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.
Private plans also include Medicare-related options along with special needs plans and coverage for persons eligible for medical assistance. Senior options include the "UPMC For Life" HMO Advantage plan that features 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 futher 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.
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" plans 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.
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.
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 $6,850/$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 $6,200/$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 $6,200 with a maximum out-of-pocket cost of $6,850.
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).
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.
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.
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.
"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.
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. UPMC offers six popular Advantage plan options that are available in Allegheny County and the surrounding area. "UPMC For Life" contracts have earned 4.5 stars (out of 5) from Medicare.
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.
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.
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.
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.