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UPMC, Highmark Reach Deal On Highmark Access To UPMC Facilities In 2015

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(Photo Credit: KDKA)

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Jon Delano Jon Delano
Jon Delano is a familiar face on KDKA-TV, having been the station's...
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CBS Pittsburgh (con't)

Affordable Care Act Updates: CBSPittsburgh.com/ACA

Health News & Information: CBSPittsburgh.com/Health

PITTSBURGH (KDKA) — UPMC and Highmark have agreed to a transition plan, sources tell KDKA-TV money editor Jon Delano.

That plan was required when UPMC announced that, effective Jan. 1, many of its facilities would no longer be available to Highmark customers at lower in-network rates.

The region’s medical giant says now that Highmark has its own health system, Highmark customers should go to Allegheny General, West Penn Hospital, and other Allegheny Health Network facilities.

Under the deal — negotiated by Gov. Tom Corbett, Attorney General Kathleen Kane, the insurance commissioner, and the state’s health secretary – UPMC facilities still open at higher “out-of-network” prices but no longer “in-network” include UPMC Presbyterian, Shadyside, Magee Women’s, Mercy, Passavant, McKeesport, East and St. Margaret.

Still in-network and available to all are UPMC Altoona, Bedford, Hamot in Erie, Horizon in Sharon and Northwest in Venango.

Not part of the deal and always open to all are Children’s Hospital and Western Psychiatric Hospital.

If you are currently insured by Highmark, it’s not cold turkey on Jan 1. The transition plan does provide some access to UPMC facilities under certain conditions.

Those now under the care of UPMC for a serious illness or pregnancy can continue that treatment at UPMC as long as Highmark agrees, and more special arrangements are expected to be announced.

Health benefits consultant Jim McTiernan says customers can switch to other insurance companies like Aetna, Cigna and United.

“Aetna, Cigna and United would be the Highmark of old with access to both UPMC and Allegheny West Penn,” says McTiernan.

Those covered by Medicare and Medicaid also have access to all health facilities.

Even though both Highmark and UPMC have signed off on this deal, there are plenty of Highmark customers who are not happy with it.

“Unfortunately, still not putting patients first, and it’s not giving us access to the hospitals that we helped to build and create here,” says Casey Swartz of Swissvale.

Swartz dashed this letter off to Gov. Corbett: “There’s only one plan that put’s patients first — affordable in network access to all hospitals for every resident regardless of the color of our insurance card.”

Under the agreed plan, Highmark customers can continue their current UPMC treatment in 2015 for serious illness or pregnancy, as long as Highmark signs off.

Will Highmark sign off?

“I think they definitely will in the short run in a transition period when it would not be appropriate to interrupt care with certain providers,” says McTiernan. “Long run, I don’t think they will be signing off on that.”

Even if Highmark agrees, customers worry what qualifies as serious.

“Is a broken leg going to be considered serious?” asks Ruth Anne Ford of Butler. “A major fracture? You can go into detail. They’ll have to come up with a whole list of things and even still, it’s not good enough. It has to be in network, all of it, no matter what your condition is, in network.”

One part of the deal everyone will like — a pledge by both not to engage in any unclear or misleading advertising.

RELATED LINKS:
More UPMC News
More Highmark News
More Reports by Jon Delano

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