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Health Care Reform for Employers

To remain in compliance with the Affordable Care Act (ACA), UPMC Health Plan has incorporated the following factors into our plan offerings for employer groups within our small market portfolio.

Actuarial value

The ACA requires that all new small market products meet specific actuarial values, which are the percentage of medical expenses, on average, paid by the insurer. The ACA uses metal levels of Platinum, Gold, Silver, and Bronze to correspond with actuarial values of 90, 80, 70, and 60 percent, respectively. Issuers must offer plans within -4/+2 for all metal types except Bronze. Certain Bronze plans allow -4/+5.

Community rating

Under community rating, premiums may vary based only upon the following four factors:

  1. Geographic area. There are nine rating regions in the state. A list of these regions by county is available from the Centers for Medicare and Medicaid Services.
  2. Single vs. family coverage. Premiums for family coverage will be based on premiums for each individual in a family. Under this approach, we will add the individual rate for each family member to arrive at a family premium. All family members age 21 and older will be added. However, only the three oldest covered children under age 21 will be counted.
  3. Tobacco use. Premiums charged for tobacco users may be up to 1.5 times higher than premiums charged for non-tobacco users.
  4. Age. Premiums based on age will work like this: Adults (ages 21–63) may have different premiums based on age, but the difference may not be more than 3 to 1. That is, the premium charged to the oldest adult may not be more than three times higher than the premium charged to the youngest adult (age 21 or older).

For children ages 0 to 14 and 15 to 20 years, the age-adjusted premiums must be the same for all individuals. For adults 21-63 and 64 years of age or older, age-adjusted premiums must be the same for all individuals. The premium charged at renewal or point of sale remains as sold until the next renewal date, when rates will be adjusted based on age bracket changes.

Essential health benefits (EHBs)

EHBs are a specific set of health benefits, items, and services that must be covered by health plans in the individual and small group markets. These benefits include, among other things, pediatric dental and vision services. Our pediatric dental and vision services are offered through UPMC Dental Advantage and UPMC Vision Care. UPMC Health Plan has embedded these benefits into its medical plans, which makes it easy for employers to administer and comply with ACA mandates. Please refer to the Schedules of Benefits, which defines the coverage for eligible dependents. Please note that if a dependent turns 19 during a plan year, that dependent will continue to have essential health benefits coverage until the end of the plan year.