A new wrinkle Consumers prepare for Highmark’s post-UPMC transition
Ed Bush compares different types of Medicare insurance plans online, along with printed materials, to decide which plan to choose. Bush and many other retirees will have to choose a provider by Dec. 7.
When Ed Bush of Clarksville looks for new Medicare coverage, he takes into consideration everything from deductibles to rating of service and if hearing, dental and vision coverage are included.
Ed Bush looks through material on new health care plans that he’ll have to choose from for Medicare. Bush has to choose a plan by Dec. 7. On Dec. 31, most of the hospital contracts between Highmark and UPMC are terminating.
CLARKSVILLE – When Ed Bush considers his purchase of Medicare insurance each year, he does his homework.
On Thursday morning, Bush, 67, of Clarksville, was surrounded by the literature of competing health insurance companies’ Medicare Advantage products while he used his computer to further research the various coverages on www.medicare.gov, which gives him the ability to compare and contrast the three plans he’ll choose from.
Bush, who has a heart condition that requires prescription medicine, looks carefully at how each plan covers the drugs. He also researches separate plans for his wife, Carol, 66, who, like him, has a heart condition, as well as Type 2 diabetes.
“He’s a researcher, for sure,” said Carol, who said she wishes the couple could select plans they could keep indefinitely, instead of going through the process each year.
But as Ed explained, the plans change significantly from year to year, noting if he decides to continue with his current plan, UPMC For Life HMO Medicare with Rx, he’ll see his monthly premium reduced to $18, down from the current rate of $37.50.
But that’s only the beginning of his research, he noted, adding he has to review everything from out-of-pocket expenses to coverage of drugs to the amount he or Carol would pay if they’re hospitalized or need skilled nursing care. He also noted that unlike past years, more Medicare Advantage plans are offering dental, vision and even hearing coverages.
This year, many retirees like Bush, as well as thousands of workers in the region who are currently in open enrollment periods with their employers, will have another aspect to consider when choosing health care coverage, as Highmark Inc. will transition to operating without a contract with UPMC hospitals in many cases.
Bush, who must make a decision on a plan by Dec. 7, was also reviewing plans from United Health Care, as well as Highmark’s new Community Blue Medicare HMO introduced last month, which is offered for no premium or deductible, but requires subscribers to use its own Allegheny Health Network and excludes UPMC facilities.
Following a legal challenge by the state’s attorney general’s office and the state Insurance Department, a commonwealth judge ruled Thursday Highmark was not in contempt when it rolled out its Community Blue Medicare HMO plan that excludes UPMC hospitals.
On Dec. 31, most of the hospital contracts between Highmark and University of Pittsburgh Medical Center are terminating, with Highmark embarking on a transition plan of it own that was approved by the state Insurance Department earlier this year.
As part of the transition, Highmark customers will, in certain instances, be able to continue using physicians and some hospitals from its rival UPMC when Highmark’s provider agreement with UPMC ends Dec. 31. The transition plan outlines the process for safeguarding consumers’ health care, minimizing patient disruption and maintaining affordable access to high-quality health care for Highmark members, and centers on the insurer’s provider network, member access to care, continuity of care and communications to customers.
One major feature of the plan is that all Highmark members will continue to have in-network access to all 22 UPMC hospitals for emergency care. If a Highmark member needs inpatient admission following emergency or trauma treatment at a UPMC facility, the patient will be admitted and all services during that admission will be treated as in-network up through the patient’s discharge.
The plan, which incorporates several of the provisions of the consent degrees agreed upon by UPMC and Highmark in late June with the assistance of Gov. Tom Corbett and Attorney General Kathleen Kane, is accessible through the Insurance Department’s website, insurance.pa.gov.
The good news for retirees like Bush is that under the consent decrees, Highmark and UPMC agreed UPMC would continue to contract with Highmark at in-network rates for seniors, who are considered part of the “vulnerable populations” in the coverage networks.
Seniors enrolled in the current network Medicare Advantage products will continue to have in-network access to UPMC facilities and physicians after Dec. 31, with the current broad-network contracts with UPMC extended until Dec. 31, 2015. About 206,000 area seniors are covered under Highmark’s two broad-network Medicare Advantage products, Freedom Blue and Security Blue. The exception is Highmark’s Community Blue Medicare HMO, which was cleared by Commonwealth Court Judge Dan Pellegrini Thursday.
Highmark spokesman Aaron Billger said Thursday the new product “really creates a level playing field” in enabling Highmark Medicare Advantage customers to have a choice among three plans with different levels of benefits and costs.
With the exception of seniors using Medicare products and those using CHIP or Medicaid coverage, subscribers to other Highmark products - the so-called commercially insured who buy health insurance from employers or on their own – will lose in-network access to UPMC doctors and hospitals after Dec. 31, meaning they will pay higher rates.
For the most part, most UPMC hospitals in the Pittsburgh region – Allegheny, Beaver, Butler, Washington, Greene and Westmoreland counties – will continue to be considered out-of-network for Highmark’s commercial members, though some exceptions include UPMC Mercy and Children’s Hospital of Pittsburgh of UPMC, which have separate contracts.
Hospitals outside the area, including UPMC-Bedford, UPMC-Hamot in Erie and UPMC of Altoona Hospital, will continue to be in-network, as will Western Psychiatric Institute and Clinic in Pittsburgh, because no similar non-UPMC alternative exists.
Under Highmark’s UPMC Contract Transition Plan, Highmark subscribers will continue to have full access to Highmark’s Allegheny Health Network, which includes its flagship Allegheny General Hospital in Pittsburgh, as well as seven satellite community-based hospitals, including Canonsburg Hospital. In 29 Western Pennsylvania counties, Highmark’s additional network includes 53 acute-care community hospitals (including Washington Health System and its Washington Hospital, Monongahela Valley Hospital and Southwest Regional Medical Center; 55 ambulatory surgery centers, including Advanced Surgical Hospital in Washington; and 249 skilled nursing facilities, along with 9,000 community hospital-affiliated and independent physicians.
In recent full-page ads in the Observer-Reporter, Washington Health System reminded its patients that regardless of which insurance they hold – UPMC or Highmark – “there is no need for concern.” It also accepts a number of other plans, including those offered by Aetna, Cigna, Coventry and United Health Care.
Earlier this year, Mon Valley Hospital and Southwest Regional Medical Center in Waynesburg said that they also would accept all health-care plans.
St. Clair Hospital said in an ad last week that it accepts all Medicare Advantage plans from all major insurers as in-network, with the exception of Highmark’s Community Blue Medicare HMO, which it will treat as out-of-network.
While Bush said he has used his current UPMC coverage to receive care at Southwest Regional and other area community hospitals, as well as AGH, he said he has yet to use any of the UPMC hospitals.
And while Highmark’s transition plan for seniors means he could use UPMC facilities for treatment if he chooses two of the three Highmark Medicare Advantage coverages, Bush said he believes coverage for anybody with any type of health-care insurance should be an across-the-board deal.
“Everybody should have equal opportunity and equal costs,” he said.
The complete details of Highmark’s transition plan are available through the Pennsylvania Insurance Department’s website, insurance.pa.gov, by clicking on the Blues plan icon, or at Stayinformed.pa.gov. Highmark also has launched a website – YourNetwork2015.com – where members can see which doctors and hospitals are expected to be in Highmark’s network for 2015.