Highmark Coverage Basics
Overview of how Highmark covers rehab.
Types of Highmark Plans and Network Rules
Breaks down PPO, HMO, EPO, and POS plans, highlighting differences in out-of-network coverage, referral requirements, and flexibility when choosing rehab.
Costs & What You’ll Pay
Breaks down deductibles, coinsurance, and why in-network care is usually the most affordable option.
How to Choose Rehab with Highmark
Step-by-step guidance to find the right level of care, confirm your plan, and verify benefits with facilities.
Finding the right treatment can be overwhelming, but your Highmark (a Blue Cross Blue Shield company) insurance can make it easier to choose care. Many Highmark plans cover life-saving addiction services. This page will help you understand how Highmark coverage typically works so you can maximize your benefits and minimize your costs.
Note: Blue Cross Blue Shield is not one single insurance company. It’s a national association of independent, locally operated Blue plans, so your coverage depends on your local BCBS company, your plan type, and your specific benefits. Some BCBS plans also use a separate behavioral health partner or administrator to manage coverage.
Most Highmark plans cover addiction treatment, but benefits vary widely. Knowing the type of plan you have will help you narrow your search for the right type of care. Coverage can come through an employer, the ACA marketplace, Medicare Advantage, or Medicaid, and most Highmark plans use one of the network types below. Network types determine which providers you can use and if you need a referral for specific services.
High-Deductible Plans (HDHP): Some Highmark plans are high-deductible plans. HDHPs are not a separate plan type, and all the network rules for PPOs, HMOs, EPOs, and POS noted above still apply to HDHPs. HDHP plans generally impact how costs are handled and when you pay for care. Many HDHPs are often also paired with a Health Savings Account (HSA). With these plans, you could potentially pay more out of pocket before your coverage begins, but an HSA can help cover costs until you meet your deductible and once the deductible is met, your plan could cover a larger portion of treatment costs.
The way you purchased your Highmark plan will also most likely impact your coverage. See details below on State Exchange (Marketplace), Medicare Advantage, and Medicaid Plans and the changes to coverage based on which program you purchased your Highmark plan through.
You can get insurance coverage through the ACA marketplace via state or federal exchanges. Plans purchased through the marketplace use familiar network types (HMO, PPO, EPO, or POS), but they often have some variations in coverage.
Some people receive insurance through Highmark Medicare Advantage plans, but coverage rules can be different for these plans versus an employer-sponsored plan.
For people with limited income, Medicaid plans are a great route to receive health insurance coverage. Coverage rules for Medicaid plans vary widely by state.
Highmark will review your specific care needs and your plan to make insurance coverage decisions like they would for other medical needs, such as a heart condition or diabetes. Because of federal parity law, coverage for addiction treatment cannot be more restrictive than coverage for other medical needs.
Coverage through Highmark varies by the type of plan you have and the state you reside in. Two people with Highmark may have very different benefits, even for the same treatment program.
The following aspects of coverage usually vary by plan and state:
Prior authorization needs
How long treatment is approved for
Differences in coverage for levels of care
Out-of-pocket maximums that put a cap on how much you pay
Learn more about how insurance and out-of-pocket costs usually work for rehab.
Choosing an in-network treatment facility is usually the best way to limit any out-of-pocket costs. We’ve provided the following illustrative example to show how Highmark could potentially handle coverage for a hypothetical residential treatment program using a PPO plan.
Note: This example is hypothetical and actual costs depend on your specific plan and provider. Actual Highmark plans may use copays, different coinsurance rates, or vary by service
If you’re trying to pick the best treatment for you and you have Highmark coverage, the following steps can help you narrow your care options to make a final decision.
Highmark will typically cover treatment based on medical necessity. Before you try to decide on a specific facility choice, it will help to understand what level of care you actually need. To help you determine the level of care that is best for you, you can speak to a medical professional.
Levels of care include:
Your specific Highmark plan will greatly impact the level of coverage you’ll receive for different facilities. You can review your insurance card or member portal to confirm your plan type. Review the table above for details on each plan type and how the different plans impact coverage at facilities both in-network and out-of-network as well as referral requirements and cost structures.
Before reaching out to specific facilities to confirm coverage details for your plan type, it is a good idea to narrow your choices to only a few facilities that will meet your care needs and are most likely in-network with Highmark. You can filter facilities by treatment needs and location and see whether a facility commonly works with Highmark plans. Review the filtered results to compare programs based on your specific treatment needs.
Some rehabs may be noted as “Blue Distinction” providers, which designate a certain quality or performance level is met. This can also be used as a deciding factor when making your short list of potential facilities.
Ghost networks
It’s important to know that some people may run into what is called a ghost network, which is when providers listed as in network are not actually available, no longer accept the plan, or have extended wait times. If you run into a ghost network, you can do the following:
Request your Evidence of Coverage: This will outline Blue Shield’s contractual obligations to you, and if in-network options aren’t available, your plan may be required to cover out-of-network care at in-network rates.
Ask for help locating active providers: If the directory appears inaccurate or outdated, ask Highmark member services or the facility to help identify providers that are actually available and currently accepting your plan.
It is also important to determine how your Highmark plan would apply to the facilities you are interested in. If you reach out, many rehabs will verify benefits for you for no cost and they can tell you whether the program is in network, what your potential costs could be, and if there are any limitations on length of stay for treatment.
Highmark will often require prior authorization for certain levels of care like detox, residential, or inpatient treatment. When you reach out, consider asking the facilities on your shortlist the following questions:
Is this program in network with my specific Highmark plan?
Do you handle prior authorization and ongoing insurance reviews?
What costs, if any, should I expect after my deductible is met?
If coverage changes, will you help plan next steps in care? If so, how?
After you create a narrow list of options with clear coverage details, you’ll most likely be deciding between just a few programs. To make a final decision, try to focus on whether the program is the best fit for you and where you are. There are many factors to consider, such as:
The facility’s experience with treating your specific needs
Family involvement in treatment and aftercare options
How the program supports care if insurance coverage changes
Learn how different treatment levels work and how clinicians determine the right level of care.
See below for facilities that report accepting Highmark. Before you make a final decision about treatment, ensure you follow the steps above to confirm network status, coverage, and out-of-pocket costs.
Acceptance of Highmark does not guarantee coverage. A facility may say they accept Highmark, but coverage will still depend on your specific plan and your medical needs. If coverage is denied, ask about options for appealing the decision.