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UPMC individual Health Plan insurance provides affordable medical coverage to Western Pennsylvania individuals and Seniors. 2018 Pa health Exchange Marketplace plans are offered. 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, including Part D prescription drug coverage, 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 2018 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 For Health Insurance

 

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 $7,350/$0 - Deductible is $7,350 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. Applicants of this plan must be under age 30.

 

Bronze Tier

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 $7,350. Generic drugs are subject to only a $30 copay ($60 for 90-day mail-order), while all other Tiers must meet a deductible.

 

Silver Tier

Advantage Silver $3,500/$25 -$3,500 deductible with $7,350 maximum out-of-pocket expenses. Office visit copays are $25 and $75 (not subject to a deductible). X-rays and blood tests are subject to a $40 copay, and imaging (MRIs, PET scans and CT scans) is subject to a $200 copay. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $25, $65, and $100. The Urgent Care copay is $75 and the ER copay is $800. Mental health, behavioral, and substance abuse outpatient services are subject to a $75 copay, and rehabilitation services are subject to a $40 copay.

 

Advantage Silver $0/$50 -$0 deductible with $7,350 maximum out-of-pocket expenses. Office visit copays are $50 and $100 (not subject to a deductible). X-rays and blood tests are subject to a $60 copay, and imaging (MRIs, PET scans and CT scans) is subject to a $600 copay. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $25, $50, and $100. The Urgent Care copay is $100 and the ER copay is $1,000. Mental health, behavioral, and substance abuse outpatient services are subject to a $60 copay, and rehabilitation services are subject to a $60 copay.

 

Advantage Silver $1,750/$50 -$1,750 deductible with $7,350 maximum out-of-pocket expenses and 20% coinsurance. Office visit copays are $50 and $80 (not subject to a deductible). X-rays and blood tests are subject to a $75 copay, and imaging (MRIs, PET scans and CT scans) is subject to 20% coinsurance. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $25, $50, and $100. The Urgent Care copay is $80 and ER visits are subject to 20% coinsurance. Mental health, behavioral, and substance abuse outpatient services are subject to a $75 copay, and rehabilitation services are subject to a $50 copay.

 

Advantage Silver HSA $2,700/20% - HSA-eligible plan with $2,700 deductible with $4,300 maximum out-of-pocket expenses and 20% coinsurance. Non-preventative expenses are subject to the deductible. Qualified medical, dental, and vision expenses can be paid with pre-tax dollars.

 

Advantage Silver $3,500/$30 -$3,500 deductible with $7,350 maximum out-of-pocket expenses. Office visit copays are $30 and $65 (not subject to a deductible). X-rays and blood tests are subject to 20% coinsurance, and imaging (MRIs, PET scans and CT scans) is also subject to 20% coinsurance. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $15, $50, and $100. The Urgent Care copay is $75 and the ER coinsurance is 20%. Mental health, behavioral, and substance abuse outpatient services are subject to a $30 copay, and rehabilitation services are subject to 20% coinsurance.

 

Gold Tier 

Advantage Gold $800/$20 - $800 deductible with $5,000 maximum out-of-pocket expenses and 10% coinsurance. Office visit copays are $20 and $55 (not subject to a deductible). X-rays and blood tests are subject to a $40 copay, and imaging (MRIs, PET scans and CT scans) is also subject to 10% coinsurance. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $45, and $90. The Urgent Care copay is $50 and the ER coinsurance is 10%. Mental health, behavioral, and substance abuse outpatient services are subject to a $50 copay, and rehabilitation services are subject to a $40 copay.

Advantage Gold $1,400/$20 - $1,400 deductible with $5,000 maximum out-of-pocket expenses and 20% coinsurance. Office visit copays are $20 and $50 (not subject to a deductible). X-rays and blood tests are subject to 20% coinsurance, and imaging (MRIs, PET scans and CT scans) is also subject to 20% coinsurance. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $40, and $75. The Urgent Care copay is $60 and the ER coinsurance is 20%. Mental health, behavioral, and substance abuse outpatient services are subject to a $20 copay, and rehabilitation services are subject to 20% coinsurance.

 

Platinum Tier

Advantage Platinum $250/$20 - $250 deductible with $1,500 maximum out-of-pocket expenses and 10% coinsurance. Office visit copays are $20 and 10% coinsurance (not subject to a deductible). X-rays and blood tests are subject to 10% coinsurance, and imaging (MRIs, PET scans and CT scans) is also subject to 10% coinsurance. The copays for generic drugs, preferred brand drugs, and non-preferred brand drugs are $10, $45, and $90. Urgent Care and ER visits are subject to 10% coinsurance. Mental health, behavioral, and substance abuse outpatient services are also subject to 10% coinsurance, and rehabilitation services are subject to 10% coinsurance.




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.

 

 UPMC healthcare information is provided by our website. We compare plans for both Seniors and persons under age 65.

 

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.  $225 outpatient surgery copay with $100 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. The outpatient rehab copay is $40 while emergency medical services extend to anywhere in the world. One routine vision exam is provided every two years ($0 copay) with $150  available for eyewear expenses. Dental benefits are not included and Part D prescription drug benefits are also not included.

 

UPMC For Life HMO Premier Rx - No deductible with $0 and $45 office visit copays. Inpatient hospital charge is $300 per day for five days, and maximum out-of-pocket expenses are $6,700. $350 outpatient surgery copay with $80 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and  x-rays are approximately $10 and $50. MRIs, PET scans, and CT scans are subject to $250 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. The outpatient rehab copay is $40 while emergency medical services extend to anywhere in the world. One routine vision exam is provided every two years ($0 copay) with $150  available for eyewear expenses. Preventative dental benefits aresubject to a $15 copay.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $42 (Tier 3), and $45% (Tier 4). 90-day copays are $0 (Tier 1), $30 (Tier 2), $126 (Tier 3), and 45% (Tier 4).

 

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 $80 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. Outpatient rehab must meet the deductible. One routine vision exam is provided every two years ($0 copay) with $100  available for eyewear expenses. Preventative dental benefits include a $15 copay for an oral exam and cleaning every six months. Bitewing x-rays are covered annually with a $15 copay.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $42 (Tier 3), and $97 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $30 (Tier 2), $126 (Tier 3), and $285 (Tier 4).

 

UPMC For Life PPO High Deductible With Rx$1,250 deductible with $10 and $50 office visit copays. Inpatient hospital charge  is $250 per stay after the deductible, and maximum out-of-pocket expenses are $6,700. Part D prescription drug benefits are included. $125 outpatient surgery copay after the deductible with $80 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.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $42 (Tier 3), and $95 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $30 (Tier 2), $126 (Tier 3), and $285 (Tier 4).

 

Compare UPMC health insurance for persons that are Medicare-eligible. Reduce out-of-pocket expenses with Supplement protection.

 

UPMC For Life HMO Rx - $1,250 deductible with $5 and $50 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. A $125 outpatient surgery copay applies with $100 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $0-$40. MRIs, PET scans, and CT scans are subject to a $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.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $42 (Tier 3), and $95 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $30 (Tier 2), $126 (Tier 3), and $285 (Tier 4).

 

UPMC For Life PPO Rx Enhanced - $0 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. A $150 outpatient surgery copay applies with $80 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $0-$20. MRIs, PET scans, and CT scans are subject to a $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.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $42 (Tier 3), and $95 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $30 (Tier 2), $126 (Tier 3), and $285 (Tier 4).

 

UPMC For Life HMO Rx Enhanced - $0 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. A $80 outpatient surgery copay applies with $100 and $50 copays for ER and Urgent Care visits. Out-of-pocket costs for lab services and x-rays are approximately $0-$20. MRIs, PET scans, and CT scans are subject to a $75 copay. Diabetic supplies and durable medical equipment are subject to 20% coinsurance. Skilled nursing facility daily copays are $0 for first 20 days and $60 for days 21-100.

30-day prescription drug preferred copays are $0 (Tier 1), $10 (Tier 2), $42 (Tier 3), and $95 (Tier 4). 90-day mail-order prescription drug preferred copays are $0 (Tier 1), $30 (Tier 2), $126 (Tier 3), and $285 (Tier 4).

NOTE: The estimated monthly rates for each plan are shown below. Not all plans are offered in each county. Medicare Part B premiums are not included.

 

Allegheny, Westmoreland, Butler, Cambria, Fayette, Blair, Crawford, Clearfield, Somerset, Armstrong, Bradford, Venango, Bedford, Jefferson, McKean, Warren, Clarion, Greene, and Washington Counties

$0 -  HMO

$0 -  HMO Premier Rx

$20 - HMO Deductible With Rx

$35 - PPO High Deductible With Rx

$81 - HMO Rx

$135 - PPO Rx Enhanced

$263 - HMO Rx Enhanced

 

Lancaster, Lehigh, Adams, and Berks Counties

$0 -  HMO

$16 - HMO Deductible With Rx

$95 - HMO Rx

 

York, Perry, Fulton, Lebanon, Dauphin, and Cumberland Counties

$20 - HMO Deductible With Rx

$35 - PPO High Deductible With Rx

$81 - HMO Rx

 

Union, Clinton, Tioga, and Snyder Counties

$0 -  HMO

$20 - HMO Deductible With Rx

$81 - HMO Rx

$263 - HMO Rx Enhanced

 

Philadelphia County

$0 -  HMO

$23 - HMO Deductible With Rx

$83 - HMO Rx

 

 

UPMC For Kids

 

This program is now the largest CHIP plan in Pennsylvania. Your child may qualify if they are under age 19, a US citizen (National or Qualified Alien may be considered), not presently covered or eligible for Medicaid, and a legal resident of the state. "Free," "Low-Cost," and "Full-Cost" benefits are provided, regardless of household income. The "Free" program waives copays for ER, Urgent Care and office visits. Regardless of income, benefits are identical. Only copays of certain services will vary.

A summary of some of the comprehensive benefits are listed below. A more detailed summary is available upon request.

Hospitalization Services - Surgical, medical, skilled nuring, mental health, and rehabilitation admissions. Transplants, physician services, blood, and anesthesia are included. Semiprivate romm charges are covered.

Emergency Room Visits - Sudden onset of a medical condition, severe pain, or a situation that involves immediate attention is typically a reason to visit the ER.

Urgent Care - When a primary care physician (pcp) is not available, sickness and/or injuries can be treated at an Urgent Care facility. Typically, the condition, if untreated, can potentially result in a more serious or emergency situation. Visits outside of the service area are also covered.

Physician Visits - Primary care physician (pcp) and specialist visits are covered, along with immuniztaions, well-child visits, and all other qualified preventative expenses. Outpatient surgery and diagnostic tests performed in the office are also covered. Allergy services (testing, injections, and serum), and hearing services (routine annual hearing exam and hearing aids and fittings every two years) are covered.

OB/GYN - Preventative visits are covered, including family planning and counseling services, outpatient surgery, pap test, breast exam, maternity care, diagnostic tests in the office, and yearly gynecolgical exam.

 

 

Special Needs Plans

UPMC For Life Dual provides coverage for persons that are enrolled in Medicare and also qualify for Medicaid. Referrals are not needed and a large network of providers is available. Prescriptions can be filled (and refilled) at nearby pharmacies, or mail-ordered. The cost of the plan is $0, although you still must pay your Part B premium. There is no deductible to meet and office visits (pcp and specialist) are covered without a copay. Inpatient hospital, outpatient surgery, ER, and Urgent Care visits are covered at 100%.

The yearly maximum out-of-pocket maximum (expenses) is $3,400. Part D prescription drug copays range from $0-$3.30 for generic, $0-$8.25 for preferred brand,  non-preferred, and specialty, and $0 for select care drugs.  

 

 

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.

 

Travel Coverage

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. Past issues 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.