Medicare Advantage landscape about to change

You’ve just sailed through the Medicare Advantage open enrollment period that ends today, delighted to be done with your 2018 plan. Now you should take time to enjoy the moment.

Next year’s open enrollment will feel very different.

If 2019 is not on your radar, you can bet it has been for UPMC and Highmark.

On June 30, 2019, the two Pittsburgh health giants’ five-year consent decree agreements expire, and hard lines will be drawn along network boundaries for seniors enrolled in the popular Medicare Advantage plans and a limited number of commercially insured members under a continuing course of treatment at UPMC.

“There obviously is going to be a disruption in the market, which is going to cause a lot of confusion,” said Brian Breisinger, president of MediConnect Insurance in Kennedy. “It’s going to get really crazy.”

Some might be forgiven for thinking “crazy” is already here.

Recently, an Oakland-based UPMC-affiliated medical practice handed out flyers telling patients that beginning in January 2019, “We will no longer be participating with any of the Highmark insurance plans,” including Highmark’s Freedom Blue and Security Blue Medicare Advantage plans.

That’s six months before the expiration of the 2014 consent decrees — and a mistake on that group’s part, acknowledged UPMC spokesman Paul Wood this week.

“The consent decree ends on June 30, 2019,” he said, and Highmark’s seniors will have in-network access to UPMC’s doctors and facilities until then.

But wait: Highmark contends that its 50,000 or so Medicare Advantage seniors retain UPMC access through Dec. 31, 2019, because the federal Centers for Medicare and Medicaid Services contracts run on a calendar year basis, a point reiterated this week by Highmark president and CEO David Holmberg.

UPMC agrees that the contract does end on Dec. 31 — but that’s Dec. 31, 2018, not 2019. With a sixmonth run-out provision, the

coverage remains through June 30, 2019, as the consent decrees require, Mr. Wood said.

To which Highmark counters that any termination of the contract before June 30, 2019, violates the consent decrees.

As with earlier disputes between the two health giants, final judgment may fall into lap of the state attorney general, or a courtroom judge.

When the final break occurs, whenever it occurs, “It’s going to impact both ways,”said Mr. Breisinger, “but the major impact will be on Highmark members because UPMC owns the most hospitals.”

Mr. Holmberg said Highmark has held numerous community events to let members know about the coming changes. And with the popularity of its same-day appointment initiative and new “Doctor Match” online survey, “The transition is already happening and what we’re doing is giving people options and choices,” he said.

“My point of view would be, ‘Let us concierge you over now so there’s not a cliff’” come 2019.