2014 Small Group Products Producer Training
Actuarial Value – Inside and Outside Health Insurance Marketplace Bronze Gold Silver Platinum Actuarial Value requirements in the ACA will require product changes in 2014.
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.
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-PocketMaximums Annual Out-of-Pocket Maximum is tied in with the bundled medical plan and applies to all covered services for medically necessary treatment
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.
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
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
2014 Portfolio for Small Group • UPMC Small Business Advantage • PPO • EPO • HMO • UPMC Consumer Advantage for Small Business • UPMCInside Advantage for Small Business • UPMC HealthyUfor Small Business
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.
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
Consumer-Driven Health Plans • HSA/HRA employer contributions count toward Actuarial Value • Options include funded HRA and HSA plans and High Deductible Health Plans
U.S. Steel Tower 600 Grant Street Pittsburgh, PA 15219 www.upmchealthplan.com