Community Blue Flex FAQs

What is Community Blue Flex?
Community Blue Flex is a tiered benefit design that be offered for 2018. Community Blue Flex gives both you a greater opportunity for cost savings by offering two levels of in-network benefits: Enhanced Value Benefits and Standard Value Benefits. At both benefit levels, you receive high quality care.

With “Enhanced Value Benefits”, you have lower cost-sharing when you receive care from in-network providers who deliver care more cost effectively. When you receive care from other in-network providers, you’ll have higher cost sharing (“Standard Value Benefits”). You may also choose out-of-network coverage at the highest level of cost-sharing.

What care is covered at the Enhanced Value Benefits level?
All Community Blue Flex providers must meet high quality standards. With Enhanced Value Benefits, you’ll have lower cost-sharing when you receive care from in-network providers who deliver care more cost effectively. Preventive and emergency care are always covered at the Enhanced Value Benefits level.

What hospitals are in the Community Blue Flex PPO network?
Please see the Community Blue Flex brochure for a list of participating providers. UPMC Hamot, UPMC Horizon, and UPMC Jameson provide care at the Standard Benefits level and are indicated with an orange circle.

What hospitals are out-of-network for Community Blue Flex PPO?
The following western Pennsylvania hospitals are out-of-network for Community Blue Flex:

• Magee Womens Hospital of UPMC• UPMC Presbyterian-Shadyside
• UPMC East• UPMC St. Margaret
• UPMC McKeesport• UPMC Passavant
• UPMC Mercy

What network physicians/professional providers will provide care at the Enhanced Value Benefits level?
All network doctors with the exception of the following who will offer care at the Standard Value Benefits level:

• Community Blue Flex network providers who do not have privileges to an Enhanced facility
• UPMC wholly owned providers with privileges to an Enhanced facility and a standard facility
• UPMC wholly owned providers with privileges to both an in-network (Enhanced and Standard) and an out-of-network facility
• Ancillary providers that are jointly owned by a Community Blue Flex network facility and UPMC or those owned by a Standard Facility
• Urgent Care Centers wholly owned by UPMC in the Greater Pittsburgh area (Allegheny, Beaver, Butler, Washington, Westmoreland counties)
• All Cancer Centers that are not independently owned or wholly/jointly owned by an Enhanced facility

What if you are currently in the middle of an episode of care covered at the Standard Value Benefits level? Can you continue to receive care from this provider?
Yes. Care covered at the Standard Value Benefits level is high-quality care from an in-network provider. If you choose to switch to receive care at the Enhanced Value Benefits level, you will receive a lower cost-sharing/higher benefits level. As long as you continue to get in-network care, you cannot be billed the difference between the provider’s charge and the allowance for the covered charge.

How can you find out if your care – including the care received from an independent provider – is covered at the Enhanced or Standard Value Benefits level?
• Use the online provider search tool at Click Find a doctor or Rx, then click Find a doctor, hospital or other medical provider. Click the ‘Pick a plan’ link and choose ‘Community Blue Flex PPO’ and continue with your search. The search results will show the Enhanced or Standard benefit levels.
• Call MyCare Navigator at 888-BLUE-428. One of our customer service representatives will assist you with your provider search.

What happens when Community Blue Flex PPO members receive care outside of western Pennsylvania?
Outside of the 29 western Pennsylvania counties:

• In Pennsylvania: Care outside the 29 western Pennsylvania counties is covered at the Enhanced Value Benefits level, with the following exceptions:

These hospitals offer care at the Standard Value Benefits level:
- Berwick Hospital Center-owned facilities: Includes the hospital, long-term care, home health care and hospice.
- Carlisle Regional Medical Center-owned facilities: Includes the hospital, rehab, cancer and surgical centers.
- Easton Hospital: Includes the hospital only.
- Geisinger Health System-owned facilities: Includes hospitals, home health care, psychiatric and hospice as well as acute care hospitals that are part of the Geisinger Health System (Bloomsburg Hospital, Shamokin Area Community Hospital and Janet Weis Children’s Hospital).

• Outside Pennsylvania: You enjoy the Enhanced Value Benefits level from all physicians and hospitals that participate with the local Blue Plan PPO. Across the U.S., the Blue Plan network will accept your Community Blue Flex PPO coverage.

Can the deductibles be combined for Enhanced Value Benefits and Standard Value Benefits levels?
Yes. A cross accumulation on the deductible will allow your claims to be applied across the Enhanced and Standard Value Benefits levels. Deductible amounts applied to Enhanced Value deductibles will also be applied to your Standard Value deductible and vice versa.

Can the coinsurance amounts be combined for Enhanced Value Benefits and Standard Value Benefits levels?
Yes. A cross accumulation on the coinsurance out of pocket amountswill allow your claims to be applied across the Enhanced and Standard Value Benefits levels. Out of pocket claims applied to Enhanced Value out of pocket amounts will also be applied to your Standard Value out of pocket amounts and vice versa.

Does Community Blue Flex include in-network access to any UPMC-owned or affiliated hospitals?
Yes. The following UPMC facilities are covered at the Enhanced Value Benefits level:

• Children’s Hospital of Pittsburgh of UPMC
• UPMC Altoona in Blair County
• UPMC Bedford Memorial in Bedford County
• UPMC Northwest in Venango County
• Western Psychiatric Institute and Clinic

Are jointly owned facilities such as Cancer Centers in the Community Blue network?
Yes. Among the jointly-owned (UPMC and community hospital) facilities included in the Community Blue Flex network are UPMC/Heritage Valley Health System (HVHS) Cancer Center, UPMC/St. Clair Hospital Cancer Center and The Regional Cancer Center in Erie. Members can check the online provider directory to see which providers are in network. Care received from those facilities that are in-network are covered at the Enhanced Value Benefits level.

Will Community Blue Flex members be “balanced billed” if they seek services at an out-of-network UPMC provider?
Yes. However, due to the provisions of the Consent Decree, UPMC cannot balance bill a member for more than 60 percent of charges.

However, that when you use non-network providers, out-of-network cost-sharing applies. That means these expenses would be subject to the benefit plan’s out-of-network deductible. After you meet the out-of-network deductible, you would also be responsible for the out-of-network coinsurance. For example, your out-of-network benefits include 60% coinsurance. You would pay 40 percent and Highmark would pay 60 percent of the “allowance.”

Example: Member receives care from a UPMC provider not in the Community Blue Flex network and the member has already met the out-of-network plan deductible.

If UPMC’s actual charge is $150, and Highmark’s professional allowance is $100, then the member is responsible for $50 and Highmark pays UPMC the remaining $50. UPMC cannot “balance bill” for more than $90 (60 percent of total charges). This applies to both facilities (such as hospitals) and professional providers (such as physicians).

Of course, if you need emergency care, it will be covered at the Enhanced Value Benefits level – even if it is received from an out-of-network provider.