State Supreme Court: Highmark Medicare Advantage members to retain in-network access to UPMC

Pittsburgh Tribune-Review (PA)

Nov. 30--The Pennsylvania Supreme Court issued a ruling Monday preserving in-network access to UPMC hospitals and doctors for 182,000 Western Pennsylvania seniors with Highmark Inc.'s Medicare Advantage health insurance plans until 2019.

The state's highest court affirmed a Commonwealth Court decision from May favoring Highmark, Inc. in a dispute over language in a state-brokered consent decree. UPMC had appealed the lower court's decision.

"Today's ruling is a win for the people of Western Pennsylvania, especially seniors," Highmark spokesman Aaron Billger said in a statement. "The ruling affirms that members in Highmark's Medicare Advantage Security Blue HMO and Freedom Blue PPO plans will have continued in-network access to UPMC."

The decision comes a week before the Dec. 7 end of Medicare Advantage's open enrollment period, during which seniors with the private alternative to traditional Medicare may switch plans. The ruling eliminates uncertainty for seniors with the Highmark plans, who didn't know whether they would be able to retain their UPMC doctors, said Ambridge-based insurance broker Robert Nelson.

"Now they're just going to be at ease knowing they don't have to switch, they don't have to worry," Nelson said of his Medicare Advantage clients.

Seniors who switched plans earlier in the enrollment period to make sure they could keep their UPMC doctors can switch back to Highmark until 11:59 p.m. Dec. 7, Nelson said.

The Supreme Court rejected UPMC's argument that Medicare Advantage seniors were not included in a paragraph on vulnerable populations in a consent decree Gov. Tom Wolf and Attorney General Kathleen Kane negotiated between the two nonprofits in 2014. The decree was meant to protect vulnerable patients, including the elderly, disabled, children and the poor, as the business relationship between the two nonprofits disintegrated.

Attorneys representing UPMC argued the health system should have been able to stop offering in-network rates -- which are much lower than out-of-network rates -- when a Medicare Advantage contract between the nonprofits was set to expire at the end of 2015, rather than extending the agreement through the consent decree's 2019 expiration.

Justices ruled 3-2 in Highmark's favor after deliberating since an Oct. 6 hearing.

"The Supreme Court, in a split decision, recognized the basic ambiguity of the consent decrees and that contracts for Medicare Advantage will remain in place," UPMC spokesman Paul Wood said in a statement. "UPMC will, of course, comply with the decision."

Justice Debra Todd wrote the majority opinion, with Chief Justice Thomas G. Saylor and Justice J. Michael Eakin joining her. Justice Max Baer filed an opinion that partly concurred and partly dissented with Todd's opinion. Justice Correale Stevens joined Baer's opinion.

"Today, I am pleased the Supreme Court ruled in favor of protecting seniors," Gov. Tom Wolf said in a statement. "This is a huge victory for seniors across western Pennsylvania."

The Supreme Court's decision settles the last major disagreement between the nonprofits over the decree. The nonprofits announced this month that they had reached an agreement through 2019 over in-network rates for people with commercial insurance who are in the midst of treatment. Also this month, an arbitration panel settled a separate dispute over cancer payments, ruling that Highmark owes UPMC Shadyside about $24 million. The two sides agreed to extend the panel's logic to UPMC's other hospitals, meaning Highmark will have to pay about $200 million.

"We have the clarity that the community's been seeking," Billger said of the settled disputes.

While affirming three parts of Commonwealth Court President Judge Dan Pellegrini's order, the Supreme Court quashed UPMC's appeal of how the state would enforce the consent decree going forward, calling it premature.

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