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ProducereNewsletterFall Producer Kickoff Summary
CommercialProductUpdatesINDEX 3page9pageDid you Know?Some health concernscan’t wait. The UPMCMyHealth 24/7 NurseLine gives membersimmediate access to aUPMC registered nurse.If you have a generalhealth question or needhelp with a non-emergencysickness or an injury,we are here to help.Our nurses can be reachedat 1-866-918-1591.AncillaryProduct UpdatesRegulatoryUpdatespagepageDIGITALINNOVATION
CommercialProductUpdatesPlans that offer coverageand flexibility, plus in-networkaccess to all of the providersand facilities of UPMC andother providers close to home.3
individualmarketRenewal processAt the end of October, existing UPMC Health Plan memberswho are enrolled in 2015 UPMC Advantage Individual andFamily plans will receive their renewal notice in the mail.Included will be a cover letter outlining the steps they need totake to re-enroll for 2016 coverage. The good news? Existingmembers do not have to take any action if they are satisfiedwith their proposed 2016 plan and premium; they simplyneed to continue to pay their monthly premiums. The letterincluded with the renewal notice advises members to contacttheir insurance agent if they want to make an active 2016plan selection. UPMC Health Plan is now offering completefunctionality to assist Individual and Family clients with there-enrollment process. When you visit Producer OnLine, youcan view your list of existing clients and their current plan,see which plans they will be automatically re-enrolled into ifthey do not make an active 2016 plan selection, and reviewcurrent and future year pricing. Additionally, the websiteallows you to manage both On and Off Exchange clients.4
2016 products and network offeringsIn 2016 UPMC Health Plan will continue to offer thesame network offerings available in 2015: Partner, Select,and Premium Networks. The Partner Network will now beavailable to residents in Bedford and Blair counties in additionto those in Allegheny and Erie counties. Also, Grove CityMedical Center in Mercer County is now part of theSelect Network.Next year UPMC Health Plan will offer the majority of thesame plans that exist in 2015, making the transition to 2016 asseamless as possible for your clients.Cost shares were altered on a fewplans to keep them within the samemetal level. Additionally, two 2015plans with low membership werediscontinued on all networks: the 2015Bronze 5,500/ 40 and the Gold 500/ 15. Members in those planswill be defaulted into the remaining2016 plans at the same metallic level.More details on specific cost-share changes can be found in theproducer webinars held in early October and available for youto view on Producer OnLine.Next year UPMC Health Plan willoffer the majority of the sameplans that exist in 2015, makingthe transition to 2016 as seamlessas possible for your clients.Producer trainingProducer webinars were held on October 6 and 8. Topicsincluded 2016 product offerings for Individual and SHOP aswell as a sneak peek at the re-enrollment platform producerswill use to manage their book of business. If you weren’t ableto join us, the presentation is available on Producer OnLine.5
groupmarketSelf Assure now availableto small groupsUPMC Health Plan is proud to expand ourSelf Assure administrative services only (ASO)portfolio. Our new offering for groups with25-199 employees combines an ASO contractwith level funding and aggregate-only stop lossin order to support groups in the transition toa self-insured market. The product designallows for a fixed amount on a monthly basis.The monthly payment is based on the year’sexpected claims. Included in that payment isthe premium for stop loss insurance, and theASO charge. When applicable, a portion ofexcess claims contributions each year willbe refunded. The refund is based on thedifference between funding versus actualclaims incurred for the year.6Introducing UPMCMyCare AdvantageA new and affordable group health plan optionwith full in-network access to UPMC providersUPMC MyCare Advantage is designed tooffer employers affordability and full in-networkaccess to UPMC as well as many outstandingcommunity partners. And with a plan designthat promotes patient-centered care, employersand their employees have the opportunity forimproved health outcomes at lower costs.UPMC MyCare Advantage is a tiered benefitplan offering two levels of in-network access.Members receive the highest level of benefitsand lowest out-of-pocket costs when theyreceive care from Level 1 providers. Membersalso have the choice of extended access toLevel 2 participating providers with increasedcost sharing. PPO plans have out-of-networkbenefits, but at the highest cost sharingfor members.
UPMC MyCare Advantage Level 1 providers are leadersin practicing patient-centered care. They include all UPMCdoctors, hospitals, and facilities as well as these communityhospitals and associated providers: Butler MemorialHospital, Excela Health, Grove City Medical Center,Heritage Valley Health System, Kane Community Hospital,Monongahela Valley Hospital, St. Clair Hospital, WashingtonHospital, and Washington Health System Greene. Level 2providers include all others participating in UPMC HealthPlan’s Premium Network for PPO plans or StandardNetwork for HMO plans.Patient-centered care works. National studies have found thatpatient-centered care practices closegaps in care, reduce medical costs,and improve patient outcomes.A two-year pilot program conductedby UPMC Health Plan resulted inlower medical and pharmacy costs,increased preventive care compliance, and lower rates ofemergency department visits and hospital readmissions.With in-network access to nationally recognized providersand facilities near home, members can enjoy patient-centeredcare at valuable cost savings.UPMC MyCare Advantage is atiered benefit plan offering twolevels of in-network access.UPMC MyCare Advantage is available beginning January 1,2016, to companies with 51 or more employees located inAllegheny, Beaver, Bedford, Blair, Butler, Washington, andWestmoreland counties.Click here to view our producer training flier.7
HealthyU just got better!HealthyU has always been about incentivizingemployees to make healthy choices. That, inturn, can lead to lower health care costs foremployers and decreased out-of-pocketexpenses for employees.Effective September 1, or at plan renewal,the new enhanced HealthyU takes this a stepfurther. We’ve enhanced the program so thatthe list of incentivized healthy activities includesonly those that are customized to themember’s unique needs.These are the activities members can completeto earn reward dollars in their health incentiveaccount. It also means members will receivea shorter, more doable, more focused, andmore impactful list of recommended healthyactivities to complete. The result: improvedhealth and productivity for members and lowerhealth care costs for your employer clients.For more information or questions regardingHealthyU, contact your UPMC Health Planrepresentative.8“Employee Choice” on SHOPBeginning January 1, 2016, employee choicewill be available in all states.Employee choice provides employees theopportunity to select the most appropriateplan for their needs and the needs of theirfamilies. Employees choose any health planat the actuarial value or metal level that hasbeen selected by their employer. Employeeswill also be able to choose different plansoffered under the same carrier.
AncillaryProduct Updates UPMC FlexAdvantageUPMC Health Plan will now oversee administration of our health savingsaccounts (HSA), and we assure you it’s a positive change!Enhancements include: Mobile app for instant access to account information. Employee access to HSA account through MyHealth OnLine.Employer groups that offer a qualified high-deductible health plan to their employees anduse BenefitWallet through UPMC Health Plan will transition to the new platform at theirnext renewal on or after October 1, 2015.Employer benefitsMember benefits Convenient employer website for easyaccount administration. Contributions, account interest, andqualified dollars spent are all tax free. Availability as a single HSA solution foremployers with multicarrier offerings. Members can set aside pretax dollarsfor qualified health expenses. Designated account manager. The HSA becomes another part of amember’s retirement nest egg that willbe there for medical expenses later in life. HSA reporting capability and much more. The money in the HSA goes with theemployee when he or she changes jobsor retires.9
UPMC Vision CareUPMC Health Plan is known for offering high-quality benefit planswith robust provider networks and outstanding customer service.We’re excited to continue that trend with our new vision product,UPMC Vision Care. Members of UPMC Vision Care will enjoy: Competitive premiums and reduced out-of-pocket costs. Access to a national network of providers, including retail vision care locations. Mail-order contact lens service. Discounts on LASIK vision correction when received from the UPMC Eye Center,TLC Vision, QualSight, or LASIK Centers of America. Access to benefits and information for all products through MyHealth OnLine,our secure member website.UPMC Vision Care will launch to pilot groups January 1, 2016, and will be available toall groups July 1, 2016. Vision Advantage will still be an option for groups until the endof 2017. Click here to access our producer training flier and here to download theVision Care slide deck.10
Bundling Discount ProgramUPMC Health Plan now offers a bundling discount on our dental andvision products. For new and renewal groups of 51 that do not currentlyoffer any UPMC Dental Advantage or Vision Advantage products, UPMCHealth Plan will lower the medical premium by 0.5 percent for each lineof business added to the group.*For current groups of 51 that do offer a dental and/or vision product, UPMC Health Plan willassume the discount based on the current ancillary policies. For example, if a current medicalclient has dental and vision plans, Underwriting will assume a 1 percent discount to themedical premium when it calculates the medical renewal.For more information on this bundling discount,contact Producer Relations.11*Maximum discount will be 1.0 percent: 0.5 percent for dental and 0.5 percent for vision.
RegulatoryUpdates12
Maximumout-of pocketupdates for 2016For 2016 the out-of-pocket (OOP) maximum amounts have changed for both Individual(self-only coverage) and Family (other than self-only coverage) plans.Individualself-only coverageFamilyother than self-only coverage20152016 6,600 6,850 13,200 13,700The 2016 Notice of Benefits and Payment Parameters clarifies how The Centers forMedicare & Medicaid Services (CMS) expects OOP limits on cost sharing for individualswithin family plans to be administered. This rule states that an individual's maximumcost exposure within a Family plan cannot exceed the self-only OOP limit (i.e., 6,850in 2016). This rule is effective for January 1, 2016, and after.13
Grandmothered& grandfathered plans“Grandmothered” plansWhen major provisions of the ACA took effect in 2014, many plans needed to bechanged or replaced to comply. CMS has allowed these existing plans, known as“grandmothered” or “transition policy” plans, to continue without making certainchanges that were otherwise required. The last date on which a grandmotheredpolicy can be renewed is October 1, 2016. Policies renewed on that date willprovide coverage through September 30, 2017. Group is covered in plan design before January 1, 2016.Rules Plan design can’t bend after January 1, 2016. Group remains in same plan type (no change in legal entity).“Grandfathered” plansIndividual or employer-sponsored plans and collectively bargained plans that existedbefore March 23, 2010, when the health care reform bill was signed, may be qualifiedas grandfathered plans. This means they are exempt from some provisions of thehealth care reform.What would cause a health plan to lose grandfathered status?If the employer makes any of the following changes to the plan, including: Elimination of all benefits to diagnose or treat a particular condition. Any increase in coinsurance. Increases in deductibles or copayment that exceed thecost-adjustment limit established by the law. A decrease in the employer contribution of more than 5 percent. Makes any other plan change prohibited by federal guidance.14
QHDHPUpdates for 2016The IRS has announced a few important changes to qualified high-deductible healthplans (QHDHP) for 2016. These changes impact out-of-pocket maximum amounts forIndividual and Family enrollments and HSA contribution limits for Family plans.QHDHPminimum deductiblesQHDHPmaximum out-of-pocket(OOP) amountsHSAcontribution limits(employer employee)20152016Individual: 1,300Family: 2,600Individual: 1,300Family: 2,600Individual: 6,450Family: 12,900Individual: 6,550Family: 13,100Individual: 3,350Family: 6,650Individual: 3,350Family: 6,750 1,000 1,000HSAcatch-up contributions(age 55 and older)15
ACA Contraceptive ChangesACA Contraceptive ChangesUPMC Health Plan recently made enhancements to preventive coverage for contraceptivesas required under the Affordable Care Act. These changes apply for plan years andrenewals beginning on or after August 1, 2015.Now covered at 0 are the following*: Vaginal contraceptive ring (Nuvaring) Sponge Cervical cap Female condom Spermicide16*When prescribed and obtained in accordance with preventive services guidelines and pharmacy benefits.
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TREATMENT ADVISER ANDMEDICAL COST ESTIMATORTreatment adviser and medical cost estimator helpmembers make well-informed, educated choicesabout their health care.What istreatment adviser?What ismedical cost estimator?The treatment adviser tool allows membersto see all of the common treatment optionsfor a medical condition. The treatmentadviser is unique from other decision-makingtools because it provides information on theexperiences of other people, includingmedical professionals.The medical cost estimator toolapproximates the total procedure costsfor medical treatments. The estimatedamount is based on the member’s specificplan and considers the member’s mostrecent medical claims.How exactly does it work?Type a condition or injury into the searchbar, for example, “knee ligament injury.” Thetool will provide a list of every commontreatment available, from simply exercisingand stretching at home to undergoingsurgery. Each option reports both its clinicaland patient-reported effectiveness. Clickingon a specific treatment explains the treatmentfurther and notes how popular it is amongpeople with the condition.Where do the patient ratings come from?Wiser Health collects survey data from peopleacross the country. It has more than four milliondata points about the treatment experiences ofboth patients and medical professionals.18How exactly does it work?Clicking on a treatment option providesthe cost for the procedure. It also displaysalternative treatments for that conditionand estimates those costs as well. For eachoption, members can see how their cost variesby the hospital or facility of their choice.How are the estimates determined?The total cost of the procedure is basedon two years’ worth of claims data for eachfacility. Out-of-pocket costs are customizedto the user, based on plan details such ascoinsurance and out-of-pocket maximumand how much of the deductible themember has met.Click here for our producer training flier.
eDERMATOLOGYFor help with skin conditions, e-visits with a UPMCboard-certified dermatologist are now available.eDermatology is a secure online e-visit experience, allowing consumers to upload photosof an affected area and receive a diagnosis and treatment plan from a UPMC board-certifieddermatologist within three business days. Get treatment for conditions such as rashes, bug bites, acne, eczema, and psoriasis. Bypass the average wait for a dermatologist. Typically costs less than a specialist office visit – and never more than 49, although UPMC HealthPlan members usually pay less. eDermatology is available only to users age three and older in PA. Children 3-18 must have a parent or guardian with them during the duration of the visit, and thatparent or guardian must have a pediatric proxy in place.Consumers can access eDermatology athttps://edermatology.upmc.com/This service is available 24/7, 365 days a year.Fact19UPMC Health Plan members get discounts on products and services like gymmemberships and spas. Search for deals at MyHealth OnLine.
125 network hospitalsBY THENUMBERS11,500 network physicians30,000 participating pharmacies176 urgent and convenience care clinicsSUCRAN E P L ANH EALT HT INGSRAINNCQARATING2015-16PRI VA T E P L A NAccording to the National Committee for Quality Assurance(NCQA)’s Private Health Insurance Plan Ratings for 2015-2016,the two HMO plans of the UPMC Insurance Division — UPMCHealth Plan and UPMC Health Coverage — are among thehighest-rated commercial plans in the nation.In fact, UPMC Health Coverage is one of only 11 plans in the nationto receive a 5 out of 5 rating — the highest rating given by NCQA.UPMC Health Coverage’s 5 out of 5 rating also makes it thetop-rated commercial HMO in Pennsylvania and the onlycommercial HMO in Pennsylvania to achieve this score.
offer any UPMC Dental Advantage or Vision Advantage products, UPMC Health Plan will lower the medical premium by 0.5 percent for each line of business added to the group.* For current groups of 51 that do offer a dental and/or vision product, UPMC Health Plan will assume the discount based on the current ancillary policies.
