Fallout over UPMC-Highmark split rankles patients forced to choose sides, confront prepay rule

Dec. 23--After mulling her options for weeks, Kelly Erickson decided to swap her Highmark insurance plan for government-issued Medicare coverage in 2019.

Erickson, 72, of Bethel Park said she'll miss some of the perks of Highmark's Community Medicare Advantage plan -- especially the SilverSneakers exercise classes. But she's willing to pay a gym fee and higher monthly premium in exchange for knowing she doesn't have to make critical health care decisions based on the insurance card in her wallet.

"With the breakup of UPMC and Highmark, I got to thinking I did not want to get injured in an accident or get a particular type of cancer and not be able to see a UPMC specialist. It was time for me to make a change," said Erickson, who was drawn to traditional Medicare and Medigap supplemental options because any U.S. doctor who accepts Medicare must accept it.

"I liked the idea of not having an insurance company dictate if I can or can't have a test. Even though it's more money, the peace of mind is so much worth it."

Forced to choose sides or consider national alternatives, longtime UPMC and Highmark-affiliated Allegheny Health Network patients across Western Pennsylvania have slammed state help lines in recent months as they reluctantly considered switching plans and carriers during the most competitive Medicare enrollment period in decades.

Testing consumer loyalty

UPMC and Highmark are in the midst of a showdown over how many Medicare Advantage patients they can retain and attract once their networks officially split in mid-2019.

Some say they will not go to UPMC because they feel as if they're being "bullied" into doing so, and the frustration over Allegheny Health Network not accepting UPMC patients "cuts the other way, too," said Bill McKendree, coordinator for the Allegheny County APPRISE program of the state Department of Aging.

"For better or worse, there has been created in our community a brand recognition with the Highmark or the UPMC-associated products that has defined a certain loyalty," McKendree said. "Now, this loyalty is being tested."

Industry observers suggest national carriers such as Aetna could benefit from a surge in new members in this region, as seniors seek to avoid feeling caught in the middle of the Highmark-UPMC feud.

Next summer's expiration of a 2014 state-brokered consent decree means most UPMC doctors and facilities will become out-of-network to Highmark-insured Medicare Advantage patients. The looming separation has forced many seniors to choose betweeen losing access to longtime doctors or confronting a set of pricey and unusually cumbersome obstacles to retain them. That includes a prepay-in-full rule UPMC will begin applying to Highmark-insured Medicare Advantage patients starting July 1.

Highmark aims to help on the prepay front

Despite the strict prepay rule, Highmark has pledged to pick up the out-of-network costs for two of its Medicare Advantage plans. The insurer says it will work with patients to reimburse them as quickly as possible.

It remains unclear just how prepared Highmark will be to process prepayment reimbursements. Its leaders have said they were surprised and displeased by UPMC's Oct. 1 announcement of the controversial prepay rule.

Meanwhile, national alternatives such as Aetna, United Healthcare and Cigna appealed to patients because they maintain in-network contracts with both UPMC and Highmark.

"It feels as though the market share has been swallowed up by those who offered the ability to work with both providers," said Sean Horn, a manager at Medi-Connect, which specializes in helping seniors choose health care plans.

Open enrollment for Medicare and Medicare Advantage -- privately offered plans that include Medicare coverage plus other benefits such as dental, hearing, vision care, free rides to medical appointments and SilverSneakers -- ended Dec. 7 for 2019 insurance coverage that begins Jan. 1. (Enrollees still have a chance to switch from one Medicare Advantage plan to another during the first three months of 2019.)

Official figures will not be released by the Centers for Medicare & Medicaid Services and carriers until early next year.

Making painful decisions

MediConnect brokers worked with about 2,600 clients from across greater Pittsburgh in the past several weeks alone, which is a 40 percent uptick from last year, according to Joe Randazzo, vice president at MediConnect. Of those new clients, nearly 80 percent chose to go with an Aetna or UnitedHealthcare plan in 2019.

Aetna covers not only UPMC and AHN providers but also regional centers such as Cleveland Clinic and University of Pennsylvania facilities, and some plans covering access to Aetna providers across 45 states. The carrier also beefed up its benefits packages while slashing monthly premium rates, Horn said.

"There were a lot of people, probably most of the people we worked with, who didn't want to cut ties with Highmark but ultimately changed their plans," Horn said."There was a tremendous amount of brand loyalty to Highmark. ... It literally pained people to have to make this decision, and probably the only reason that the national carriers won people over was because of how heavily they invested in the benefits of their programs."

Jackie Rechter, 72, of Penn Township was forced to stay with Highmark even though she gets treatment from UPMC doctors. As a former Gateway Health nurse, she must stay on a specific Highmark plan to retain access to an $8,000 account in retiree health care benefits. At the same time, she wants to keep her nationally ranked UPMC pulmonologist and 30-year UPMC primary care physician.

"I'm in that predicament: Do I leave my PCP after 30 years? She knows me. She knows everything about me, and she's very caring," said Rechter, who's been frustrated by the lack of answers and still is skeptical about assurances made by Highmark about her coverage going forward, including that she can continue to see some of her UPMC doctors.

"I'm 72, and I have to start again?" she said. "I'm hoping I don't."

Prepay rule could backfire

Starting in July, Highmark-insured Medicare Advantage patients no longer will be able to receive nonemergency treatment from most UPMC doctors and hospitals unless they obtain a cost estimate, schedule an appointment using a centralized system and pay for treatment in full in advance. UPMC will not accept partial payments nor arrangement plans; it will bill patients directly for any additional costs that arise during treatment.

UPMC officials described the prepay option as making an accommodation for Highmark members who choose to schedule visits at UPMC doctors once the decree ends and it's no longer obligated to treat them.

"UPMC's prepay policy for our Medicare Advantage out-of-network members is not something we have seen other providers do, anywhere," Highmark spokesman Aaron Billger said. "It is certainly not patient friendly."

For patients with kidney failure, for instance, Highmark will pay any claims from third-party dialysis providers as well as UPMC nephrologists, Billger said. He noted that DaVita Dialysis, for instance, is an in-network provider and said "no UPMC physicians have terminated with us."

UPMC spokesman Paul Wood said UPMC will not bill Highmark directly and "whether the insurer reimburses the patient is between the insurer and the patient."

"It's going to be a rough option. First, you have to be able to front a potentially big amount of money," McKendree said. "Second, you've got to be willing to take the risk that Highmark is able to pivot based on the announcement and create an efficient structure that's going to reimburse them in a timely fashion, and if not they're going to be caught waiting a significant amount of time to get that reimbursement."

State politicians and officials such as Health Secretary Alex M. Azar II and Pennsylvania Attorney General Josh Shapiro have said the rule and ensuing confusion have caught their attention, though none has discussed any potential next steps. Shapiro said he plans to make an announcement related to the issue early next year.

"This is certainly a wild card," McKendree said. "I believe there's a sincere effort on the part of the state Attorney General's office to weight in for this conflict that's impacting a significant number of people and a significant number of areas within our state. I'm hopping what that announcement is going to help us with some kind of satisfying resolution, but we have yet to see."

UPMC says the change is fully permissible within federal regulations governing Medicare Advantage plans.

War for market share

The projected movement toward national carriers seems to mark a shift from previous years, when "people have been really reluctant to go to the national carriers in these parts," said Stephen Foreman, professor of health care administration at Robert Morris University.

Spokespersons for those carriers would not comment yet on the outcome of the 2019 Medicare Advantage enrollment period nor provide projections.

UPMC and Highmark officials touted high interest and momentum in their offerings in recent weeks. The rivals continue to move on aggressive growth plans and are investing billions of dollars in new hospitals and facilities across Pennsylvania and neighboring states.

"Some of this competition has held down rates," Foreman said. "The real question is, 'How long will UPMC (and Highmark) continue to accept Aetna and Coventry patients?' "

McKendree's Allegheny County helpline received triple as many inquiries from seniors seeking help choosing plans on busy days this year compared to last year, taking as many as 300 calls a day and making more than 15,000 contacts from mid-October through November. He's told fellow helpline workers to be prepared for another influx in calls early next year.

From Jan. 1 to March 31, people who chose Medicare Advantage plans are permitted to make a one-time change from one MA plan to another, including an MA plan by a different carrier.

McKendree recommends that consumers make a full list of not only the facilities they wish to use but also every doctor they see or would like to see in 2019, and calling each directly to check on possible limitations of their plan's coverage.

"If you were compelled for whatever reason to move from your comfort zone and you find you're not happy, you get an opportunity now, from Jan. 1 to March 31, to reassess how that's working and switch to something else," McKendree said. "If you're discovering that this isn't exactly what was promised or there are some drawbacks, this is the opportunity to correct it."

Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, [email protected] or via Twitter @NewsNatasha.

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