With about two weeks to go, this year’s open enrollment period for Medicare Advantage insurance plans in Western Pennsylvania is on track to mark the most pivotal shift and uptick in plan-switching in years, industry experts say.
Intensifying competition for market domination amid next year’s network split of two of the region’s largest health care rivals, UPMC and Highmark, is requiring seniors to rethink coverage choices.
“That’s why we’re seeing such a hot market right now, because the transition is upon us,” UPMC Chief Financial Officer Rob DeMichiei said. “The fact that we’re not in-network any more has forced people to assess the situation and say, ‘I’ve got to shop.’ ”
The split means seniors must navigate additional hurdles and costs if they want to continue using hospitals and doctors in both nonprofit systems, or opt for alternatives such as a national insurer, traditional Medicare or Medi-Gap supplemental option.
Flocking to national carriers
Insurance brokers and industry observers report that so far, many are choosing neither Highmark nor UPMC, instead opting for a national carrier such as Aetna, Aetna Coventry, Cigna or United Healthcare.
“It’s hitting them, finally, that this UPMC-Highmark thing is really happening and it may be time to really start looking at other options,” said Sean Horn, manager at Medi-Connect, which enrolls about 4,500 individuals in Medicare-type plans a year. “Many of them were still looking to keep their (provider) networks, and in order to do that, they decided to go with a national carrier. We’re seeing a lot of traction that way.”
Medicare Advantage plans are privately offered alternatives to traditional Medicare. They include additional benefits such as hearing aids, vision care, transportation to appointments, home meal delivery and the ever-increasingly popular SilverSneakers fitness classes. Medicare-subsidized plans are available to people over 65 or with disabilities.
Both UPMC and Highmark officials touted optimism about interest and sign-ups as of this week. Neither would release figures or projections for the enrollment period, which continues through Dec. 7.
UPMC’s DeMichiei said its system’s Medicare Advantage enrollment period has been “on fire” and he expects to make significant membership gains over last year. “This is shaping up to be one of our best years ever,” DeMichiei said this week during a discussion about UPMC’s third-quarter financial statements.
Ellen Galardy, Highmark’s vice president of Medicare products, said by phone Wednesday that more than 100 informational meetings about Medicare Advantage offerings have drawn 20 to 50 people each since October. “We’re doing everything we can to help ensure our members can access whatever health system they need,” she said.
Prepay rule to take effect
A 2014 state-brokered consent decree between UPMC and Highmark intended to ease the transition of their insurance network split for consumers is set to expire at the end of June.
Beginning July 1, 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 and will bill patients directly for any additional costs that arise during treatment.
RELATED: These UPMC hospitals won’t accept Highmark patients as in-network next summer
Though the split was expected, the prepay rule was not.
The Oct. 1 announcement by UPMC clashed with reassurances made the same day by Highmark Health officials that under two of its Medicare Advantage insurance plans — Freedom Blue and Security Blue — members could continue seeing out-of-network doctors at the likes of UPMC facilities for the same price and billing method, at least through the end of 2019.
Highmark has asked UPMC to rethink the prepay rule, which Galardy said “just hasn’t been done” in the Medicare population. She said Wednesday that consumers still are hopeful that UPMC will agree and determine the rule is “unnecessary,” and bill Highmark directly rather than forcing individuals to prepay in full. Highmark typically doles out tens of millions of dollars in out-of-network reimbursements directly to carriers a year, she said.
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. UPMC says the change is fully permissible within federal regulations governing Medicare Advantage plans.
“We think there are options for everybody,” DiMichiei said.
Aetna is an example of a national carrier that’s marketed itself as a choice that “means not changing doctors,” with its plans covering 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.
Highmark is urging members to consider Highmark’s Medi-Gap plan. Though traditionally only available to seniors within their first six months of enrolling in Medicare, Highmark is offering existing members the flexibility to switch, Galardy said. Like traditional Medicare recipients, Medigap card holders can see any doctor who takes Medicare anywhere.
Highmark also has a Medicare Advantage plan that already has made UPMC’s network off limits, its $0 premium HMO Community Blue plan, which has grown from 14,000 customers three years ago to more than 25,000.
The bitter feud between UPMC and Highmark dates to Highmark’s growth into the provider side of the health care business with Allegheny Health Network, with UPMC saying it wouldn’t contract with competing hospitals.
“We can’t say, sell insurance under the guise of sending people to the Hillman (Cancer Center) when they’re (Highmark) spending billions of dollars to create their own competitive network … and they’re building regional cancer centers in Butler and Latrobe,” DeMichiei said. “It’s very difficult to think of a reality where they’re actually going to send their patients to UPMC. They’ve built a network not to send people to UPMC.
“It’s a hyper competitive market,” DeMichiei said. “And who is benefiting from that? The seniors are benefiting from that, by shopping and saving. Yes, they have to shop, and that’s a bit of a disruption, but I think we underestimate the seniors.”
Dec. 7: Coverage decisions must be made by this date.
Jan. 1: Coverage takes effect.
First three months of 2019: Option to switch from one Medicare Advantage plan to another Medicare Advantage plan.
June 30: UPMC and Highmark officially end relationship. Most UPMC hospitals and doctors will be out-of network for Highmark members after this date.
July 1: UPMC’s prepay in full rule for nonemergency treatment takes effect for Highmark-insured MA members.
RESOURCES : Call a specific insurer for details on their Medicare Advantage offerings. The Medicare Plan Finder tool from the Medicare website Medicare.gov (or call 1-800-MEDICARE to get it) lets you compare Medicare Advantage and Part D plans. The Plan Finder compares plans based on the drugs you need, the pharmacy you visit and your drug costs.
Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, email@example.com or via Twitter @NewsNatasha.