UPMC Agreement

On Friday, June 27, 2014, Governor Corbett announced an arrangement between Highmark and UPMC that addresses the continued concern about Highmark members having access to UPMC doctors and facilities.  Additionally, the following Q&A’s were developed by Highmark to address concerns:

Will there be a Highmark/UPMC contract?

Highmark and UPMC do not have a contract or contract extension. Formally, the arrangement consists of two consent decrees that provide a road map for how Highmark health plan members can access health care across Western Pennsylvania, including UPMC, Allegheny Health Network and a comprehensive network of community hospitals. This new arrangement sets out a series of guidelines and delivers continuity of care and stability to the region’s health care marketplace.  The most current information regarding the Consent Degree is available at discoverhighmark.com/consentCP. 

If this is not a contract, what does the new arrangement provide to Highmark members/customers?

ER Access: Highmark members who seek care at any UPMC emergency room will be covered at in-network rates. This care includes not only the emergency room visit, but also any inpatient admissions and continuity of care. 

Cancer Coverage: Highmark members have in-network access to all UPMC services, facilities, doctors and joint ventures for oncology care and for any illnesses/complications resulting from the cancer diagnosis, including, but not limited to, endocrinology, orthopedics and cardiology.  This provision in effect until 6/27/2019. 

Continuation of Care: Members who are in the midst of a course of treatment for a chronic/persistent condition in 2014 or 2015 with a UPMC provider will continue to have access to that provider in 2016.  This provision in effect until 6/30/2019. (Subject to change pending final outcome on the scope of "continuation of care")

Seniors: All seniors – in any existing Highmark plan – have access to UPMC providers on an in-network basis. This includes Medicare Advantage plans, Medigap Blue, Signature 65 and other group “carve out” plans.

Safety Net: Any existing UPMC patient who is a Highmark member and who received care from a UPMC provider in 2014, can continue to receive care from that same provider, at the same benefit level for one year if those members are unable to find an alternative physician in their area.  This provision is for the 2015 benefit year only. 

Physicians:

  • In-network access to all UPMC-owned physicians located outside the five county Greater Pittsburgh area (Allegheny, Beaver, Butler, Washington, Westmoreland)
  • In-network access to all UPMC-owned physicians when they are practicing at any of the UPMC hospitals that continue to be in-network or at community hospitals
  • All UPMC-owned oncology providers
  • All UPMC pediatricians at in-network facilities
  • All UPMC behavioral health providers at in-network facilities

What happens if I receive care from a UPMC provider who is not in the network in 2015?

If you do not qualify for in-network benefit level access to UPMC providers because of the oncology, continuation of care or safety net provisions and you choose to receive care from an out-of-network UPMC provider, you will be responsible for the out-of-network cost-sharing according to your benefit design. UPMC can only “balance bill” Highmark members the difference between Highmark’s payment amount and 60 percent of their actual charge.  This provision in effect till 6/30/19.

What support will Highmark provide to help find a new physician?

Highmark will partner with our group customers to determine the best way to support efforts to transition members who need to find new physicians. For example, if the employer requests, Highmark will send letters to members who have recently used UPMC physicians, identifying these physicians and providing suggestions for alternative physicians that members may want to consider.

Who decides if Highmark members should receive cancer care from UPMC or another provider?

Cancer patients will work with their doctors to determine the best provider to treat them. Highmark wants to ensure that patients have a choice so that they get the best care for their specific condition.

What happens in case of an emergency?

If you receive care at any UPMC emergency room, it will be covered at the in-network level of benefits. This includes not only the emergency room visit but also any inpatient admissions and continued care for the emergency condition for which you were treated.

If I'm admitted to a UPMC hospital for an emergency, will Highmark have me transferred to another hospital?

As is the practice now, patients and their doctors will determine if and when a transfer to another facility may be appropriate.

Which hospital facilities are included in this new arrangement?

These UPMC hospitals will continue to be in-network:

Continued In-Network UPMC Locations
UPMC Facility Contract Expires
Children's Hospital of Pittsburgh UPMC 6/30/2022
UPMC Altoona 6/30/2019
UMPC Bedford 6/30/2019
UPMC Hamot and its affiliate Kane Community Hospital 6/30/2019
UPMC Horizon 6/30/2019
UPMC Northwest 6/30/2019
Western Psychiatric Institute and Clinic 6/30/2019
Hillman Cancer Center 6/30/2019
UPMC Mercy 6/30/2016

The following UPMC hospitals will be out-of-network effective January 1, 2015:

  • Magee Women’s Hospital of UPMC - Members who have been treated by a UPMC physician for pregnancy in 2015 are eligible to deliver at Magee in 2016 (subject to change pending final outcome of arbitration on the scope of "continuation of care")
  • UPMC East
  • UPMC McKeesport
  • UPMC St. Margaret
  • UPMC Passavant
  • UPMC Presbyterian-Shadyside

Will Highmark members be able to keep their doctor?

For the vast majority, the answer is yes, and in the instances where they won’t, Highmark will help facilitate the transition to high-quality, in-network doctors and hospitals.

In addition, if members would like to know about other physicians who will be in the Highmark network in 2015, they can visit the website, mycarenavigator.com.   There you will find an updated online directory to help locate doctors who are right for your needs.  You may also call My Care Navigator at 1-888-258-3428 (1-888-BLUE-428)

Without a contract, does Allegheny Health Network (AHN) have the needed capacity for Highmark members?

Yes. Between Allegheny Health Network and Highmark’s affiliated independent community hospitals and physicians, Highmark is more than able to accommodate health plan members who may need to be transitioned away from UPMC.

Additional Resources