ATTENTION- Pennsylvania members in the Pittsburgh area

UPMC Summary

Background:
Because a mutual agreement could not be reached between Highmark and UPMC, UPMC became out of network effective January 1, 2015.  In June, 2014, a new arrangement was announced by Governor Corbett whereby residents of the five-county greater Pittsburgh area and Western Pennsylvania had new levels of protection that allowed for continuing care at UPMC providers and facilities through June 30, 2019.

This arrangement, called the “Consent Decree”, allows Anthem members’ access to UPMC providers for the treatment of cancer, for members in a continuing course of treatment (regardless of the diagnosis) and emergency care which is outlined below under “What members can expect through June 30,2019”. In-network access is available for all UPMC‐owned oncology providers, UPMC pediatricians and UPMC behavioral health providers through June 30,2019.

Impacted areas:

o   Greater Pittsburgh Area: Allegheny, Westmoreland, Washington, Beaver, and Butler counties.

o   Western PA (outside of Greater Pittsburgh Area): Armstrong, Blair, Bedford, Cambria, Cameron, Centre (Western half only), Clarion, Clearfield, Crawford, Elk, Erie, Greene, Fayette, Forest, Huntington, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, and Warren counties.

Out of Network Hospitals:

·         See list of Out of Networks providers attached

·         Currently, if you use a UPMC provider that is out-of-network basis you may be billed by UPMC for the difference between the allowance, and the amount UPMC charges.  If you have no out-of-network coverage, you will be responsible for all UPMC charges. Generally, payment will be made on the out-of-network claim directly you, after subtracting the out-of-network deductible and coinsurance under the Verizon benefit plan. 

What members can expect through June 30, 2019

There are four specific provisions in the Consent Decree:

o   Access for cancer patients: Members will continue to have access on an in-network basis to all UPMC services, facilities, doctors and joint ventures (with other hospitals) for oncology care and for any illnesses/complications resulting from cancer treatment, including (but not limited to) endocrinology, orthopedics and cardiology.

o   Continuation of care: Members who were in a continuing course of treatment at UPMC in 2013, 2014 or 2015 (and through June 30, 2016, at UPMC Mercy) for a chronic or persistent medical condition can continue to see their doctor up through June 30, 2019, for care reasonably related to their chronic condition.

o   Balance billing protection for out-of-network services: Members who choose to receive care from UPMC providers even though they don’t qualify for in-network benefits based for one of the provisions of the Consent Decree, will be responsible for the out-of-network cost sharing according to their specific benefit design. But UPMC can only “balance bill” you up to 60 percent of their actual charge.

o   Access to emergency care: If members receive care at any UPMC emergency room, it will be covered on an in-network basis. This includes not only the emergency room visit but also any inpatient admissions and continued care for the emergency condition for which the member was treated.

In addition to the specific provisions above, members can receive care on an in-network basis from the following UPMC hospitals through June 30,2019:

o   In Allegheny County:

o    Children’s Hospital of Pittsburgh of UPMC

o   Western Psychiatric Institute and Clinic

o   All UPMC-owned and jointly operated cancer facilities, including Hillman Cancer Center

o   In other counties in Western PA:

o   UPMC Altoona

o   UPMC Bedford

o   UPMC Hamot

o   UPMC Horizon

o   UPMC Kane Community Hospital

o   UPMC Northwest

·         Any physicians who have admitting privileges at any of the UPMC hospitals listed above will be in-network under certain circumstances.

·         Members will continue to have In-network access to all UPMC-owned physicians located outside the five-county Greater Pittsburgh area. In-network access to all UPMC-owned physicians when they are practicing at any of the UPMC exception hospitals or practicing at the community hospitals; all UPMC-owned oncology providers; all UPMC pediatricians; all UPMC behavioral health providers and many more UPMC-owned physicians.

             What members can expect after June 30, 2019

There are four specific provisions in the Consent Decree that are most important for members:

o   Access for cancer patients: Members will continue to have access on an in-network basis to all UPMC services, facilities, doctors and joint ventures (with other hospitals) for oncology care and for any illnesses/complications resulting from cancer treatment, including (but not limited to) endocrinology, orthopedics and cardiology.

o   Continuation of care: Members who are in a continuing course of treatment at UPMC for a chronic or persistent medical condition may continue to see their doctor for care reasonably related to their chronic condition.

o   Access to emergency care: If members receive care at any UPMC emergency room, it will be covered on an in-network basis. This includes not only the emergency room visit but also any inpatient admissions and continued care for the emergency condition for which the member was treated.

Members will have access to the attached list of hospitals for an additional period of time, which is noted in the spreadsheet. Members will also continue to have access to UPMC doctors and hospitals for:

·         Emergency Care

·         High Specialized Transplants(performed in UPMC Pittsburgh)

·         Care related to cystic fibrosis

·         Cancer care in centers for a period of time (listed in the attached spreadsheet)

·         Continuation of care, if medically appropriate

Members who have questions related  to the consent decree, who need help location a new provider, or who are in a course of treatment for a chronic condition should contact Anthem at 1(866) 832-1229 to discuss their options.

           Anthem Resources:

           2018/2019 FAQ: https://newcotraining-a491211.sites.us2.oraclecloud.com/upmc/

           Provide direct contacts within the Member Service team, who will work directly with Highmark or internal Anthem teams (BCC), if needed. This will give members one point of contact.

           Additional Highmark Resources:

            Highmark on-site support

            Count On Blue (finding a provider, flyer attached): https://faqs.discoverhighmark.com/count-on-highmark/