What the UPMC-Highmark truce does and doesn’t mean for patients | TribLIVE.com
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What the UPMC-Highmark truce does and doesn’t mean for patients

Natasha Lindstrom
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A day after UPMC and Highmark reached a 10-year pact, patients across Western Pennsylvania are awaiting answers on precisely what the unexpected deal between the nonprofit health giants means for them.

Patients who severed ties with longtime doctors are hopeful they can return to the physician teams who know them best.

Others already have begun new treatment plans with new sets of doctors and are unsure how to proceed.

Some expressed frustration that they switched insurance plans away from Highmark to avoid being caught in the middle of the corporate feuding, only to learn now they won’t have to worry about a prepay-in-full rule they’d been told would take effect at most UPMC facilities next week.

Pennsylvania Attorney General Josh Shapiro on Monday morning lauded the leadership of UPMC and Highmark for striking an agreement outside the courtroom to preserve access for most patients in the region.

While the truce was welcome news for many, “it doesn’t solve everything, and it actually creates new questions, new issues that are going to take a while to resolve,” said Bill McKendree, coordinator for Allegheny County’s APPRISE program, a state-funded service that helps seniors choose health insurance plans.

RELATED: UPMC, Highmark reach 10-year deal for patient coverage

Several patients said they remain skeptical and unsure of the deal’s impact until they get guarantees directly from their insurers and doctors.

McKendree said, in coming weeks, advocates and counselors like him as well as insurance brokers and other industry observers will be paying close attention to the specific terms, costs and limitations folded into the new UPMC-Highmark contract, which takes effect Monday and expires in 2029.

The private contract, which was not made public, awaits approval from the state Department of Insurance.

“There are still some details that have to be enumerated before we know exactly what to expect,” McKendree said. “We still have a lot of unanswered questions.”

In the meantime, here are some things we do know:

Does the truce guarantee that all patients with UPMC or Highmark insurance plans can go to doctors and hospitals in both networks?

No, not for everyone. The truce is broad in that it applies not only to Medicare-eligible and cancer patients but to patients of every age and those on individual as well as employer-based plans — as long as they are enrolled in so-called “broad-based” plans, or plans that include at least partial benefits to other networks. Highmark also agreed not to charge patients more for care received at UPMC facilities than they do for care within Highmark’s Allegheny Health Network.

The truce means that both systems must at least offer every type of patient the choice of a plan that includes access to both UPMC and Allegheny Health Network providers. Blue Cross/Blue Shield patients who travel to the region also will be able to choose UPMC doctors or facilities for care, Highmark spokesman Aaron Billger said.

But, under the new contract, UPMC and Highmark agreed they each have the right to continue rolling out narrow or exclusive network plans that specifically exclude the other. It’s unclear how many of those plans will materialize and how their costs may differ. Some exist already and tend to cost less than broad-based or PPO options.

So, who is left out?

Narrow-network plans such as Highmark’s fast-growing Medicare Advantage Community Blue $0 monthly premium HMO plan will not be guaranteed access to UPMC. Similar narrow-network plans exist in commercial, non-Medicare markets, too. It’s unclear what will happen if such a patient tries to get care from a UPMC doctor or facility. Highmark presumes UPMC would not impose the prepay rule, CEO David Holmberg told the Tribune-Review. UPMC previously had said it was imposing the rule because Highmark failed to commit to paying UPMC for such claims directly and instead wanted to give patients an allowance to pass along. UPMC did not want to chase payments.

The truce also is limited geographically. It only applies to a 29-county region of Western Pennsylvania that includes greater Pittsburgh and Erie.

Contracts in Central Pennsylvania and other regions are set to expire in coming years, and this 10-year contract does not apply to them.

Exceptions that will remain accessible to everybody, no matter their insurance card, include: UPMC Hillman Cancer Center, UPMC Children’s Hospital of Pittsburgh and UPMC Western Psychiatric Hospital, as well as hospitals of either provider in rural areas or places where they are the only option.

I switched plans because of the looming split. Now that there’s a truce, can I switch back?

For most people, the answer is no, you will not be able to change plans until the next scheduled enrollment period.

A select group of Highmark-insured seniors and people with disabilities will have the chance to switch sooner.

The Centers for Medicare & Medicaid Services announced last week that it will be opening a special enrollment period for 1,300 people enrolled in two of Highmark’s Medicare Advantage plans who have used UPMC facilities within the past three months. Those enrolled in Highmark’s Freedom and Security Blue plans are among those eligible and should have received mail informing them of the option late last week.

Everyone else will have to wait until the next scheduled enrollment period, which begins Oct. 1 for Medicare Advantage patients.

Is Shapiro’s fight against UPMC over?

In terms of active litigation, yes. With the truce, Shapiro said he was dropping what’s left of his legal case against UPMC in Commonwealth Court. Less than two weeks ago, Judge Robert Simpson ruled against Shapiro by deciding that the June 30 expiration date of a 2014 state-brokered consent decree between UPMC and Highmark could not be changed. But the judge left open remaining charges alleged by Shapiro, including that UPMC was violating public charities and consumer protection laws.

As recently as June 8, Shapiro had said he was ready to fight UPMC for years, if necessary, and that he wanted “to pore though UPMC’s documents” to examine issues such as UPMC’s relationship with the University of Pittsburgh, the individual conduct of UPMC board members and UPMC CEO Jeffrey Romoff’s “use of charitable assets for personal use.”

On Monday, Shapiro said he appreciated the last-minute hustle by the executives and boards of both UPMC and Highmark and said the truce should usher in a new era of cooperation in the name of public interest. Shapiro emphasized that, though his legal fight is over for now, he and his team will continue to exercise oversight on UPMC, Highmark and “purely public charities” statewide.

“It doesn’t mean that our oversight responsibilities and the other work we do will cease. That will, of course, continue,” Shapiro said, “but that actual lawsuit will be withdrawn.”

How can I learn more about how this affects me and my loved ones?

Highmark and UPMC urge consumers to contact customer services representatives and their local doctors. Insurance brokers also are standing by to help. Medicare-eligible patients can get free counseling at APPRISE by calling 412-661-1483. Reach Highmark’s customer service at 800-294-9568 or www.highmark.com/. Reach UPMC Health Plan at 888-876-2756 or UPMC.com/.

Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, [email protected] or via Twitter .

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