For Individuals

1. I currently have coverage from UPMC Health Plan. Do I need to do anything because of health care reform?
   
   No. Although health care reform will bring some changes for everyone, your existing coverage with UPMC Health Plan will not be interrupted. As required by the law, we will notify our members of the changes we are making, and the materials you receive at your next annual renewal will reflect any new coverage provisions.
   
   
2. When does health care reform go into effect?
   
   The Affordable Care Act (ACA) was signed into law on March 23, 2010. It was modified by the Health Care and Education Reconciliation Act (HCERA). However, the ACA is regarded as the source of health care reform and, as such, March 23, 2010, is considered to be the effective date.
   
   The ACA prescribes a wide variety of changes across many areas of health care and health insurance. Some provisions go into effect immediately, while others are scheduled for 2014 and beyond. UPMC Health Plan is diligently monitoring the new regulations and official guidance as we implement the many important changes that health reform requires.
   
   
3. Does health care reform mean that everyone has to buy health insurance?
   
   The answer is yes, but not immediately. The law’s requirement for everyone to buy insurance (known as the “individual mandate”) goes into effect in 2014. At that time, the government will start collecting penalties from anyone who remains uninsured. There are some limited exemptions that apply to people for whom insurance coverage is unaffordable. Details from the federal government on this provision are pending.
   
   
4. What about people with pre-existing conditions? Will everyone be eligible for coverage?
   
   In 2014, the new law provides that everyone will be eligible for coverage. In addition, health insurers cannot vary premiums based on someone’s pre-existing condition. For plan renewals after September 23, 2010, pre-existing condition exclusions are prohibited for children under the age of 19. Until 2014, individuals who have been uninsured for six months and are unable to obtain private coverage because of their pre-existing condition(s) will be able to enroll in Pennsylvania’s high-risk pool. For more information, visit the PA Fair Care website.
   
   
5. My employer does not offer coverage. Will it have to offer coverage?
   
   Although there is no “employer mandate” requiring all employers to offer coverage, employers with 50 or more employees could face fines beginning in 2014 if they do not offer a minimum level of coverage.
   
   
6. What are the new rules for covering my children and dependents?
   
   For plan renewals after September 23, 2010, if your health plan extends coverage to your dependents, they are eligible for coverage under your plan until age 26. If you have grandfathered coverage, your dependents may only be eligible for coverage under your plan if they do not have the opportunity to enroll in coverage from an employer of their own. Some employers in Pennsylvania have also exercised a special ”state option” that permits continued coverage until age 30, but this eligibility requires dependents to be unmarried and have no dependents of their own (beginning at age 26). For more details on dependent coverage, see our Reform Highlights section. You may also want to check with your employer to find out if dependent coverage after age 26 is available.
   
   
7. My son/daughter is currently covered as a dependent under my health plan. Does my coverage now extend to their children (my grandchildren)?
   
   No. The extension of dependent coverage only applies to your direct dependents.
   
   
8. My son/daughter just stopped being a full-time college student. Do I have to remove them from my coverage?
   
   No. Your dependents no longer have to be full-time students in order to continue coverage until age 26. For administrative purposes, your health plan may still ask whether your dependent is a full-time student, but your answer will not impact that dependent’s eligibility under the ACA to be covered by your plan.
   
   
9. I’ve heard that birth control and other women’s preventive services are available for free.
   Is this true?
   
   For plan years beginning on or after August 1, 2012, certain Women’s Preventive Services, including birth control, will be added to the list of preventive services available to qualified commercial plan members as $0 cost-sharing preventive services. Click here for a list of the preventive services that may be available to you. Certain limits and restrictions may apply to these and other preventive services. For specific details about the coverage of preventive services under your plan, please contact us.
   
   
10. What is a Health Insurance Exchange?
    
    Health Insurance Exchanges, which will be launched in 2014, will be a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans, including plans from UPMC Health Plan. For more information, see the Health Insurance Exchanges section of our website.
    
    
11. Will everyone have to buy their coverage from Healthcare.gov or a health insurance Exchange?
    
    No. Healthcare.gov is only a tool to help consumers identify their options. For most consumers, it is expected that participation in a health insurance Exchange will still be voluntary.
    
    
12. What is a grandfathered plan?
    
    A grandfathered plan is the ACA's term for certain health insurance coverage that was in effect prior to March 23, 2010. Plans that are given grandfathered status are exempt from making certain changes that would otherwise be required and can only make very limited changes to their plan’s design or members’ cost-sharing. Keep in mind that not every plan that was in effect before March 23, 2010, is a grandfathered plan.
    
    
13. How do I know if I am enrolled in a grandfathered health plan?
    
    If you are enrolled in a grandfathered plan, you will receive a notice with your enrollment materials for renewals.


14. Why is the cost of my employer-sponsored coverage being added to my annual W-2 form?
    
    This reporting requirement is designed to help consumers better understand the total cost of their employer-sponsored group health insurance coverage. Beginning with the 2012 calendar year (W-2 forms issued in January 2013), most employers will be required to report the cost of employer-sponsored coverage on employees' W-2 forms. This reporting requirement does not change the non-taxable status of your employer-sponsored coverage. Please click here for more information on this new requirement and answers to some common questions.
    
    
15. What new information is available to members who receive notice of an adverse benefit determination or file an appeal?
    
    Members who receive an adverse benefit determination may ask their health plan to provide them with corresponding diagnosis and treatment codes (and their meanings). In addition, a health plan must provide a member who is appealing his or her adverse benefit determination with any new or additional evidence considered, relied upon, or generated in connection with the plan's benefit determination so that the member has an opportunity to respond to that evidence.


16. Can I request benefit determination notices in a language other than English?
    
    Members of both group and individual health plans may be entitled to receive notice of adverse benefit determinations in non-English languages. Members to whom this applies will be so notified when they receive an adverse benefit determination.


17. Does Pennsylvania have an external review process?
    
    Pennsylvania has historically provided fully insured members with access to its external review process. More recently, it even extended its review process to self-funded group members. However, in August 2011, the Department of Health and Human Services made a preliminary determination that Pennsylvania's external review did not meet all of the new federal standards. As such, unless Pennsylvania challenges this determination or amends its existing external review process, insurers and health plans in Pennsylvania will have to follow a new federal or private Independent Review Organization process.
    
    
18. I’m a college student enrolled in my school’s Student Health Plan. How does health care reform apply to my plan?
    
    The ACA requires Student Health Plans to follow many of the same guidelines that apply to other coverage in the group and individual market. However, certain changes do not apply to Student Health Plans or will apply at a later date. Your school and/or your health plan are the best source of information on the benefits available to you. If you have questions about your student health plan coverage with UPMC Health Plan, please contact us.

For Medicare Members

1. What health care reform changes are coming to Medicare Advantage plans?
   
   Health care reform will result in reduced funding for the Medicare Advantage program. Over time, this may result in adjustments to premiums or benefits for program members. There are also changes designed to simplify the annual Open Enrollment Period.
   
   
2. What is the Part D Donut Hole Rebate? Who is eligible to receive it?
   
   A one-time, non-taxable rebate of $250 is available for Medicare Part D beneficiaries who reach the donut hole in 2010 (incurring costs above the initial drug coverage limit of $2,830 but below the maximum out-of-pocket costs of $4,550) and are not already receiving Medicare Extra Help. Rebate checks are issued automatically, and individuals do not need to submit a rebate application or form. The rebate is only available for 2010. Note: Donut hole dollar limits change yearly. The numbers provided are for 2010.
   
   Beginning in January 2011, Part D enrollees who do not already receive Medicare Extra Help will receive a 50% discount on brand name and biologic drugs once they reach the donut hole.
   
   
3. What is the CLASS Act?
   
   The Community Living Assistance Services and Supports Act (CLASS Act) is a voluntary insurance program designed to help pay the costs of long-term care for the elderly and disabled. The program provides cash to eligible enrollees who have functional limitations and equivalent cognitive impairments that limit their everyday activities, such as bathing, dressing, and eating. Cash benefits of at least $50 a day (dependent on the person’s level of disability) are provided once participants have contributed for five years, either through payroll deduction or directly if self-employed. As of October 2011, the Department of Health and Human Services has delayed this program indefinitely.
   
   
4. I’ve heard preventive services are now free. Does this apply to Medicare recipients or Medicare Advantage members?
   
   UPMC for Life Medicare Advantage members currently do not have any cost-sharing amount for a variety of preventive services when obtained from our network providers. Beginning in January 2011, traditional Medicare recipients will no longer be responsible for preventive screening copayments.

Read more information about Health Care Reform.