Producer eNewsletterFall Producer Kickoff Summary

INDEX

Did you Know?

Some health concerns can’t wait. The UPMC MyHealth 24/7 Nurse Line gives members immediate access to a UPMC registered nurse. If you have a general health question or need help with a non-emergency sickness or an injury, we are here to help. Our nurses can be reached at 1-866-918-1591.

Regulatory Updates

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Commercial Product Updates

Plans that offer coverage and flexibility, plus in-network access to all of the providers and facilities of UPMC and other providers close to home.

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individual market

Renewal processAt the end of October, existing UPMC Health Plan members who are enrolled in 2015 UPMC Advantage Individual and Family plans will receive their renewal notice in the mail. Included will be a cover letter outlining the steps they need to take to re-enroll for 2016 coverage. The good news? Existing members do not have to take any action if they are satisfied with their proposed 2016 plan and premium; they simply need to continue to pay their monthly premiums. The letter included with the renewal notice advises members to contact their insurance agent if they want to make an active 2016 plan selection. UPMC Health Plan is now offering complete functionality to assist Individual and Family clients with the re-enrollment process. When you visit Producer OnLine, you can view your list of existing clients and their current plan, see which plans they will be automatically re-enrolled into if they do not make an active 2016 plan selection, and review current and future year pricing. Additionally, the website allows you to manage both On and Off Exchange clients.

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2016 products and network offeringsIn 2016 UPMC Health Plan will continue to offer the same network offerings available in 2015: Partner, Select, and Premium Networks. The Partner Network will now be available to residents in Bedford and Blair counties in addition to those in Allegheny and Erie counties. Also, Grove City Medical Center in Mercer County is now part of the Select Network.

Next year UPMC Health Plan will offer the majority of the same plans that exist in 2015, making the transition to 2016 as

seamless as possible for your clients. Cost shares were altered on a few plans to keep them within the same metal level. Additionally, two 2015 plans with low membership were discontinued on all networks: the 2015 Bronze $5,500/$40 and the Gold $500/$15. Members in those plans will be defaulted into the remaining 2016 plans at the same metallic level.

More details on specific cost-share changes can be found in the producer webinars held in early October and available for you to view on Producer OnLine.

Producer trainingProducer webinars were held on October 6 and 8. Topics included 2016 product offerings for Individual and SHOP as well as a sneak peek at the re-enrollment platform producers will use to manage their book of business. If you weren’t able to join us, the presentation is available on Producer OnLine.

Next year UPMC Health Plan will offer the majority of the same plans that exist in 2015, making the transition to 2016 as seamless as possible for your clients.

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group market

Self Assure now available to small groupsUPMC Health Plan is proud to expand our Self Assure administrative services only (ASO) portfolio. Our new offering for groups with 25-199 employees combines an ASO contract with level funding and aggregate-only stop loss in order to support groups in the transition to a self-insured market. The product design allows for a fixed amount on a monthly basis. The monthly payment is based on the year’s expected claims. Included in that payment is the premium for stop loss insurance, and the ASO charge. When applicable, a portion of excess claims contributions each year will be refunded. The refund is based on the difference between funding versus actual claims incurred for the year.

Introducing UPMC MyCare AdvantageA new and affordable group health plan option with full in-network access to UPMC providers

UPMC MyCare Advantage is designed to offer employers affordability and full in-network access to UPMC as well as many outstanding community partners. And with a plan design that promotes patient-centered care, employers and their employees have the opportunity for improved health outcomes at lower costs.

UPMC MyCare Advantage is a tiered benefit plan offering two levels of in-network access. Members receive the highest level of benefits and lowest out-of-pocket costs when they receive care from Level 1 providers. Members also have the choice of extended access to Level 2 participating providers with increased cost sharing. PPO plans have out-of-network benefits, but at the highest cost sharing for members.

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UPMC MyCare Advantage Level 1 providers are leaders in practicing patient-centered care. They include all UPMC doctors, hospitals, and facilities as well as these community hospitals and associated providers: Butler Memorial Hospital, Excela Health, Grove City Medical Center, Heritage Valley Health System, Kane Community Hospital, Monongahela Valley Hospital, St. Clair Hospital, Washington Hospital, and Washington Health System Greene. Level 2 providers include all others participating in UPMC Health Plan’s Premium Network for PPO plans or Standard Network for HMO plans.

Patient-centered care works. National studies have found that patient-centered care practices close gaps in care, reduce medical costs, and improve patient outcomes. A two-year pilot program conducted by UPMC Health Plan resulted in lower medical and pharmacy costs,

increased preventive care compliance, and lower rates of emergency department visits and hospital readmissions. With in-network access to nationally recognized providers and facilities near home, members can enjoy patient-centered care at valuable cost savings.

UPMC MyCare Advantage is available beginning January 1, 2016, to companies with 51 or more employees located in Allegheny, Beaver, Bedford, Blair, Butler, Washington, and Westmoreland counties.

UPMC MyCare Advantage is a tiered benefit plan offering two levels of in-network access.

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HealthyU just got better!

HealthyU has always been about incentivizing employees to make healthy choices. That, in turn, can lead to lower health care costs for employers and decreased out-of-pocket expenses for employees.

Effective September 1, or at plan renewal, the new enhanced HealthyU takes this a step further. We’ve enhanced the program so that the list of incentivized healthy activities includes only those that are customized to the member’s unique needs.

These are the activities members can complete to earn reward dollars in their health incentive account. It also means members will receive a shorter, more doable, more focused, and more impactful list of recommended healthy activities to complete. The result: improved health and productivity for members and lower health care costs for your employer clients.

For more information or questions regarding HealthyU, contact your UPMC Health Plan representative.

“Employee Choice” on SHOPBeginning January 1, 2016, employee choice will be available in all states.

Employee choice provides employees the opportunity to select the most appropriate plan for their needs and the needs of their families. Employees choose any health plan at the actuarial value or metal level that has been selected by their employer. Employees will also be able to choose different plans offered under the same carrier.

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Ancillary Product Updates

UPMC FlexAdvantage

UPMC Health Plan will now oversee administration of our health savings accounts (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 and use BenefitWallet through UPMC Health Plan will transition to the new platform at their next renewal on or after October 1, 2015.

Employer benefits

• Convenient employer website for easy account administration.

• Availability as a single HSA solution for employers with multicarrier offerings.

• Designated account manager.

• HSA reporting capability and much more.

Member benefits

• Contributions, account interest, and qualified dollars spent are all tax free.

• Members can set aside pretax dollars for qualified health expenses.

• The HSA becomes another part of a member’s retirement nest egg that will be there for medical expenses later in life.

• The money in the HSA goes with the employee when he or she changes jobs or retires.

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UPMC Vision Care

UPMC Health Plan is known for offering high-quality benefit plans with 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 to all groups July 1, 2016. Vision Advantage will still be an option for groups until the end of 2017. Click here to access our producer training flier and here to download the Vision Care slide deck.

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Bundling Discount Program

UPMC Health Plan now offers a bundling discount on our dental and vision products. For new and renewal groups of 51+ that do not currently 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. For example, if a current medical client has dental and vision plans, Underwriting will assume a 1 percent discount to the medical premium when it calculates the medical renewal.

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For more information on this bundling discount, contact Producer Relations.

*Maximum discount will be 1.0 percent: 0.5 percent for dental and 0.5 percent for vision.

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Regulatory Updates

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The 2016 Notice of Benefits and Payment Parameters clarifies how The Centers for Medicare & Medicaid Services (CMS) expects OOP limits on cost sharing for individuals within family plans to be administered. This rule states that an individual's maximum cost exposure within a Family plan cannot exceed the self-only OOP limit (i.e., $6,850 in 2016). This rule is effective for January 1, 2016, and after.

Individual self-only coverage

$6,600 $6,850

2015 2016

Family other than self-only coverage

$13,200 $13,700

For 2016 the out-of-pocket (OOP) maximum amounts have changed for both Individual (self-only coverage) and Family (other than self-only coverage) plans.

Maximum out-of pocket updates for 2016

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“Grandfathered” plans

Individual or employer-sponsored plans and collectively bargained plans that existed before March 23, 2010, when the health care reform bill was signed, may be qualified as grandfathered plans. This means they are exempt from some provisions of the health 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:

• Group is covered in plan design before January 1, 2016.

• Plan design can’t bend after January 1, 2016.

• Group remains in same plan type (no change in legal entity).

• Elimination of all benefits to diagnose or treat a particular condition.

• Any increase in coinsurance.

• Increases in deductibles or copayment that exceed the cost-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.

“Grandmothered” plans

When major provisions of the ACA took effect in 2014, many plans needed to be changed or replaced to comply. CMS has allowed these existing plans, known as “grandmothered” or “transition policy” plans, to continue without making certain changes that were otherwise required. The last date on which a grandmothered policy can be renewed is October 1, 2016. Policies renewed on that date will provide coverage through September 30, 2017.

Grandmothered & grandfathered plans

Rules

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2015

QHDHP minimum deductibles

Individual: $1,300 Family: $2,600

Individual: $1,300 Family: $2,600

2016

QHDHP maximum out-of-pocket (OOP) amounts

Individual: $6,450 Family: $12,900

Individual: $6,550 Family: $13,100

HSA contribution limits (employer + employee)

Individual: $3,350 Family: $6,650

Individual: $3,350 Family: $6,750

HSA catch-up contributions (age 55 and older)

$1,000 $1,000

The IRS has announced a few important changes to qualified high-deductible health plans (QHDHP) for 2016. These changes impact out-of-pocket maximum amounts for Individual and Family enrollments and HSA contribution limits for Family plans.

QHDHP Updates for 2016

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• Vaginal contraceptive ring (Nuvaring)

• Sponge

• Cervical cap

• Female condom

• Spermicide

ACA Contraceptive Changes

UPMC Health Plan recently made enhancements to preventive coverage for contraceptives as required under the Affordable Care Act. These changes apply for plan years and renewals beginning on or after August 1, 2015.

Now covered at $0 are the following*:

ACA Contraceptive Changes

*When prescribed and obtained in accordance with preventive services guidelines and pharmacy benefits.

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TREATMENT ADVISER AND MEDICAL COST ESTIMATOR

Treatment adviser and medical cost estimator help members make well-informed, educated choices about their health care.

What is medical cost estimator?The medical cost estimator tool approximates the total procedure costs for medical treatments. The estimated amount is based on the member’s specific plan and considers the member’s most recent medical claims.

How exactly does it work?Clicking on a treatment option provides the cost for the procedure. It also displays alternative treatments for that condition and estimates those costs as well. For each option, members can see how their cost varies by the hospital or facility of their choice.

How are the estimates determined?The total cost of the procedure is based on two years’ worth of claims data for each facility. Out-of-pocket costs are customized to the user, based on plan details such as coinsurance and out-of-pocket maximum and how much of the deductible the member has met.

Click here for our producer training flier.

What is treatment adviser?The treatment adviser tool allows members to see all of the common treatment options for a medical condition. The treatment adviser is unique from other decision-making tools because it provides information on the experiences of other people, including medical professionals.

How exactly does it work?Type a condition or injury into the search bar, for example, “knee ligament injury.” The tool will provide a list of every common treatment available, from simply exercising and stretching at home to undergoing surgery. Each option reports both its clinical and patient-reported effectiveness. Clicking on a specific treatment explains the treatment further and notes how popular it is among people with the condition.

Where do the patient ratings come from?Wiser Health collects survey data from people across the country. It has more than four million data points about the treatment experiences of both patients and medical professionals.

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eDermatology is a secure online e-visit experience, allowing consumers to upload photos of an affected area and receive a diagnosis and treatment plan from a UPMC board-certified dermatologist 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 Health

Plan 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 that

parent or guardian must have a pediatric proxy in place.

Consumers can access eDermatology at https://edermatology.upmc.com/This service is available 24/7, 365 days a year.

Fact

For help with skin conditions, e-visits with a UPMC board-certified dermatologist are now available.

eDERMATOLOGY

UPMC Health Plan members get discounts on products and services like gym memberships and spas. Search for deals at MyHealth OnLine.

According 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 — UPMC Health Plan and UPMC Health Coverage — are among the highest-rated commercial plans in the nation.

In fact, UPMC Health Coverage is one of only 11 plans in the nation to 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 the top-rated commercial HMO in Pennsylvania and the only commercial HMO in Pennsylvania to achieve this score.

NCQA RATING

BY THE NUMBERS

125 network hospitals

11,500 network physicians

30,000 participating pharmacies

176 urgent and convenience care clinics

HEA

LTH

IN

SURANCE PLAN

RATIN

GS

PRIVATE PLAN

2015 -16