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Question: I have heard there was a recent court ruling regarding the UPMC/Highmark dispute. Will Highmark Medicare Advantage members still have in-network access to UPMC hospitals in Pittsburgh and Erie after June 30?

Answer: There indeed was a ruling concerning the ongoing battle and it’s extremely important that people understand the implications or lack thereof. The PA Attorney General had petitioned the Court to extend the consent decree past June 30th, which would allow those on Highmark Medicare HMO and PPO’s to continue to have in-network access to UPMC.

Although the ruling allows for the AG to quickly appeal his decision to the State Supreme Court, Commonwealth Judge Robert Simpson clearly stated that the Consent Decree between UPMC and Highmark ends June 30th, 2019. And with it, so does affordable access to UPMC doctors and hospitals for as many as 150,000 Highmark Advantage Plan members.

The basis for Simpson’s ruling was that the Commonwealth Court itself did not have the power to extend the date of the Consent Decrees because the PA Supreme Court previously ruled last year that the June 30, 2019 termination date did not have to be extended.

My understanding is the other three counts are, in essence, an attempt to force UPMC to enter into a new contract with Highmark outside of the Consent Decree. Simpson concluded that because those could be fought in court for years without resolution, he decided not to rule on them at this time, choosing to focus on the one count that had a chance to be heard by the Supreme Court before June 30th. 

However, there is the possibility that the Supreme Court may not agree to hear the appeal at all. If they do, there’s only 76 days until July 1st. Even if the they force both UPMC and the AG to move lightning fast, which is very uncommon, there simply may not be enough time logistically for both sides to make necessary preparations and the Court to hear the case as well as make a ruling.

As I mentioned, the number of people who will not have access to UPMC come July 1st if the Supreme Court doesn’t rule in the AG’s favor could be close to 150,000! Not only is that a huge number of people who are going to essentially be cut off from receiving care at our area’s biggest hospital system, UPMC, it means only approximately 20,000 people switched from Highmark Advantage Plans to another HMO, PPO, or Supplement during the past Open Enrollment Periods. I’m extremely surprised that figure was so low. I thought it would be closer to 50,000 or more.

I believe there a few possible factors so few people made a change.

 1) Many believed there would be government intervention and UPMC would be forced to give network access to those on Highmark Advantage Plans. And there has been with the Attorney General getting involved in the last couple of months. But it appears it may be a bit too late. I’m not sure why this was put off until the last minute. The resolution regarding the Consent Decree and the date mutually agreed upon by both UPMC and Highmark when access for Highmark Advantage Plan members would end took place in 2014!

2) People have been told by Highmark they would still have access to UPMC and pay the same or very similar co-pays as they would at an in-network provider after June 30th. As I have written before, this is very concerning, and in my opinion not close to as simple as it was made to sound. That’s because the reality is, starting July 1st, anyone who has a Highmark Advantage Plan HMO or PPO will have to pay the full cost for services at a UPMC provider up front resulting in being forced to pay hundreds, even thousands of dollars prior to medical services being rendered at a UPMC doctor or facility. The patient will then have to file their own claim to Highmark for reimbursement as UPMC has stated they will not be directly billing Highmark after June 30th.

3) Many seniors, and I’ve met a ton, have had some form of Blue Cross Blue Sheild for 40 years or more and are extremely fearful of changing companies, even as their premiums increased 400 to 500 percent and potential out of pocket costs doubled over an 8 to 10-year period. I’ve written this on several occasions. If there was one silver lining that came out of this, it was that people who had never done so were motivated to finally shop around, compare plans side by side and find options that offer better value in terms of a combination of lower premiums, lower co-pays, and less exposure to annual out of pocket medical bills.

4) Myself and my agents have spoken to many seniors who are not happy with UPMC. Many mistakenly think in order to go to UPMC doctors and hospitals one must have a UPMC Medicare plan, and out of anger refused to go on one of their plans. You don’t have to have their insurance to get network access to UPMC providers. There are other Advantage Plan and Supplement companies that provide access to all Western Pennsylvania hospitals, including UPMC and AHN.

5) Some obviously don’t feel the need to have network access to UPMC facilities or doctors and/or are willing to change physicians.

For questions regarding this week’s column or any others relating to Medicare, feel free to call one of our offices and speak to a licensed agent. You are also welcomed to call or email me personally. This email address is being protected from spambots. You need JavaScript enabled to view it.

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