Highmark Plan Can Exclude Upmc, Judge Rules Program for Seniors Found in Compliance

By Langley, Karen | Pittsburgh Post-Gazette (Pittsburgh, PA), October 31, 2014 | Go to article overview

Highmark Plan Can Exclude Upmc, Judge Rules Program for Seniors Found in Compliance


Langley, Karen, Pittsburgh Post-Gazette (Pittsburgh, PA)


HARRISBURG - A state judge ruled Thursday that the exclusion of UPMC physicians and hospitals from a low-cost Highmark insurance plan for seniors does not violate an agreement state regulators brokered between the feuding Pittsburgh health giants.

Pennsylvania insurance and health officials had argued that the new, narrow-network Medicare Advantage "Community Blue" plan from Highmark violated protections for "vulnerable populations," such as seniors, in the so-called consent decrees that in June codified ongoing connections between the entities after their contract expires Dec. 31.

The state argued in court last week that those agreements require Highmark to provide seniors with in-network access to UPMC care. Highmark countered that it is required to offer seniors an option with that access but also could offer Medicare Advantage products without UPMC in the network.

In an opinion issued Thursday, President Judge Dan Pellegrini agreed.

"Nowhere in the text of the provision is there a requirement that Highmark include UPMC in all of its Medicare-Advantage products," he wrote.

State officials said they were reviewing the ruling.

"The Commonwealth will continue to aggressively hold both parties accountable when any of the protections of the consent decrees are jeopardized," J.J. Abbott, a spokesman for Attorney General Kathleen Kane, said in a statement. "We are reviewing the court's decision and evaluating our next steps to best protect Western Pennsylvania patients."

Rosanne Placey, a spokeswoman for the state Insurance Department, said the same, adding that the state would work to ensure consumers understand the limited network provided by the plan.

A spokesman for UPMC said the decision raises questions about what protections really are provided by the consent decrees.

"Based on the court's decision today, it appears that the Commonwealth did not secure all of the protections for Highmark subscribers that it believed it had secured when the consent decrees were signed on June 27," UPMC spokesman Paul Wood said in an email. "Now there's more uncertainty than ever about the consent decrees' protections and the in-network access to UPMC that Highmark subscribers will have when the existing contracts expire in two months. …

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