Highmark / UPMC Consumer Questions

Questions and Answers: Highmark and UPMC


NOTE: The following information represents the department’s view of current conditions and may not reflect the positions or interpretations of Highmark or UPMC. The information provided below is subject to change. The department will continue to monitor this situation and provide additional information as conditions change. Please check back regularly for updates. updated 09/20/13


What are the issues between UPMC and Highmark?

Highmark and UPMC started to air extensive advertising campaigns in late spring/ early summer 2013. The advertisements address the pending expiration of their commercial contract with one another on 12/31/14. The expiring contract controls the terms under which UPMC hospitals and physicians will provide services to Highmark members.


Highmark’s ads call for an extension of the contract; UPMC’s ads state that there cannot be an extension for competitive reasons now that Highmark has purchased its own health care provider system. Each has complained that the other’s position constitutes anti-competitive behavior.


If the contract expires on 12/31/14, Highmark commercial subscribers (individuals who have Highmark insurance through their employer) will not have in-network access to most UPMC hospitals and physicians.


What is the current status of Highmark subscribers’ access to UPMC facilities?

Highmark subscribers are generally eligible to be treated in UPMC’s hospitals and by UPMC physicians on an “in-network” basis (see below) through 12/31/14. This means that UPMC will accept Highmark insurance coverage, subject to any standard co-pay or deductible the Highmark policy provides for.


Highmark Community Blue subscribers have in-network access to all Highmark participating hospitals and physicians, five specific UPMC facilities (Children’s Hospital of Pittsburgh of UPMC, UPMC Bedford Memorial, UPMC Northwest, Western Psychiatric Institute and Clinic and UPMC Altoona) and certain limited oncology services determined by UPMC on a case-by-case basis.


While some Community Blue products provide an out-of-network benefit, UPMC does not offer hospital or physician services on an out-of-network (see below) basis to Community Blue subscribers.  After 12/31/14, UPMC will provide hospital and physician services to Community Blue subscribers on an out-of-network basis.  Emergency services are available to Community Blue subscribers at any UPMC hospital at all times.


Medicare and Highmark Medicare Advantage beneficiaries have access to all Highmark and UPMC facilities.  This will remain unchanged, regardless of whether Highmark and UPMC extend their commercial contract after 12/31/14.


CHIP beneficiaries currently have access to all Highmark and UPMC facilities.  It is expected that this access will continue.


What happens if the Highmark/UPMC commercial contract does expire on 12/31/14 and how would it affect me?

Highmark subscribers will continue to have in-network access to:

·         Children’s Hospital of Pittsburgh of UPMC,

·         UPMC Bedford Memorial,

·         UPMC Northwest,

·         Western Psychiatric Institute and Clinic,

·         UPMC Altoona, and

·         certain limited oncology services determined by UPMC on a case-by-case basis.


They will also have access to all other UPMC hospitals and physicians on an out-of-network basis. The out-of-network access will result in additional out-of-pocket costs for Highmark subscribers.


Community Blue subscribers may have access to certain UPMC hospitals and physicians on an out-of-network basis, depending on the specific terms of the contracts. They will also continue to have in-network access to the five UPMC hospitals and certain limited oncology services as explained earlier, as listed above.  


Medicare and Highmark Medicare Advantage beneficiaries will experience no change in facility access because of the Highmark and UPMC contract dispute.


CHIP beneficiaries currently have access to all Highmark and UPMC facilities.  It is expected that this access will continue.


What’s the difference between an in-network and out-of-network benefit?

In-Network Benefit: Insurance companies contract with hospitals and physicians to form what is called a provider network. If you use your insurance policy and get medical treatment from an “in-network” hospital or physician, you may be responsible to pay a co-pay, a deductible and/or a co-insurance amount, depending on the terms of your insurance policy.  Your insurance company will then pay a negotiated dollar amount to the hospital or physician.  The hospital or physician will not be able to bill you for any difference between the negotiated rate and the actual cost of the services beyond your co-pay, deductible, and/ or co-insurance.  This is generally the most cost effective way to obtain hospital or physician services.


Out-of-Network Benefit: Your hospital or physician is considered “out-of-network” if you get non-emergency medical treatment from a hospital or physician not participating with your insurance company. If your policy has an out-of-network benefit, your health insurance company agrees to pay a specified dollar amount towards the cost of the medical services by a hospital or physician even if the health insurance company does not have a contract with them. Not all health plans offer this benefit. More than likely, the health insurer will not cover the full cost of the medical services. The out-of-network hospital or physician may bill you the difference between the charges for the health care services rendered and the amount paid by your insurer - this is called balance-billing.  Before you obtain medical services out-of-network, please carefully investigate the costs you may incur.


What is the Insurance Department’s role?

We have asked both companies to act in a way that keeps the best interests of Western Pennsylvania consumers in mind.  In addition, an Interagency Consumer Protection Task Force has been assembled between the Departments of Insurance and Health. This Task Force will work to address a number of consumer protection issues, such as making sure that consumers receive truthful and timely communications.


The Insurance Department does not have the authority under current law to force Highmark and UPMC to enter into a commercial contract.


Who should I contact?

The department recommends that you review your contract options carefully, and speak with a licensed health insurance agent. A consumer must make their own informed choices, by carefully weighing the costs and the potential benefits of any given plan with an insurance professional prior to purchasing coverage.


The department maintains a website, www.pahealthoptions.com to provide unbiased information about health insurance coverage options.


You may also call the department and speak to someone in our Consumer Services office. Please email us at ra-in-commissioner@pa.gov  or call us toll-free at 877-881-6388. Or, feel free to reach out directly to UPMC and Highmark to convey any concerns you may have.