UPMC Advantage 2014 Individual & Family Plans Producer Training

1. UPMC Advantage 2014 Individual & Family Plans Producer Training

2. 2014 Rating Limitations – Inside and Outside Health Insurance Marketplace Rating Area Age Tobacco (1.5:1) (3:1) Single/Family

3. Essential Health Benefits

4. Actuarial Value – Inside and Outside Health Insurance Marketplace Bronze Gold Silver Platinum Actuarial Value requirements in the ACA will require product changes in 2014.

5. 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

6. UPMC Advantage Plans for 2014 9 portfolios of plans

7. New for 2014 for ALL Individual and Family Plans • 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

8. Dental Benefit • 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

9. Pediatric Dental Coverage PPO Plan 100/80/50/50 Benefit CoverageIn-NetworkOut-of-Network Class I 100% 80% Class II 80% 60% Class III 50% 30% Class IV 50% 50% Annual DeductibleIn-NetworkOut-of-Network Single Child $50 $75 Two or More Children $150 $200 Applies to AllNo, Waived on Class I BenefitsBenefits and Orthodontia • Orthodontia deductible is tied in with the bundled medical plan • HMO Plan • 100/60/50/50 • Benefit Coverage In-Network • Class I100% • Class II 60% • Class III 50% • Class IV $3,450 • 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

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. • 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.

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

12. Essential Health Benefit – Vision Coverage

13. “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

14. Secure Plan

15. 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 Enhanced Plan Features

16. Enhanced Plans

17. 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

18. Value Plans Pharmacy: $8-$45-$90-50% (up to $500)

19. 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

20. Goals Plan *Members can earn up to $400 individual/$800 family to help pay for deductible, coinsurance, and pharmacy copayments.

21. 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

22. Examples of HIA activities 150+ activities available at www.upmchealthplan.com

23. 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

24. Premium Plans

25. 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

26. Premium Savings Plans Pharmacy: $8-$45-$90-50% (up to $500); subject to plan deductible

27. 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

28. Essential Bronze Plan

29. 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

30. Value Plus Plans

31. 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

32. Inside Advantage for Individuals Plans

33. Premium Tax Credits For consumers with incomes between 100%-400% FPL Help consumers pay for coverage 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

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

36. Select Network • 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

37. 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 MyHealthOnLine • 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

38. 2013-2014 Transition for Individual Members • UPMC Health Plan will allow current Individual Advantage members to retain their current coverage through December 2014. • 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 2014. • Members with February-December anniversaries will have a shorter benefit period in 2014. Premiums associates with these plans will reflect the rate filing from April 2013 (6.5% increase), which will remain in effect through 2014.

39. Visit www.upmchealthplan.com to learn more!

40. 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

42. Plan Selector Tool

43. U.S. Steel Tower 600 Grant Street Pittsburgh, PA 15219 www.upmchealthplan.com