Ritter Insurance Marketing, Craig Ritter

PA Supreme Court Rules Highmark Access to UPMC Ends in 2019

Around 50,000 seniors in Western Pennsylvania have a big decision to make this Annual Enrollment Period: stick with their Highmark Medicare Advantage plan and lose in-network access to UPMC doctors in the middle of next year OR change their Medicare coverage and continue seeing UPMC doctors at in-network costs.

On Wednesday, the Pennsylvania Supreme Court overruled a lower court, declaring that the state-brokered consent decree between Highmark and UPMC would end in-network access to UPMC providers for Highmark members effective June 30, 2019.

Highmark previously argued that their members’ access to UPMC providers should extend to June 30, 2020, according to their interpretation of the consent decree.

What Does This Mean for Highmark MA Members?

Highmark MA plan members will have this year’s Annual Enrollment Period to consider their options and make changes to their coverage. Between October 15 and December 7, those members can choose to switch plans or re-enroll in their current one for 2019.

According to the Pittsburgh Tribune-Review, about 50,000 seniors in Erie and Allegheny counties currently have plans that will lose in-network access to UPMC providers.

Potential for a Special Election Period

According to the Tribune-Review, one Medicare enrollment advocate expressed the possibility that CMS could provide a window for Highmark MA members to switch plans after losing access. There is no guarantee that will happen, though.

The Nail in the Coffin

The decision ends a nearly five-year conflict between the two companies that began when Highmark health plan bought Allegheny Health System to form its own hospital network, Allegheny Health Network, in Spring 2013. UPMC has held the position that it wouldn’t contract with an organization that owns competing hospitals.

UPMC operates more than 30 hospitals and covers 3.4 million members with its insurance services, including around 143,000 Medicare Advantage members.

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