Medicare Members and the Consent Decree

Is anything changing in 2018?

No. We’re happy to say, there’s no change to your current plan.

How does the latest Highmark UPMC ruling affect me?

It doesn’t affect you this year since there’s no change to your 2018 plan. So you can keep going to UPMC, plus the other great doctors and hospitals included in your plan, for the rest of 2018.

What does this mean for next year?

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.

What if my doctor becomes out-of-network?

If your doctor is no longer in-network, you can find a doctor that’s in-network or use the new See Any Provider Benefit for 2019. Visit medicare.highmark.com for an up to date listing of in-network providers or shop for a 2019 Medicare Advantage plan.

How can I find an in-network doctor?

We give you three 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 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
Out-of-Network

  • 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.
We’re putting the choice back in your hands so whether you want to stay in-network and access one of the 50+ hospitals and 7600 PCPs and Specialists in WPA, or choose to see another provider outside of your plan network – you’ll pay a similar price for in or out-of-network care.
 
My UPMC doctor said he/she won’t see me unless I switch plans, is that true?
If you are a Freedom Blue or Security Blue member, then no this is not true for two reasons:
  1. UPMC has not terminated any physician contracts, it has only terminated hospital contracts for facilities in Allegheny and Erie Counties.
  2. On October 1, 2018, UPMC Health System publicly confirmed that they will treat any Highmark Freedom Blue and Security Blue MA member who wishes to receive care at an OON UPMC facility after June 30, 2019.

It is likely that your UPMC Doctor was not aware of your Highmark plan’s out-of-network benefits prior to them being announced on October 1, 2018. Should you need assistance regarding this situation, please call us at 1-866-871-7710 (TTY users may call 711), 8 a.m. to 8 p.m. seven days a week.


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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