UPMC individual Health Plan insurance provides affordable medical coverage to Western Pennsylvania residents and offers coverage on the 2016 Pa Health Exchange. As one of the top non-profit providers in the US, 10 different personal plan choices are available for individuals and families, including the self-employed. Policies are also available to larger businesses in the area.
Personal plans also include Medicare-related options along with special needs plans and persons eligible for medical assistance. 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.
There are 28 available plans and we'll help match the policy that provides the most needed benefits for you. UPMC continues to update and offer their portfolio for the Pa State Exchange by offering "guaranteed issue" plans which started in 2014. 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 2015 and 2016 Exchange plans are the "Advantaged Select Silver Select," "Advantage Value Silver," "Advantage Enhanced Silver," and Advantage Premium Silver." All four plans are eligible for considerable cost-sharing provisions that Silver contracts enjoy if you receive the federal subsidy. And, these plans get a boost since UPMC has been again rated "A-" from A.M.Best Company, one of the leading financial rating services.
Marketplace policies are separated into the following classifications:
Enhanced: Lower deductibles but higher coinsurance. Several of the plans remove the deductible from primary-care and specialist office visits, drug costs and emergency room visits.
Essential: Very affordable premiums with higher out-of-pocket costs for large medical claims. 100% coverage on preventive visits and three additional visits are only subject to a $10 copay. $15 copay on generic drugs.
Goals: Features a "Health Incentive Account" (HIA) that allows you to earn up to $800 per family for completing healthy activities. This reward money can then be utilized to pay for copays, coinsurance or deductibles. The Goals "Gold" plan features a low $15 copay on office visits.
Inside Advantage: Three options are available. You can utilize "Level One" facilities, which include Warren General, Kane Community, UPMC Hamot, Horizon and Northwest hospitals. Any other owned facility can also be used. And you can be treated outside the Network.
Premium: Plenty of out-of-Network coverage in case you have a primary care physician or specialist that you don't want to give up. Of course, using provider-Network doctors will still be less expensive. Unlike an HMO, you don't have to get a referral to get specialized care.
Some of the popular "Premium" plans are available Gold, Silver and Bronze Metal classifications. $5,000, $3,000 and $1,000 deductibles are available.
Premium Savings: These plans are the UPMC high-deductible health plans (HDHP) that can be used in conjunction with HSA contracts. In addition to the tax benefits, dental and vision expenses can also be paid with pre-tax dollars. The Silver and Gold plans are offered in most areas.
Secure: Because of higher deductibles and more out-of-pocket expenses paid by the applicant, premiums are lower than most other policies. A $6,350 deductible must before the policy pays most other non-preventive expenses. However, three PCP visits are allowed with a $30 copay.
Value: Since there is 0% coinsurance after the deductible, and $0 copays, the costs of these policies are generally higher than most of the others. Deductibles as low as $1,000 are offered.
Value Plus: A very simple concept. Meet your deductible and then you have no other cash outlay since there is no coinsurance. $15 and $35 copays are included for regular doctor and specialist visits. Since this plan is only available at Gold and Platinum levels, if you don't qualify for a subsidy, it will be an expensive option.
The “Single-Term Non-Renewable” plan is designed for needs that are six months or less and is not available through the Marketplace. There are two deductible options ($500 and $1,000) and the cap on benefits paid is $1 million for the policy period. But many preventive coverages (unlike many other temporary policies) are covered at 80% without having to meet the deductible.
However, although available throughout the year, this temporary plan does not meet ACA mandatory guidelines and you may be liable for the Obamacare tax for not having qualified medical coverage. This penalty is currently 2.5% of household income and increases each year. Typically, short-term coverage is designed to fill in a gap (less than six months) where you otherwise would be uninsured.
On all temporary plans, routine physicals and mammograms, pap tests, and pediatric immunizations will have very little (or no) out of pocket cost. And generic drugs are covered with a small copay. This feature is very attractive and unusual, considering that most other short-term policy from other carriers places a deductible on these types of benefits.
Prices are the least expensive of any of their policies. For example, a 40-year old would pay just $99 per month for the $1,000 deductible and $120 per month for the $500 option. Separate applications are needed for each insured member. If you're unsure how long you will need to be covered or the type of plan you need, this option will get you covered quickly.
The individual "Advantage" policies now offer a "Goals Plan" option that allows the policyholder to earn up to $400 per person ($800 per family) on HIAs. There are more than 100 "healthy activities" that will earn bonus dollars. Most other contracts from other carriers have fewer than 10 of these activities.
Even 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.
"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) along with travel assistance. Please keep in mind that 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.
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.
UPMC and Highmark were previously (2013) waging a war of the airwaves battle. 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. 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.
The most recent tussle involves a Highmark television advertising campaign. UPMC has alleged that Highmark is falsely advertising hospital admissions information about customers. The lawsuit was filed in the US District Court in Pittsburgh. Highmark stands by the commercials and plans to provide 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 HealthAmerica also offer attractive priced policies.
October 2013 - 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.
November 2013 - 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.
January 2014 - 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.
February 2014 - 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.
April 2015 - 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.
August 2015 - 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.