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Highmark Medicare Plans will lose in-network
Seniors with the plans will lose in-network access at the end of June 2019, when a state-brokered consent decree between the two health care giants expires. A Commonwealth Court judge had interpreted the consent decree to mean UPMC would have to continue to accept the insurance through June 2020.
Doctor visits and hospital services typically cost much less when the doctors and hospitals are in an insurer’s network than when they aren’t. Seniors with Highmark Medicare Advantage plans who see UPMC doctors will have to either switch doctors or pay much higher prices to see their UPMC doctors as of next July. Or they can switch insurers during the open enrollment period for the plans, which will run from Oct. 15 to Dec. 7, to pick a plan that includes their UPMC doctors and hospitals. Some Highmark Medicare Advantage plans include access to UPMC hospitals and doctors and some don’t. About 50,000 seniors living in Allegheny and Erie counties have Security Blue and Freedom Blue plans, which include UPMC, Billger said. People with Community Blue plans, which don’t include UPMC, won’t see any changes, he said. About 17,000 seniors in Westmoreland County have Medicare Advantage plans that provide access to UPMC.
The change to networks coming in the middle of the plan year could create confusion for seniors who don’t know it’s coming, said Bill McKendree, coordinator for the Allegheny County APPRISE program, which helps seniors with enrollment. McKendree said the federal Centers for Medicare and Medicaid Services could decide to create a special window in which seniors losing access to UPMC doctors could switch plans after June 30. Or CMS might not do that, he said. “This is a big old question mark,” he said. UPMC Health Plan, Aetna, Cigna and United Healthcare have all sold Medicare Advantage plans in the region in previous years. Highmark owns Allegheny Health Network and includes its hospitals in its plan networks. Seniors may also elect to enroll in traditional Medicare, rather than the Medicare Advantage plans. The traditional program includes all hospitals and doctors in the country who accept Medicare. McKendree advises seniors considering traditional Medicare to think about getting a Medigap supplemental plan, which covers many of the co-pays, deductibles and other costs of traditional Medicare. McKendree said all hospitals and doctors who accept Medicare must accept Medigap. The state brokered the consent decree between Highmark and UPMC in 2014 to govern relations between them until 2019. The two nonprofits had been unable to resolve contract disputes on their own that arose after Highmark Inc. announced it was buying the former West Penn Allegheny Health System to form the basis of Allegheny Health Network. UPMC said it wouldn’t contract with an organization owning competing hospitals. |
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Thousands of seniors with Highmark’s Medicare Advantage plans will lose in-network access to UPMC hospitals a year earlier under a Wednesday state Supreme Court decision than they would have under a lower court’s ruling.
“We are disappointed in today’s Pennsylvania Supreme Court ruling,” Highmark spokesman Aaron Billger said in an emailed statement. “While this is not how we interpreted the consent decrees intended to guide the Highmark and UPMC relationship, we will work in full compliance with the ruling and trust UPMC will do the same.”
“UPMC is grateful the Supreme Court expeditiously reached this decision, allowing seniors ample time to make the best choices for their health care,” UPMC spokesman Paul Wood said in an emailed statement.
Medicare Advantage and Medicare supplemental insurance (Medigap) are each intended to enhance the value of traditional Medicare coverage. Understanding how Medicare Advantage and Medicare Supplements operate can help agents determine how to structure, market and support these plans. What are the differences between Medicare Advantage and Medigap insurance, and what does each offer its beneficiaries?
CMS will no longer provide “Medigap C and F” plans by 2020, which are plans that cover extra Part B costs
The Better Medicare Alliance, a Washington-based coalition for companies and groups with an interest in the Medicare Advantage has posted a copy of a memo that shows CMS is reinterpreting the phrase “primarily health related” when deciding whether a Medicare Advantage plan can cover a specific benefit.
The Medicare Advantage programs lets insurers offer consumers comprehensive plans that serve as an alternative to traditional Medicare coverage. CMS tries to control current costs, avoid any incentives for patients to get more care, and help patients shop for plans on an apples-to-apples basis by putting tight limits on the benefits the plan issuers can offer.
But the 
The CMS is also moving forward with plans to increase the use of encounter data to determine risk scores for plans. As a result of the finalized rule, 75% of Medicare Advantage risk scores will be based on traditional fee-for-service data, and 25% based on encounter data. That differs from 2018, when the agency used a risk score blend of 85% fee-for-service data and 15% encounter data.
Stakeholders such as the American Hospital Association have pushed back at using encounter data after a January 2017 Government Accountability Office report found such information often isn't accurate.
"Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased percentage of encounter data in the blend," the agency said in a release Monday.
The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Instead, they'll be locked into one pharmacy or prescriber for Medicare Part D benefits.
This lock-in will limit an at-risk beneficiary's access to coverage for frequently abused drugs to those that are prescribed by a specified pharmacy or provider.
Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.
Stakeholders such as the American Hospital Association have pushed back at using encounter data after a January 2017 Government Accountability Office report found such information often isn't accurate.
"Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased percentage of encounter data in the blend," the agency said in a release Monday.
The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Instead, they'll be locked into one pharmacy or prescriber for Medicare Part D benefits.
This lock-in will limit an at-risk beneficiary's access to coverage for frequently abused drugs to those that are prescribed by a specified pharmacy or provider.
Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.
