UPMC individual Health Plan insurance provides affordable medical coverage to Western Pennsylvania residents and offers plans on the 2017 Pa Health Exchange Marketplace. As one of the top non-profit providers in the US, several different personal plan choices are available for individuals and families, including the self-employed. Policies are also available to larger businesses in the area. Senior Medigap coverage, and plans not subsidized by the federal government are also available.
Senior private plans also feature Medicare-related options along with special needs plans and coverage for persons eligible for medical assistance. Medicare-eligible policies include the "UPMC For Life" HMO Advantage plan that offers a very low premium. Office visit copays are $5 for primary-care physicians, and $45 for specialists. Pa Advantage plans replace original Medicare benefits and should be appropriately reviewed prior to enrollment. Additional Senior plan information is discussed further below.
If you are a business-owner (large and small companies), employer-sponsored programs will help you offer your workers multiple benefit choices, including dental and vision. The SHOP Exchange (administered through the federal government) can also make it easy for your employees to review group benefits. Many additional benefits can be offered to employees, including dental, vision, life, and disability.
Available Plans (Under Age 65)
There are 24 available plans, and we help match the policy that provides the most needed benefits for you. UPMC continues to update and offer their portfolio by offering "guaranteed issue" coverage which began when the Affordable Care Act legislation was passed. Currently, discounts are offered for hearing aids and LASIK eye procedures along with the mandatory "essential" benefits (mental illness, pediatric wellness, maternity etc...)
Some of the most popular 2017 individual and family plans are the Advantage Silver-tier options. These policies are eligible for considerable "cost-sharing" provisions that only Silver contracts enjoy, if you receive the federal subsidy. The entire portfolio of plans get a boost since UPMC is again rated "A-" from A.M.Best Company, one of the leading financial rating services. In most situations, Highmark plan rates are higher. NOTE: Additional policies are expected to be offered in 2018, when Trump Administration changes begin to be implemented.
UPMC Provider Networks
UPMC Partner Network - Included counties are Allegheny, Bedford, Blair, Erie, Lawrence, Mercer, and Venango. Considered an EPO (Exclusive Provider Organization), treatment outside of the area is not covered, unless it is considered an emergency. A partial list of hospitals and facilities include Children's Hospital, Magee-Womens, Eye And Ear Institute, Western Psychiatric Institute And Clinic, Corry Memorial, Grove City Medical Center, Kane Community, and Jameson Hospitals.
UPMC Select Network - Included counties are Allegheny, Beaver, Butler, Washington, and Westmoreland. Hospitals include Grove City Medical Center, UPMC facilities, and many community hospitals. Also an EPO.
UPMC Premium Network - Pictured above, the largest of the three Networks, the "Premium" option covers all of Western Pennsylvania, and extends towards the central portion of the state. As a PPO (Preferred Provider Organization), out-of-network benefits are more extensive than the previous two options.
Eleven Urgent Care facilities are also conveniently located throughout the region. Locations are: Shadyside (Centre Avenue), McCandless (McKnight Road), Monroeville (William Penn Highway), Robinson (Steubenville Pike), Wexford (Perry Highway), Natrona Heights (Broadview Boulevard), North Huntingdon (Route 30), Hermitage (North Hermitage Road), Franklin (Allegheny Boulevard), Erie South (Peach Street), and Erie West (West 26th Street).
Individual And Family Plans (Under Age 65)
On and off Marketplace policies are separated into five tier classifications: Catastrophic, Bronze, Silver, Gold, and Platinum. Premiums, out-of-pocket-expenses, copays, coinsurance, and deductibles, will vary, depending on the specific policy. Three different provider network options are available and discussed later in the article.
Catastrophic (Must be under age 30 or prove "financial hardship")
Advantage Catastrophic $7,150/$0 - $30 copay for first three primary-care physician (pcp) office visits. Deductible is $6,850 with 0% coinsurance. The concept of this policy is simple. Once you meet the deductible, there are no out-of-pocket expenses for covered benefits. However, you can not utilize a federal tax credit (subsidy) for this type of contract. Thus, Bronze-tier options should always be considered.
Advantage Bronze $6,950/$35 - Least expensive subsidized plan features unlimited pcp office visits ($35 copay) for every family member. Specialist visits are subject to the deductible but receive generous network-negotiated repricing to reduce cost. The deductible is $6,950 with a maximum out-of-pocket cost of $7,150. Generic drugs are subject to only a $30 copay while all other Tiers must meet a deductible.
Advantage Silver $3,250/$10 - Lower $3,250 deductible with very attractive $10 pcp copay. Deductible does not apply to specialist visits ($70 copay), and generic drugs are covered with a $10 copay. An online "e Visit" also will cost only $5. Preferred and non-preferred brand drugs are subject to copays only ($45 and $90). Outpatient lab and professional services are subject to a $30 copay while ER services must meet a $750 copay.
Advantage Silver $3,500/$30 - $3,500 deductible with very $30 pcp copay. Deductible does not apply to specialist visits ($65 copay), and generic drugs are covered with a $15 copay. An online "e Visit" also will cost only $5. Preferred and non-preferred brand drugs are subject to copays only ($50 and $100). Outpatient lab and professional services are subject to 20% coinsurance while ER services must meet a $750 copay. The Urgent Care copay is $75.
Advantage Silver $1,750/$30 - Lower deductible ($1,750) than previous plan, although maximum out-of-pocket expenses are identical at $6,600. Office visit copays are also higher ($30 and $80) and rate is also about 2% more.
Advantage Silver HSA $2600/20% - HSA-eligible plan with $2,600 deductible and maximum out-of-pocket expenses of $4,100 and 20% coinsurance. Copays after deductible on Tiers 1, 2, and 3 drugs are $10, $45, and $90 respectively. It is possible that qualification for cost-sharing on this plan, may eliminate your HSA-eligibility.
Advantage Silver $0/$50 - $0 deductible with maximum out-of-pocket expenses of $7,150. Pcp and specialist office visits are covered with $50 and $100 copays. Drug copays are the same as previous plan.
Advantage Gold $750/$10 - $750 deductible with maximum out-of-pocket expenses of $3,500 and 10% coinsurance. Office visit copays are only $10 and $45. Outpatient lab and professional services are subject to only a $30 copay. Copays after deductible on Tiers 1, 2, and 3 drugs are $10, $45, and $90 respectively.Tier 4 specialty drugs must meet a 50% coinsurance.
Advantage Platinum $250/$20 - $250 deductible with maximum out-of-pocket expenses of $1,500 and 10% coinsurance. Pcp office visit copay is $20, but specialist visits must meet deductible and copay. Prescription drug benefits are identical to previous plan. This policy is the most expensive UPMC option.
Federal Employees Health Benefits
Three HealthyU options are available to Federal employees. They are:
High Deductible Health Plan (HDHP) - Deductibles are $2,000 for a single policy and $4,000 for a family policy. Monthly HSA contributions into the account are $83.33 for a single plan, and $166.67 for a family plan. The coinsurance is 15%, and maximum out-of-pocket expenses for one person is $5,000, and $10,000 for a family.
High Option HMO - Deductibles are $650 and $1,300 (single and family) with 15% coinsurance. Maximum out-of-pocket expenses are $4,000 and $8,000 for an individual and family.
Standard Option HMO - Deductibles are $800 and $1,600 (single and family) with 20% coinsurance. Maximum out-of-pocket expenses are $5,000 and $10,000 for an individual and family.
HealthyU provides 100% coverage (no copay, coinsurance, or deductible) for qualified preventative expenses. Also included is a "Health Incentive Account" (HIA) that provides the opportunity to earn $250 (single) or $500 (family) for making healthy choices. Several personalized activities will earn "reward dollars," that can be utilized to pay out-of-pocket expenses, such as copays, coinsurance, and deductibles.
Several popular reward include preventative lab screening ($25), preventative Colonoscopy or mammogram ($50), checkup or routine physical ($50), and completing the MyHealth assessment ($50). Additional savings and discounts are available for spas and fitness centers. The list of available facilities is annually updated.
Also available are the programs set up for kids in low-income households (CHIP). The Lehigh Valley Health Network is considered a participating provider. They have about 600 physicians and specialists and offer specialized treatment in about 100 facilities. Benefits are very comprehensive and preventative and wellness visits are highly encouraged.
Pittsburgh and the Western portion of the state are not the only areas where you can utilize benefits. If you travel abroad, you'll still be in good hands. The Advanced Radiosurgery Center Of Excellence (San Pietro FBF Hospital) in Rome is one of the most respected resources in Italy for treating tumors. UPMC has another location in Sicily along with other facilities in Ireland, China, Singapore and Japan. Compared to other major regional carriers, the UPMC provider network is very large.
Health Plan Maternity Program
Both mother and baby receive special care and attention with this special program. A unique gift is also presented when all requirements are met. Both pre-delivery and post-delivery assistance is provided. Participation should begin before the 34th week of pregnancy. Several of the program requirements include 10 prenatal office visits, completion of required lab tests and x-rays, and signing of consent form. A visit with a provider within the first 13 weeks of pregnancy also must be completed.
"text4baby" is also offered to recent mothers and pregnant women. After signing up (it's free!), periodic tips and assistance will be provided, with information based upon the expected delivery date.Texts are free and do not count against a maximum limit, if you use one of these carriers: Alltel, Assurance Wireless, AT&T, Bluegrass Cellular, Boost Mobile, Cellular South, Cellcom, Centenial Cellular, Cincinnati Bell, Cricket, Metro PCS, nTelos, Nex-Tech Wireless, Sprint Nextel, T-Mobile, US Cellular, Verizon, and Virgin Mobile USA.
UPMC Medigap Information
"UPMC For Life" also offers four affordable HMO options for its Medicare Advantage portfolio. Some of the newer benefits include unlimited fitness, low $5 copay for doctor visits and a policy with no premium. The fitness benefit allows the customer to pick any fitness facility, and a portion of the cost will be reimbursed. Two PPO plans are also available along with vision and dental coverage (dental is a discount) and travel assistance. NOTE:Part B benefits should not be terminated.
As you approach age 65, and have not previously been covered by Medicare, a seven-month window is available to enroll in Parts A and B. This period begins three months prior to the month of your 65th birthday. If you are still receiving benefits through an employer, once you retire, approximately eight months is provided to enroll in Parts A and B.
Senior Medicare Advantage Health Plans
Medicare Open Enrollment is not related to the Health Exchange. Affordable Medicare Supplement rates in Pennsylvania are also offered by many large and reputable carriers. The previously-mentioned UPMC Advantage plan options that are available in Allegheny County and the surrounding area are very moderately-priced. "UPMC For Life" contracts have earned 4.5 stars (out of 5) from Medicare. Most plans offer preventative dental benefits (exams and cleanings). The six available options are:
UPMC For Life HMO - No deductible with $5 and $45 office visit copays. Inpatient hospital charge is $350 per stay and maximum out-of-pocket expenses are $3,400. Part D prescription drug benefits are not included. $225 outpatient surgery copay with $75 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $5 and $30. MRIs, PET scans, and CT scans are subject to $110 copay. Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $20 for first 20 days and $80 for days 21-100.
UPMC For Life HMO Deductible With Rx - $750 deductible with $5 and $50 office visit copays. Inpatient hospital charge is $300 per stay and maximum out-of-pocket expenses are $4,000. Part D prescription drug benefits are included. $125 outpatient surgery copay after the deductible with $75 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $10. MRIs, PET scans, and CT scans are subject to $100 copay after the deductible. Diabetic supplies and durable medical equipment are subject to 20% and 0% coinsurance after the deductible. Skilled nursing facility daily copays are $0 for first 20 days and $160 for days 21-100. Drug copays are $14, $47, $100, and 33% for Tiers 1, 2, 3, and 4 respectively.
UPMC For Life PPO High Deductible With Rx - $1,250 deductible with $10 and $50 office visit copays. Inpatient hospital charge is $300 per stay and maximum out-of-pocket expenses are $6,700. Part D prescription drug benefits are included. $125 outpatient surgery copay after the deductible with $75 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $10. MRIs, PET scans, and CT scans are subject to $100 copay after the deductible. Diabetic supplies and durable medical equipment are subject to 20% coinsurance after the deductible. Skilled nursing facility daily copays are $0 for first 20 days and $160 for days 21-100. Drug copays are $14, $47, $100, and 33% for Tiers 1, 2, 3, and 4 respectively.
UPMC For Life HMO Rx - No deductible with $5 and $40 office visit copays. Inpatient hospital charge is $350 per stay and maximum out-of-pocket expenses are $3,400. Part D prescription drug benefits are included. $250 outpatient surgery copay with $75 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $5 and $40. MRIs, PET scans, and CT scans are subject to $200 copay. Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $20 for first 20 days and $80 for days 21-100. Drug copays are $12, $47, $100, and 33% for Tiers 1, 2, 3, and 4 respectively.
UPMC For Life PPO Rx Enhanced - $500 deductible with $5 and $40 office visit copays. Inpatient hospital charge is $250 per stay and maximum out-of-pocket expenses are $6,700. Part D prescription drug benefits are included. $150 outpatient surgery copay with $75 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $5 and $20. MRIs, PET scans, and CT scans are subject to $100 copay. Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $0 for first 20 days and $160 for days 21-100. Drug copays are $12, $47, $100, and 33% for Tiers 1, 2, 3, and 4 respectively.
UPMC For Life HMO Rx Enhanced - No deductible with $5 and $25 office visit copays. Inpatient hospital charge is $125 per stay and maximum out-of-pocket expenses are $3,400. Part D prescription drug benefits are included. $80 outpatient surgery copay with $75 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $0 and $20. MRIs, PET scans, and CT scans are subject to $75 copay. Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $10 for first 20 days and $60 for days 21-100. Drug copays are $12, $47, $100, and 33% for Tiers 1, 2, 3, and 4 respectively.
NOTE: The estimated monthly rates for the six plans (Allegheny County) are shown below. Not all plans are offered in all counties.
$0 - HMO
$22 - HMO Deductible With Rx
$37 - PPO High Deductible With Rx
$83 - HMO Rx
$137 - PPO Rx Enhanced
$255 - HMO Rx Enhanced
Employer Plans (Small And Large Businesses)
Medical, dental, and vision coverage is available for your employees. Flexible customized plans are offered with a large network that includes more than 11,000 physicians, 125 hospitals and related facilities, 30,000 pharmacies for your prescription and non-prescription drugs, and many Urgent Care centers. Flexible spending accounts are offered, along with high-deductible, and more conventional comprehensive Group plans.
Dental coverage can be bought privately, or through an employer-sponsored Group plan. The regional network of providers is very large, and a national network is available through DenteMax. Choosing a primary dentist is not required since PPO plans are utilized. Pre-existing conditions are generally covered, and major services do not require pre-authorization.
Available medical options include:
HealthyU - Comprehensive plan with living incentives. Funds can be accumulated to help pay out-of-pocket expenses (coinsurance, copays, and deductibles) by engaging in healthy activities that promote wellness. Groups of any size can qualify.
Inside Advantage - Workers are provided a choice of network facilities. When a Level-1 hospital or provider is utilized, the out-of-pocket cost is less. Qualified Groups must have at least two employees.
Small Business Advantage - Comprehensive healthcare options are available, along with vision discount benefits and other options.
If you are more than 100 miles away from home and need medical assistance, help is just a phone call away. "Assist America" partners with UPMC to provide access to physicians, specialists, hospitals, pharmacies, and other medical facilities where you are located. There is no cost for the benefit, and you may also utilize help in other countries 24/7. Experienced professionals can provide valuable help when traveling abroad.
Several of the most useful services include healthcare repatriation, communication of emergency information, prescription drug advice, hospital and ER admission help, and health evaluation. Toll-free phone numbers are provided for inside and outside the United States, along with an identification number.
UPMC Vs. Highmark
UPMC and Highmark have previously waged a war of the airwaves. UPMC had stated that Highmark patients could no longer use their facilities, beginning at the end of 2013. If they were willing to pay higher costs, then the usage could continue. However, a court-ruling has extended the network coverage to 2019. Both companies should end their bitter war, or patients will continue to suffer.
However, UPMC continues to be recognized for their outstanding service. The National Committee For Quality Assurance (NCQA) rated the UPMC commercial and Medicaid HMOs the best in the state with the highest available marks for customer service and treatment. The November (2013) issue of "Consumer Reports" will provide additional details. NCQA ratings are based on quality, satisfaction and standards.
In the past, UPMC had alleged that Highmark was falsely advertising hospital admissions information about customers. A lawsuit was filed in the US District Court in Pittsburgh. Highmark stood by the commercials and provided information backing its claims. Previously, UPMC aired some commercials that Highmark felt were misleading.
You can easily compare specific policy rates and more specific details on our website when you request a quote. Along with Highmark, Western Pa is very well-represented with affordable medical plan options. Aetna and UnitedHealthcare also offer attractive priced policies.
Updates From The Past
UPMC will be considering Highmark facilities "non-network" at the end of 2014, which could drastically increase the cost for many users. Legislation has now been introduced that will require UPMC to accept Highmark members as "in the network." The bill (introduced by Reps Frankel and Christiana) is designed to protect consumers in the Western portion of the state.
The feud may be nearing an end. The antitrust lawsuits between UPMC and Highmark are over, according to their attorneys. Although the network-provider issue is still unresolved, it is a step in the right direction.
UPMC and Highmark have decided to dismiss their lawsuits against each other. A judge had also ruled last month for the dismissal. The original litigation between the two huge companies started in 2009. Both carriers offer healthcare coverage in Western Pa.
The National Football League (NFL) has awarded a grant to UPMC for concussion research. Brain imaging research is being used to help in the treatment and discovery of concussions. Football players, of course, are very prone to head injuries, despite recent rule changes.
UPMC might be terminating its Medicare Advantage plans with Highmark, and the Blue Cross company is not happy. Governor Tom Wolf would like the action reversed, and has threatened to take action to protect consumers. However, the main issue seems to be if the terms of an existing contract were broken when Highmark reduced its network payments for cancer-care.
Financially, this has been a good year. Operating revenues, income and margin have all increased, according to the most recent report (effective June 30). Enrollment revenues including insurance services increased, which should keep rates fairly stable, despite increases in many other costs, including patient care and drug prescription expenses.
More than 2.7 million person are now covered by UPMC for their individual or group medical benefits.This has helped expand local capital expenditures, including the Lemieux Sports Complex in Cranberry Township.
UPMC rates are still very attractive in the Pittsburgh area and Allegheny County. In surrounding counties (Westmoreland, for example), prices are typically very low compared to Highmark, Aetna, and other major companies. However, there are several provider network options, and it is very important to ensure your personal physician (or specialist) is approved for the specific plan you are considering.