UPMC MERCY HOSPITAL CONTRACT TERMINATION LETTER TO MEMBERS
Access to the Doctors and Services at UPMC Mercy Hospital As you may know, UPMC has terminated Highmark's contract with UPMC Mercy hospital. This agreement will end on June 30, 2016. As of July 1, 2016, UPMC Mercy will be out of network
for Highmark members. This includes UPMC Mercy health centers and any free-standing sites offering lab, radiology, physical therapy, rehabilitation and other services. It also includes the doctors who list UPMC Mercy as their primary admitting hospital. This change does not affect Medicare or Medicare Advantage members.
As a result, some or all of the care Highmark members receive at UPMC Mercy after June 30, 2016, could be out-of-network. This may result in members paying a larger share of the cost when they use UPMC Mercy, except under certain protections afforded by the Consent Decree established by the Commonwealth of Pennsylvania and explained below.
We have many, easy ways to help your employees find a new, in-network doctor who can coordinate all their health care needs. - Call... My Care Navigator at 1-888-258-3428.
Representatives can schedule priority appointments and transfer medical
records.
- Click... Find a Doctor at highmarkblueshield.com.
- Schedule ... An in-person meeting at a Highmark
Direct store at highmarkdirect.com.
- Get
Acquainted ... At Meet Dr. Right community events where members can meet
20 to 30 local primary care and specialty physicians face-to-face, make a
personal connection and schedule priority appointments. Go to meet-dr-right.com
to find an event schedule.
- Contact ... Allegheny Health Network
(412-DOCTORS) or any other in-network provider. There are many high
quality and convenient providers that contract with Highmark.
Exceptions under the Consent Decree
Though UPMC Mercy will be out of network as of July 1, 2016, some services will still be treated as in-network. Under the Consent Decree, members can continue to use UPMC Mercy and its doctors at in-network rates in these special circumstances: - Emergency
- Emergency services at UPMC Mercy will be covered at in-network rates, including an inpatient admission due to the emergency with coverage through discharge, and any related follow-up care within 90 days of discharge.
- Oncology -
Members who are diagnosed with cancer are covered at in-network rates for all UPMC oncology services, provided that their physician has determined in consultation with the member that the member should be treated by a UPMC oncologist. This includes services through June 30, 2019, at UPMC Mercy and other UPMC facilities, including doctors and community hospital joint ventures that provide oncology services with UPMC.
- 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 Mercy) for a chronic or persistent medical condition can continue to see their doctor (at the in-network rate) up through June 30, 2019, for care reasonably related to their chronic condition.
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Members may not be referred to or treated by a new UPMC doctor on an in-network basis, whether it is for a chronic or persistent condition or any other condition, unless the care is covered by another provision of the Consent Decree.
- Routine, preventive or acute care does not qualify as a chronic or persistent medical condition and will only be covered as in-network if received during treatment for a chronic or persistent condition.
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Maternity - Members who were treated at UPMC Mercy or by a UPMC Mercy physician for a confirmed pregnancy on or before June 30, 2016, may continue to access Mercy on an in-network basis for maternity care, delivery and post-partum care related to that pregnancy.
- Access for Seniors, CHIP and Medicaid
- Members (excluding those with Community Blue Medicare Advantage HMO) who are age 65 or older, and covered by or eligible for Medicare, will continue to have in-network access to all UPMC providers. This in-network access to all UPMC providers also applies to CHIP and Medicaid members.
Using Out-of-Network Providers
After June 30, 2016, care received at UPMC Mercy may no longer be covered at the in-network rate. This means that if members use UPMC Mercy for services, they will pay a larger share of the cost.
If your employee plan has out-of-network benefits and members continue to use UPMC Mercy, Highmark will cover their care at the out-of-network rate. Members with out-of-network benefits who use an out-of-network UPMC provider: -
Are billed directly by the UPMC provider for services rendered
- Receive payment directly from Highmark for any applicable out-of-network benefits
- Have to pay the difference between the plan's payment and up to 60 percent of what the UPMC provider actually charges for covered services
If your employee plan d
oes not have out-of-network benefits and your employees continue to use UPMC Mercy, services will not be covered. They will have to pay up to 60 percent of UPMC's actual charges. Highmark will not make any payments.
To understand more about members' rights under the Consent Decree, you can read about access to UPMC at
discoverhighmark.com/consentCP. You can also contact your authorized agent or Highmark representative.
If members have questions about their coverage, they can call Highmark Member Service, using the phone number on their ID card, before they schedule any appointments at UPMC Mercy or with UPMC Mercy physicians. Members who need assistance finding an alternative in-network hospital or physician can call My Care Navigator (1-888-258-3428) or may use one of the other options listed above.
If you have any questions, please contact your Highmark client manager. |
