Know Your Options for Care
Access for Children
Highmark currently is in a long-term contract with Children’s Hospital of Pittsburgh of UPMC, which provides in-network access to both Children’s Hospital of Pittsburgh of UPMC and its pediatricians (CHP) until at least 2022. Highmark has every intention to continue to renew this contract. You will have access to the services provided by Children’s Hospital of Pittsburgh of UPMC and the physicians who practice there.
Why Choose In-Network Providers?
Highmark continues to provide high-quality, affordable health care across central Pennsylvania with comprehensive network of community hospitals.
Choosing in-network providers makes life easier for members because providers file the claims and get any necessary approvals. Additionally, providers coordinate care so any referrals will be kept in-network. This helps members save money by using in-network providers.
We can help you find in-network providers and even schedule your appointment and transfer your medical records. To get started call My Care Navigator at 1-844-462-2551.
What you need to know about temporary access to UPMC.
When UPMC terminated most of its commercial contracts with Highmark, the Governor’s Office facilitated a Consent Decree to allow members limited and temporary access to UPMC in certain circumstances through June 30, 2019. The specific terms of coverage will be according to the member’s benefit plan and covered claims from UPMC providers may process at a lower level of benefits in certain plans.
Members who have been diagnosed with cancer have in-network access to all UPMC services, facilities, doctors and joint ventures for oncology covered services through June 2019. (Where the member’s physician in consultation with the member has determined that the member should be treated by a UPMC oncology provider.) This also includes care for illnesses/complications resulting from cancer treatment, such as endocrinology, orthopedics and cardiology. 1
Continuation of Care
Members who were in a continuing course of treatment for a chronic or persistent condition in 2013, 2014 or 2015 (and through June 30, 2016 at UPMC Mercy) with a UPMC provider or an independent provider, and received care for that condition at UPMC, can continue to receive care from the same provider at the in-network level of benefits through June 2019 if the care is for that chronic or persistent condition. Routine, preventive and acute care that is received during such a visit for treatment of your chronic or persistent condition will also be at the in-network level of benefits. Otherwise, routine, preventive and acute care will not be covered on an in-network basis.1 You cannot be referred to or treated by a new UPMC doctor on an in-network basis for care related to your chronic or persistent condition or other conditions you might have or develop.
Members who seek care at any UPMC emergency room will be covered at in-network rates at the highest level of benefits, including any inpatient admission through discharge. After discharge, patients may choose to receive any related follow-up care for up to 90 days at UPMC which will be covered at the lower level of benefits. 2
Access for Seniors
Highmark members (excluding Community Blue Medicare Advantage HMO) who are age 65 or older, and covered by or eligible for Medicare, will have access to most UPMC providers on an in-network benefit level through June 2019. This in-network access also applies to CHIP and Medicaid members.
Balance Billing Protection
Out-of-network UPMC providers can only bill Highmark members up to the difference between the Plan’s payment and 60% of the UPMC provider’s billed charges for covered services.
Temporary in-network access to UPMC facilities (includes the physicians who practice there)
|UPMC FACILITY||CONTRACT EXPIRES:|
|Western Psychiatric Institute and Clinic||6/30/2019|
|Hillman Cancer Center||6/30/2019|
|UPMC Hamot and its affiliate Kane Community Hospital||6/30/2019|
In-network access to Children’s Hospital of Pittsburgh of UPMC and their physicians will continue until 6/30/2022.