Highmark-UPMC dispute may hurt seniors

May 28, 2013, 12:28pm EDT UPDATED: May 28, 2013, 2:48pm EDT

Kris B. Mamula

Reporter-Pittsburgh Business Times

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Senior citizens with Medicare Advantage coverage may feel the sting of the Highmark-UPMC contract dispute more than others. Here’s why.

Medicare Advantage plans have an unusually high penetration rate in Allegheny County – exceeding 50 percent. And Highmark has a controlling 55.5 percent of the Medicare Advantage market in the 29 counties of southwestern Pennsylvania, according to an Insurance Department filing.

UPMC is a distant second with 24.8 percent of the market and everybody else trails in the single digits: HealthAmerica, 8.7 percent; UnitedHealthcare, 3.3 percent; and Aetna, 3 percent, to round out western Pennsylvania’s top five Medicare Advantage insurers.

UPMC has said there will be no contract extension with Highmark. That means seniors with Medicare Advantage coverage, like Highmark’s commercial members, may find UPMC doctors and hospitals out-of-network come Jan. 1, 2015.

Whether Highmark's Medicare Advantage members will be drawn into the contract dispute isn't clear.

Hospital executives have said the sticker prices for services have little or no meaning. But the reality is out-of-network means Highmark members could be responsible for up to 70 percent of UPMC’s charges.

A routine emergency room visit to UPMC Presbyterian Shadyside Hospital for abdominal pain, for example, would mean an out-of-pocket expense of $8,400, well outside what most seniors could afford.