Editor’s Note: This post was updated November 14, 2015 to reflect an update of the Continuation of Care provision under the Consent Decree.
If you live in western Pennsylvania, you’re probably familiar with the uncertainty over access to UPMC providers and facilities for Highmark health plan members.
Most of our contracts with UPMC expired on Dec. 31, 2014. As a result, depending on your plan, what is considered in-network for you may have changed. You may have different providers to choose from. And choosing to stay in network or to go out of network may also have a significant impact on what you pay out of pocket when you receive care.
We hope this information helps you prepare for your health care in the year ahead. We’re always here to assist if you have questions.
In June 2014, then-Pennsylvania Governor Tom Corbett and Attorney General Kathleen Kane facilitated agreements with Highmark and with UPMC in the form of “consent decrees.” They include several protections for you. See which scenarios apply to you:
Are you receiving cancer care? All Highmark members will continue to have access to all UPMC oncologists and facilities for cancer treatment and follow-up care, including the Hillman Cancer Center. These visits will be considered in-network for all members. All deductibles, coinsurance and copays will be determined according to the terms of your selected health insurance plan.
Are you seeing a UPMC provider now? If you were in the middle of a course of treatment for a chronic or persistent condition with a UPMC provider in 2013, 2014, or 2015, you may continue to see that provider on an in-network basis for that condition. Again, all deductibles, coinsurance and copays will be determined according to the terms of your selected health insurance plan.
Did you see a UPMC provider in 2015 under the “safety net” provision? The safety net provision helped members who received care from a UPMC provider at least once in 2014 and couldn’t find another in-network doctor in their area to replace that provider. These members were able to continue to see their UPMC provider — for example, for routine care like a physical or flu shot — on an in-network basis through 2015.
In this way, the safety net gave Highmark members time to find an in-network provider. It expired Dec. 31, 2015. If you choose to stay with a UPMC provider for routine care after 2015, any care you receive from that provider will be considered out-of-network.
Are you covered by Medicare, Medicaid or CHIP? If you’re covered by or eligible for Medicare, or have CHIP or Medicaid, you will have access to all UPMC providers at an in-network benefit level. But Medicare Advantage members with Community Blue Medicare HMO* will not have this in-network access.
Are you concerned about emergency care? All Highmark members, including members of Community Blue Medicare HMO,* can go to any UPMC emergency room and it will be considered in-network. If you need to be admitted to a UPMC hospital for that emergency condition, that inpatient care will also be in-network.
Are you pregnant and planning to deliver in 2016? If you had a confirmed pregnancy in 2015 and saw a UPMC provider, you can continue seeing that doctor and have the option to deliver at Magee-Womens Hospital of UPMC in 2016. Your care will be considered in-network.
Are you worried about access to Children’s Hospital of Pittsburgh of UPMC? You can continue to use Children’s Hospital and its providers. Our network contract with Children’s extends through 2022.
What do you need to know about balance billing? Balance billing occurs when physicians or other providers bill you for the difference between the amount they charge and the amount that your insurance pays.
We know you might want to see a UPMC provider even if you don’t qualify for in-network benefits under the Consent Decree. If you decide to see a UPMC provider on an out-of-network basis, it’s important to realize you will be responsible for a greater portion of the costs.
Under the Consent Decree, UPMC can only balance-bill you for up to 60 percent of its charges for out-of-network care. For certain kinds of out-of-network care, such as extended hospitalization, these charges — and your out-of-pocket costs — could add up. Make sure you know a provider’s network status in your plan when you make health care decisions.
Are you a Community Blue member? As of Jan. 1, 2015, UPMC can no longer deny medical services to our members with Community Blue plans. If you’re a member of any Community Blue plan (except Community Blue Medicare HMO*), you can access all UPMC facilities and providers, although most will be out-of-network and higher cost sharing may apply. However, UPMC can only charge a maximum of 60 percent of the cost of that out-of-network care (see balance billing section).
Are you a Community Blue Flex member? Community Blue Flex includes two in-network levels, Standard Value and Enhanced Value Level of Benefits, which have different levels of cost sharing.
At the Standard Value Level of Benefits, Community Blue Flex members are covered by all of the Consent Decree protections outlined above plus in-network access to UPMC Hamot and UPMC Horizon.
At the Enhanced Value Level of Benefits, Community Blue Flex members have access to more than 50 hospitals, including Allegheny Health Network, community hospitals throughout the region and the following UPMC facilities: UPMC Altoona, UPMC Bedford, Children’s Hospital of Pittsburgh of UPMC, Kane Community Hospital, UPMC Northwest, and Western Psychiatric Institute and Clinic of UPMC. Emergency care — at UPMC hospitals or any out-of-network hospitals — is also covered at the Enhanced Value Level of Benefits.
Are you a Community Blue Medicare HMO* member? Please note that members of our Community Blue Medicare HMO* do not have in-network access to UPMC facilities. UPMC was offered the opportunity to participate in the network, but chose not to do so. The statements above, unless otherwise noted, do not apply to Community Blue Medicare HMO* members.
We’re ready to help if you have questions about the Consent Decree, want to know if your doctor is in-network, or need help finding a new in-network doctor.
*Community Blue Medicare HMO is a limited network plan. If you want access to Highmark’s full provider network, including UPMC hospitals and physicians, you may wish to consider our Security Blue HMO and Freedom Blue PPO Medicare Advantage products.
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