Highmark / UPMC Consumer Questions
Highmark/ UPMC Consent Decrees - Frequently Asked Questions (updated 7/17/14)
What is the issue between Highmark and UPMC?
The contract under which UPMC hospitals and physicians provide services to Highmark subscribers is set to expire on December 31, 2014. This contract expiration has created a level of uncertainty for patients and consumers in Western Pennsylvania regarding access to UPMC hospitals and physicians after December 31, 2014.
In an effort to provide clarity and certainty for consumers, Highmark and UPMC have each entered into a consent decree with the Office of Attorney General (OAG), the Insurance Department (PID) and the Department of Health (DOH).
How do the consent decrees address this issue between Highmark and UPMC?
The consent decrees are the first step in providing clarity and certainty to consumers on issues such as provider access and continuity of care by requiring: (1) access to certain services continues for patients and consumers; and (2) parties reach mutual agreement through continued negotiation or be subject to binding arbitration. The resulting terms would then be incorporated in the transition plan to be filed by Highmark with the PID by July 31, 2014.
Is this a new contract between Highmark and UPMC?
No, there is no new contract between Highmark and UPMC. The consent decrees and the transition plan to be filed by Highmark by July 31, 2014 are initial steps toward an orderly transition for patients and consumers. To ensure that the focus remain on patients and consumers, the OAG, PID and DOH will remain engaged and continue to have regulatory oversight throughout this transition process.
What key aspects of a transition plan do the consent decrees identify?
The consent decrees address key areas of concern for patients and consumers, with special focus on the patient-physician relationship:
- Emergency Services. Patients will continue to have access to emergency and trauma treatment. Highmark and UPMC will negotiate an agreement so that emergency and trauma services will continue to be accessible at in-network rates at Allegheny Health Network (AHN) and UPMC hospitals.
- Continuity of care. Highmark and UPMC agree that the care of a Highmark subscriber in the midst of a course of treatment at UPMC will be continued on an in-network basis for as long as the patient’s treating physician deems the continuing course of treatment necessary.
- Vulnerable Populations. Vulnerable populations, which include consumers age 65 or older who are eligible for or covered by Medicare or Medicare advantage, Medigap, Signature 65, as well as enrollees in Medicaid, CHIP will not be impacted by the contract expiration.
- Local Community Needs. Highmark subscribers will have ongoing access to unique UPMC local providers and services where the patient’s treating physician believes the patient needs such services and the services are not available from another source.
- Oncology. Highmark subscribers will have ongoing access to UPMC providers for cancer treatment and resulting illnesses if a patient’s treating physician determines that the treatment is necessary. Access for oncology services includes UPMC joint ventures, and physician services provided at or on behalf of independent hospitals.
- Unique/Exception Hospitals/Physicians. Highmark and UPMC are to negotiate a contract for care delivered at Western Psychiatric Institute and Clinic, UPMC Bedford, UPMC Venango (Northwest), UPMC/Hamot, UPMC/Altoona, UPMC Horizon, and facility, physician or other provider services located outside the Greater Pittsburgh area currently owned or acquired in the future by UPMC. The existing contract for Children’s Hospital is not impacted.
- Out-of-Network Benefit. For all other Highmark subscribers whose care is not otherwise governed by other provisions in the consent decrees, UPMC will provide services on an out-of-network basis beginning January 1, 2015.
- Referrals and Transfers of Patients. Highmark and UPMC agree to not require AHN or UPMC physicians to refer to their respective entities, nor shall the physicians refuse to transfer a patient when appropriate.
- Safety Net. Highmark and UPMC agree that there will be a one-year safety net beginning January 1, 2015, for any existing Highmark subscriber and UPMC patient who are unable to find alternative physicians and services in their area.
How do the consent decrees deal with Highmark and UPMC’s advertising campaigns?
Highmark and UPMC have agreed not to engage in any public advertising that is unclear or misleading to consumers.
Further, Highmark and UPMC will each contribute $2 million toward outreach and education efforts to be made by the OAG, PID and DOH during the transition period.
How will the OAG, PID and DOH enforce the consent decrees?
If the OAG, PID or DOH believes that a consent decree violation has occurred, the party will be advised and provided with the opportunity to correct the violation. If the violation is not corrected in 20 days, the OAG, PID or DOH may seek enforcement of the consent decrees in the Commonwealth Court.
Individuals may also file a complaint with the OAG, PID or DOH.
Are there going to be further agreements between Highmark and UPMC?
The consent decrees were the first step in getting both parties to the negotiating table; and contemplate that the parties will continue to negotiate in good faith and reach agreement on a number of issues. The decrees provide not only a framework for continued negotiations but they also provide the structure for resolving disputes. Agreed upon terms will then be incorporated into the transition plan that Highmark will file with the PID by July 31, 2014.
PID will continue to provide any new developments on this FAQ page and recommend that you check back for further updates.
How will I know if my specific medical condition or provider relationship is impacted by the consent decrees?
If you are currently seeing a UPMC doctor for a medical condition, undergoing cancer treatment, or expect to access one of the exception hospitals, you may want to confirm with both your doctor and Highmark that these provisions apply to your situation. While the consent decrees contain a number of provisions placing the decision-making process with patients and their doctors, each medical situation is unique and it’s best to check if you’re unsure. Consumers may also contact PID, DOH or OAG with questions.
You can speak to:
PID Consumer Services Office toll free at 877-881-6388; or email
DOH Bureau of Managed Care at 717-787-5193;
You may call Highmark or UPMC directly.
The department also maintains a website providing general, unbiased information on health insurance coverage options at www.pahealthoptions.com