Pennsylvania Insurance Department, Highmark spell out coverage plan after UPMC split

Health insurer Highmark Inc. and the Pennsylvania Insurance Department have spelled out a plan for Highmark customers to continue using doctors and some hospitals from the rival University of Pittsburgh Medical Center once Highmark's provider agreement with UPMC ends Jan. 1.

Highmark says 80 percent of UPMC's doctors can still serve Highmark subscribers at lower rates after the split, a claim UPMC spokesman Paul Wood disputes.

Highmark said UPMC doctors who provide services at UPMC hospitals outside the five-county greater Pittsburgh region — or who also do some work at non-UPMC hospitals — will be considered in-network for Highmark subscribers, meaning they'll be cheaper to use.

But Wood contends the 80 percent number is "grossly exaggerated," and argued more than 40 percent of UPMC's doctors will be considered out-of-network providers for Highmark.

UPMC and Highmark announced a deal in June to allow some Highmark insurance customers to continue using UPMC doctors and facilities at in-network rates after Gov. Tom Corbett and Attorney General Kathleen Kane pushed for a deal to protect Highmark subscribers. But details — some of which are still being worked out — weren't released until Tuesday.

When the contract between Highmark and UPMC ends in January, most Highmark subscribers will lose in-network access to UPMC doctors and hospitals, meaning they will pay higher rates.

But Highmark has said fewer than 10 percent of its 3.2 million insurance subscribers in western Pennsylvania had used a UPMC doctor or facility in the last year anyway.

Corbett's administration had not pressed the companies to extend their contract, but the governor did want to ensure that no patients in the midst of treatment would have to find new doctors or travel farther for hospital care after the contract ends.

Highmark and UPMC have still not agreed on rates that UPMC will charge Highmark subscribers for emergency room services.

Overall, most UPMC hospitals in the Pittsburgh region — Allegheny, Beaver, Butler, Washington and Westmoreland counties — will still be considered out-of-network for Highmark subscribers, though some exceptions exist including UPMC Mercy and Children's Hospital of Pittsburgh of UPMC, which are governed by separate contracts.

Hospitals outside that area, including UPMC Bedford, UPMC Hamot in Erie and UPMC of Altoona Hospital, will continue to be in-network, as will Western Psychiatric Institute and Clinic in Pittsburgh, because no similar non-UPMC alternative exists.

UPMC is western Pennsylvania's dominant network, with 22 hospitals and 400 outpatient sites. It refused to extend the in-network provider agreement with Highmark after the Pittsburgh-based insurer acquired seven area hospitals from Erie to Pittsburgh.