Does Highmark Cover Rehab Treatment?

Understanding Highmark Insurance Coverage

When considering rehab treatment, it's important to understand the coverage provided by Highmark Insurance. Highmark Insurance offers various healthcare plans, and the specific coverage for rehab treatment depends on the individual's plan.

Coverage Overview

Highmark Insurance policies generally provide coverage for substance abuse treatment and mental health care. The extent of coverage varies based on the specific plan and individual treatment needs. Highmark Insurance policies may cover a range of treatments, including medical detox programs, medication-assisted treatment, inpatient rehab programs, dual diagnosis treatment, and outpatient rehab programs. To determine the coverage details, it is recommended to check the Member Portal or contact the insurance provider directly.

ACA Compliance

Highmark Insurance policies are compliant with the guidelines of the Affordable Care Act (ACA). This means that they offer coverage for substance use disorder treatment and behavioral health services. The ACA mandates that insurance plans provide coverage for essential health benefits, which include substance abuse treatment and mental health services.

To make the most informed decisions regarding rehab treatment, it's important to verify the specific coverage details of your Highmark Insurance plan. This can be done through the Member Portal or by contacting a Highmark representative. Understanding the coverage provided and any potential limitations is crucial to ensure that you can access the necessary treatment while minimizing out-of-pocket expenses.

In the following sections, we will explore the types of rehab treatments covered by Highmark Insurance, the factors that can affect coverage, and the different plan options available to individuals seeking rehab treatment.

Types of Rehab Treatments Covered

When it comes to rehab treatment, Highmark Insurance offers coverage for a range of options, catering to the diverse needs of individuals seeking recovery. The types of rehab treatments covered by Highmark Insurance include inpatient programs, outpatient programs, and continuing care options.

Inpatient Programs

Highmark Insurance policies provide coverage for inpatient rehab programs, which involve individuals staying at specialized facilities for a certain period of time. Inpatient programs offer intensive care, supervision, and a structured environment to support individuals in their recovery journey. The coverage for inpatient programs may vary based on the specific healthcare plan and individual treatment needs. Inpatient rehab programs are often recommended for individuals with severe addiction or those who require a higher level of care and support during their recovery process.

Outpatient Programs

Highmark Insurance also covers outpatient rehab programs, which allow individuals to receive treatment while residing at their own homes. Outpatient programs offer flexibility and enable individuals to attend therapy sessions, counseling, and other necessary treatments on a scheduled basis. Coverage for outpatient rehab programs may include outpatient care, partial hospitalization programs, counseling, and behavioral therapy as part of mental health treatment. Outpatient care tends to be less expensive than inpatient programs, making it a viable option for individuals with less severe addiction or those who have completed an inpatient program and require continued support.

Continuing Care Options

Highmark Insurance policies also cover continuing care options as part of their rehab treatment coverage. Continuing care involves ongoing support and treatment after completing an inpatient or outpatient program. This may include outpatient services, group therapy, individual therapy, and other forms of aftercare. The coverage for continuing care options may vary, and additional services such as sober living communities or residential treatment programs may have different coverage levels. Continuing care is crucial in maintaining long-term recovery and preventing relapse, as it provides ongoing support and resources for individuals transitioning back into their daily lives.

By covering inpatient programs, outpatient programs, and continuing care options, Highmark Insurance aims to support individuals seeking rehab treatment by providing coverage for a variety of recovery programs. The specific coverage details may vary based on the individual's healthcare plan and treatment requirements, so it is important to verify coverage and consult with Highmark Insurance to ensure the most accurate and up-to-date information regarding rehab treatment coverage.

Factors Affecting Coverage

When it comes to rehab treatment coverage, several factors come into play that can affect the extent of coverage offered by Highmark insurance. Understanding these factors is important in order to make informed decisions regarding rehab treatment options.

In-Network vs. Out-of-Network

Highmark insurance plans often differentiate between in-network and out-of-network providers. In-network providers have established agreements and contracts with Highmark, which typically results in lower out-of-pocket costs for individuals seeking treatment. On the other hand, out-of-network providers may not have a contract with Highmark, potentially resulting in higher costs for the individual.

It's important to note that Highmark typically pays up to 50% co-insurance for out-of-network providers, but it is recommended to seek treatment at an in-network rehab facility to maximize benefits. Some providers may not accept Highmark insurance, so it is crucial to confirm coverage with a Highmark representative and admission counselor before beginning treatment.

Co-Insurance Details

Co-insurance refers to the percentage of the total cost of treatment that the individual is responsible for paying after the deductible has been met. Highmark insurance plans often cover up to 50% of the co-insurance for out-of-network providers. However, it's essential to confirm the specific co-insurance details outlined in the individual's insurance plan to understand their financial responsibility.

To avoid unexpected costs, individuals should confirm coverage with a Highmark representative before starting treatment. This helps ensure a clear understanding of the co-insurance details and potential out-of-pocket expenses.

Authorization Requirements

In order to access rehab treatment benefits, Highmark insurance plans may require pre-authorization or prior approval. This means that individuals must obtain approval from Highmark before receiving certain types of treatment or services. Failure to obtain authorization may result in reduced coverage or denial of benefits.

It is important to familiarize oneself with the specific authorization requirements outlined in the Highmark insurance plan. This can help individuals navigate the authorization process and ensure that they meet all necessary criteria to receive the maximum coverage for rehab treatment.

By understanding the factors that affect coverage, such as in-network vs. out-of-network providers, co-insurance details, and authorization requirements, individuals can make well-informed decisions when seeking rehab treatment. Confirming coverage with a Highmark representative and understanding the terms and conditions of the insurance plan are crucial steps in maximizing the benefits available for rehab treatment.

Highmark Insurance Plan Options

Highmark offers a range of insurance plan options to meet the diverse needs of their members, covering approximately 5.6 million people in Pennsylvania, Delaware, and West Virginia. These plan options include Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), Point-of-Service (POS) programs, and Health Maintenance Organizations (HMOs).

PPOs

Preferred Provider Organizations (PPOs) offered by Highmark allow members the flexibility to choose healthcare providers from both in-network and out-of-network providers. With a PPO plan, members have the freedom to see specialists or receive treatment without requiring a referral from a primary care physician. PPO plans typically offer a higher level of coverage for out-of-network providers, but at a higher cost compared to in-network providers.

EPOs

Exclusive Provider Organizations (EPOs) provided by Highmark offer coverage exclusively through a network of healthcare providers. In an EPO plan, members must receive care from in-network providers and facilities, except in cases of emergency care. EPO plans generally do not require referrals for specialist visits, making it convenient for members seeking specialized rehab treatment.

POS Programs

Point-of-Service (POS) programs offered by Highmark combine elements of both HMO and PPO plans. With a POS plan, members have the flexibility to choose either in-network or out-of-network providers. However, if they opt to see an out-of-network provider, they may need to pay a higher deductible or coinsurance. POS plans typically require members to select a primary care physician, who can then refer them to specialists or rehab treatment facilities.

HMOs

Health Maintenance Organizations (HMOs) provided by Highmark require members to seek care exclusively from a network of healthcare providers and facilities. In an HMO plan, members are typically required to select a primary care physician who coordinates their healthcare needs. Referrals from the primary care physician are generally necessary for specialized rehab treatment. HMO plans often offer lower out-of-pocket costs compared to other plan options, but may have more restrictions on choosing providers.

When considering rehab treatment coverage with Highmark, it is important to review the specifics of each plan option and understand how they align with your needs and preferences. Coverage levels, including coverage for rehab treatment, may vary based on the specific plan, state of residence, in- or out-of-network facility, length of stay, and insurance plan level.

Specifics of Rehab Treatment Coverage

When it comes to rehab treatment coverage, Highmark Insurance offers a range of benefits for individuals seeking help with mental health and substance abuse issues. The specific coverage provided may vary depending on the individual's plan and the type of treatment required.

Mental Health Treatment

Highmark Insurance policies are compliant with the guidelines set forth by the Affordable Care Act (ACA). As a result, they offer coverage for mental health treatment and behavioral health services. The coverage for mental health treatment may include services such as therapy, counseling, and psychiatric care.

The details of the coverage for mental health treatment will depend on the specific Highmark Insurance plan. It is important to review the policy documents or contact Highmark directly to understand the extent of coverage for mental health treatment.

Substance Abuse Treatment

Highmark Insurance recognizes the importance of addressing substance abuse issues and provides coverage for substance abuse treatment. The level of coverage may vary based on the individual's plan and the specific treatment needs. Some of the treatments that may be covered include medical detox programs, medication-assisted treatment, inpatient rehab programs, and outpatient rehab programs.

The coverage for substance abuse treatment is designed to help individuals overcome addiction and achieve long-term recovery. It is essential to review the policy details or consult with Highmark directly to understand the specific coverage for substance abuse treatment under the individual's plan.

Co-Occurring Mental Illnesses

Highmark Insurance also recognizes the significance of co-occurring mental illnesses, which are mental health disorders that coexist with substance abuse issues. Highmark provides coverage for the treatment of these co-occurring conditions in addition to drug and alcohol addiction treatment.

The coverage for co-occurring mental illnesses is designed to address the complex needs of individuals who are dealing with both substance abuse and mental health disorders. It is important to review the specific policy details or consult with Highmark to understand the extent of coverage for co-occurring mental illnesses.

By understanding the specifics of rehab treatment coverage provided by Highmark Insurance, individuals can make informed decisions about seeking the necessary help for mental health and substance abuse issues. It is advisable to review the policy documents, contact Highmark directly, or consult with a healthcare professional to ensure a clear understanding of the coverage and maximize the benefits available for rehab treatment.

Ensuring Coverage and Making Informed Decisions

When it comes to rehab treatment coverage with Highmark insurance, it's important to understand the verification process, utilization management tools, and available provider resources. By familiarizing yourself with these aspects, you can ensure coverage for rehab treatment and make informed decisions regarding your healthcare.

Verification Process

Before seeking rehab treatment, it's crucial to verify your coverage with Highmark insurance. The verification process involves confirming your eligibility and understanding the specific benefits provided by your plan. Highmark requires service preapproval based on the member's benefit plan and eligibility at the time of review and approval. Providers are responsible for verifying member eligibility and covered benefits.

To start the verification process, reach out to Highmark's customer service or visit their online member portal. Provide them with your insurance details and inquire about the coverage for rehab treatment. They will guide you through the necessary steps to ensure that your treatment is covered under your plan.

Utilization Management Tools

Highmark offers utilization management tools to streamline the authorization process for various healthcare services. One such tool is the Predictal Auth Automation Hub. This tool allows healthcare offices to submit, update, and inquire about authorization requests. It helps expedite the process and ensures efficient communication between healthcare providers and Highmark insurance. Providers can access resources and support from Highmark to navigate the authorization process.

Additionally, Highmark has partnered with eviCore healthcare for specific programs, such as the utilization management of physical medicine services and Post-Acute Care for Medicare Advantage members. These partnerships aim to enhance the utilization management process and provide comprehensive care to members.

Provider Resources

Highmark offers a range of resources to assist healthcare providers in the authorization process. The Highmark Provider Resource Center provides valuable information and guidance on procedure and service authorization requirements. Providers can access the Highmark Provider Manual, specifically Chapter 5 (Care & Quality Management), for detailed information on authorizations. These resources help providers navigate the complex landscape of rehab treatment coverage and ensure compliance with Highmark's policies.

To make informed decisions about rehab treatment, it's essential to leverage these provider resources. Providers can stay updated on Highmark's requirements, policies, and any changes that may impact coverage for rehab treatment.

By understanding the verification process, utilizing the available utilization management tools, and accessing provider resources, individuals can ensure coverage for rehab treatment and make informed decisions regarding their healthcare with Highmark insurance.

References

• ‍https://www.aristarecovery.com/blog/does-highmark-cover-rehab-treatment
• ‍https://rehabs.com/insurance-coverage/highmark/
• ‍https://www.addictioncenter.com/treatment/highmark-insurance-addiction-treatment/
• ‍https://hbs.highmarkprc.com/Claims-Payment-Reimbursement/Procedure-Service-Requiring-Prior-Authorization