Medicare Members and the Consent Decree

What does the end of the Consent Decree mean to me?

Some Western Pennsylvania UPMC facilities will be out of network in 2019. For a listing of these hospitals, please see below.

Can I still go anywhere for emergency care?

Yes. You’re always covered when it matters most. When there’s an emergency, your Highmark Medicare plan always covers your care the same as in-network care, no matter where you go. This includes all UPMC facilities.

This is also true if the Emergency Department admits you. Your Highmark Medicare plan will cover your emergent inpatient care the same as in-network care up through the time you are discharged.

What if my doctor becomes out-of-network?

Should you receive notification that your doctor is no longer in-network for your insurance plan, you have options to consider:

  • If you are a Highmark Freedom Blue or Security Blue Medicare Advantage member, you have a See Any Provider Benefit that gives you the flexibility to access any primary care physician or specialist that accepts Medicare, even those outside of your network.
  • In order to use your See Any Provider Benefit, the doctor must be willing to accept you as a patient. As with any in- or out-of-network service, we want to make sure you know what to expect. So we encourage you to call us before scheduling out-of-network care so we can help you navigate the process, including explaining your covered benefits, reviewing medical necessity, and outlining how claims are paid.
  • Visit https://www.highmarkbcbs.com/home/ for our provider directory to check if your doctor is in-network.

How can I find an in-network doctor?

Visit https://www.highmarkbcbs.com/home/ for our provider directory to check if your doctor is in-network.

Also, we give you easy ways to find your ideal doctor:

  • Call 1-866-871-7710 (TTY users may call 711), 8 a.m. to 8 p.m., seven days a week
  • Stop by your local Highmark Direct health insurance store – To find a store near you, visit HighmarkDirect.com
  • Take our Dr. Match Quiz and get paired up with an in-network doctor that suits your unique needs.

What are out-of-network benefits?

Out-of-network benefits are benefits that cover services when you see a provider or hospital that is not in the plan’s network of providers. Often, insurance plans have different member cost-sharing for in-network and out-of-network services.
However, this is not always the case. For example, Highmark’s 2019 Freedom Blue and Security Blue Medicare Advantage plans have no difference, or little difference, in cost-sharing for in-network or out-of-network care.
Members are only responsible for the copay or cost-sharing amount stipulated by there plan. Remember that emergent and urgent care is always covered as in-network coverage regardless of your plan.
 
How do I get answers about my 2019 Medicare plan?
We can meet with you by phone, at an in-person meeting, or at a Highmark Direct health insurance store near you. Visit medicare.highmark.com.
 
What if I’m seeing a UPMC doctor for a chronic condition?
While it’s usually best to transition your care to an in-network doctor, many Highmark members can see an out-of-network doctor for the same cost as an in-network doctor. Members in Highmark’s Freedom Blue PPO and Security Blue HMO-POS products may continue to see out-of-network providers, using their out-of-network benefits that offer similar member cost-sharing (such as copay, coinsurance) both in and out-of-network. Please discuss any care transitions with both Highmark and your provider before starting a new course of treatment. For assistance, call 1-866-871-7710 (TTY users may call 711), 8 a.m. to 8 p.m., seven days a week. 
 
Which UPMC hospitals will be part of my network in 2019?
For Medicare Advantage Plans, the following hospitals will be in-network in 2019:
 
UPMC Hospitals in the Greater Pittsburgh Area In-Network after 6/30/2019
  • UPMC Children’s Hospital of Pittsburgh
  • UPMC Western Psychiatric Hospital
UPMC Western PA Hospitals outside the Great Pittsburgh Area In-Network after 6/30/2019
  • UPMC Altoona
  • UPMC Bedford
  • UPMC Horizon (both campuses)
  • UPMC Jameson
  • UPMC Kane
  • UPMC Northwest
  • UPMC Somerset
UPMC Hospitals in the Central & Eastern PA Area that are In-Network
  • UPMC Cole
  • UPMC Pinnacle Carlisle
  • UPMC Community Osteopathic in Harrisburg
  • UPMC Pinnacle Hanover
  • UPMC Pinnacle Harrisburg
  • UPMC Pinnacle Lancaster
  • UPMC Pinnacle Lititz
  • UPMC Pinnacle Memorial in York
  • UPMC Pinnacle West Shore in Mechanicsburg
  • UPMC Susquehanna Divine Providence in Williamsport
  • UPMC Susquehanna Lock Haven
  • UPMC Susquehanna Muncy Valley
  • UPMC Susquehanna Soldiers + Sailors in Wellsboro
  • UPMC Susquehanna Sunbury
  • UPMC Susquehanna Williamsport Regional
Which UPMC hospitals will be considered out of network after June 30, 2019?
For Freedom Blue and Security Blue Medicare Advantage Plans, the following hospitals will be considered out-of-network after June 30, 2019:

  • UPMC Magee-Womens Hospital
  • UPMC East
  • UPMC Hamot
  • UPMC McKeesport
  • UPMC Mercy
  • UPMC Passavant
  • UPMC Presbyterian
  • UPMC Shadyside
  • UPMC St. Margaret
Out-of-network/non-contracted providers are under no obligation to treat Freedom Blue PPO members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
 
If I have traditional Medicare along with Medicare supplement insurance, am I affected by this?
Consumers with Medicare supplemental insurance have access to all providers who accept Medicare, including UPMC. Highmark’s Medicare supplemental policies do not have networks. Therefore, there is no concept of in-network or out-of-network.
 
How will my coverage work if my doctor becomes out-of-network?

Many of our plans offer you the freedom to access out-of-network doctors and hospitals across Pennsylvania and around the country. Other plans include defined networks that do not allow you to see out-of-network providers. Highmark’s Medicare Advantage Security Blue HMO-POS and Freedom Blue PPO both offer rich out-of-network benefits that allow you to see any doctor willing to accept you as a patient at a similar cost.

As with any in- or out-of-network service, we want to make sure you know what to expect. So we encourage you to call us before scheduling out-of-network care. We can help you navigate the process, including explaining your covered benefits, reviewing medical necessity, and outlining what you may need to pay.

 


Highmark Choice Company, Highmark Senior Health Company, and Highmark Senior Solutions Company are Medicare Advantage plans with a Medicare contract. HM Health Insurance Company is a PDP plan with a Medicare contract. Enrollment in Highmark Choice Company, Highmark Senior Health Company, Highmark Senior Solutions Company, and HM Health Insurance Company depends on contract renewal.
 
Out-of-network/non-contracted providers are under no obligation to treat Freedom Blue PPO members, Security Blue HMO-POS and/or Community Blue Medicare PPO members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

 

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