add, or drop buy-up dental coverage at renewal.

48. Cart Summary
The original mapped plan will always appear in the cart summary.
If a member wants to change plans at renewal, he must check the box next to the new plan(s).

49. Enrollment and Premium Summary
There is no premium screen. We will continue to use the payment information we have on file if enrolled for auto-deduction.
There is no additional step for member acceptance. From here, the member will be asked to sign the renewal application and the renewal will be complete.

50. UPMC Individual Advantage
Rate Change

51. UPMC Individual Advantage Rate Change
Members can remain in their medically underwritten plans at least through the end of 2015.
The PID has approved a rate increase for all Individual Advantage plans (Value, Savings, and Goals), which will be applied to all members effective January 1, 2015.
Members will receive a letter and in November informing them of the rate change.
Benefits will still reset upon their 12-month policy anniversary date in 2015.

52. Shopping for a 2015 ACA-Compliant Plan
Individual Advantage members can easily shop for and switch to a 2015 ACA plan.
Start by clicking on the Shop Now button in the blue banner on the top of member dashboard.
They will be able to see all the 2015 plan options and systematically switch to a new 2015 plan via IKA I&F.
Members will retain the same member ID.
The option to change to a new plan will be available to members during the open enrollment period (11/15/14-2/15/15).

53. 2015 Individual & Family Public Shopping Tool Overview
Collaborative effort between Marketing and CI
Login button not working off the home screen (FYI)

54. Revised Homepage on November 15

55. New Learning Landing Page – Accessed From “Get the Facts”

56. 11/7 – 11/14: Window Shopping

57. New Dashboard – For Returning Users Only
Orients returning user to what they have done and next steps.
Content is dynamic, based on the status we receive from the FFM.
Example: This user has an estimated tax credit but did not go to the FFM. Basic census information is included here because the user did not go to the FFM where that information is required.
2 primary flows: 1) not been to the FFM/incomplete ffm – users have 3 links 2) Completed subsidy verification on FFM – users have 2 links
There are 8 variations of this page depending on what the user has completed – see Gemini for the others (2 are shown here)
0$ estimated tax credit, have not been to the Gov Marketplace
Recalculate estimated tax credit using new info – goes to the tax credit calculation page
Change information about covered individuals – goes to the covered individual page (if changes on this page change the subsidy recalculation occurs on the plan rate page.
Continue shopping – goes to the narrow plans page
Skipped estimated tax credit calculation, have not been to the Gov Marketplace
Use our tax credit tool to see if you have qualify
Change information about covered individuals
Continue shopping
Skipped tax credit, no census entered
Same as above but covered individual status is blank
Received >$0 estimated tax credit, have not been to the Gov Marketplace (Screen Shown here)
Visit Healthcare.gov to start/update your application for a tax credit (FFM or Go Health)
Received >$0 estimated tax credit, have been to FFM but status is incomplete
Same 3 options as above
Tax credit status shows incomplete FFM
Received >$0 estimated tax credit, have been to FFM and have an error
Tax credit status shows error
Received >$0 estimated tax credit, FFM Complete
Status indicates what the tax credit is
Option 1 – visit healthcare.gov to make any updates
Option 2 – continue shopping
(They have a final tax credit – should not be updating any covered individuals here – need to do that on the exchange)
Received 0$ tax credit and FFM complete
Same 2 options as above
Since they’ve been to the FFM, they should be going back there to make any updates

58. New – Tax Credit Calculation Screen
Replaces the “likely to qualify” screen.
Users who have completed the FFM tax credit verification process will not see this screen; they will see the dashboard.
If zip spans multi counties, county selection field will appear (current functionality)
Content change “eligible for financial help”
Users that already have completed the FFM tax credit verification process on the Gov’t site, they will be taken to the dashboard (if they click on the header navigation).

59. New – Plan Display and Enhanced Filters
Networks based on ZIP code entered
- Products grouped by network. Network shown first w/products under each network.
- If live in a region with one network choice, they will only see one and the plans under it will be expanded.
- The carrot and “see plans” expand the section
-“(est)” not there if there is no tax credit
- Filter: coverage type changes to plan type, view all is the default
- Filters are also dynamic – is user does not live in a zip that has premium, premium won’t show on the page or as a network filter option

60. Plan and Rate Displays Per Network
Shoppers will see two rates if
they qualify for a tax credit. This
rate will indicate (est.) for
estimate if they have not verified
the amount on the FFM.

61. Existing - Off-Exchange Purchase (via IKA) - Cart
If user selected “Add to cart” or Skip Tax Credit
Off-Exchange purchase via IKA
Profile created if haven’t already done so
- If skipped tax credit button selected (user did get a tax credit and they are opting not to use it) – add verbiage below about not receiving your tax credit. This verbiage will not show if they clicked “add to cart” no tax credit was available to them.
- If they have not done a profile here and they apply, they will be required to fill one out.
Added the save, print icons, and phone w/hours

62. New - Exchange Purchase Experience (FFM Direct) - Cart
User clicked on “use tax credit” button next to the rate.
This user has not been to the FFM to apply/verify their tax credit (user has an estimated tax credit).
Apply for a tax credit takes the user to the profile screen if they have not yet completed one with instructions on what will happen (screen 16). They will be redirected to the Marketplace to verify their tax credit.
- Apply will take user to our direct enrollment FFM experience or the Go health direct enrollment FFM experience.
- User will return to the narrow plans page from the FFM once verification occurred. If they broke their session, after login/accessing their profile, be taken to a dashboard screen.

63. New - Exchange Purchase Experience (FFM Direct) - Cart
User clicks “Use tax credit” on rate page.
User has verified/applied for tax credit on the FFM and has returned (non estimated rate).
User will be purchasing an exchange product with government approved subsidy applied.
Purchase will take the user to the attestation screen.
Added “Your tax credit has been applied” to this scenario – if they have been to the FFM and have a tax credit

64. Responsive Design – Existing
Can view same site:
Online
Tablet
Smartphone
From S. Tillman

65. Producer Commissions Collaborative effort between Marketing and CI
Login button not working off the home screen (FYI)

66. 2015 Standard Producer – Individual Commissions
 SELECT AND PARTNER
NETWORK
 PREMIUM
YEAR 1
$18.00
$14.00
YEAR 2
$10.00
YEAR 3
$12.00
$8.00
YEAR 4+
$6.00
$5.00
Note: You are not required to write business through a GA. You can write business directly with UPMC Health Plan.

67. Commission Increase Override Schedule
Standard Producer/Agency Override Schedule
members: $1.00 per member override
members: $2.00 per member override
1,000+ members: $4.00 per member override
*Book of business assessment based upon total individual block of business ending June 30 of every calendar year.

68. 2015 Resources and Materials
Producer Update containing 2015 rate sheets and producer sales brochure will be sent within the next few days.
“Window Shopping” for 2015 plans begins on 11/7; visit to learn more.
Producer OnLine will be updated with 2015 plan documents.

69. Appendix

70. Key Components – Public I&F Shopping
11/7 – 11/15 single webpage providing products, rates, and the Inside Sales phone number.
New learning homepage: One place where users can go to learn about health insurance, ACA, etc.
Subsidy/tax credit calculation
Dynamic links to our FFM direct enrollment experience
Prospects will start on our site; we will route them to the FFM to verify their subsidy/tax credit; they will be redirected back to our site for enrollment (plan selection, plan details, compare/print/ , checkout, and payment)
New plan display, incorporating the networks
Incorporating rates with and without subsidy/tax credit applied
Usability modifications
Updating covered individuals
Revised filter logic
Minor updates to the plan details

71. Current Value-Adds in Today’s Experience
Profile information collected for remarketing
Responsive design (coded specifically for desktop, mobile, and tablet)
Ability to continue to IKA for “on exchange” purchases
Ability to compare up to three plans
Print, , and save results
Return to where the user left off
Hesitation screen popup for help if no keyboard or mouse movement by the user
Analytics and tracking