Highmark

Highmark, an independent licensee of the Blue Cross Blue Shield Association, provides health insurance coverage across multiple states including Pennsylvania, Delaware, West Virginia, and parts of New York. As a major health insurer, Highmark recognizes the importance of mental health care as an essential component of overall wellness and offers comprehensive behavioral health coverage to its members.

If you or a loved one is exploring mental health treatment options, understanding how Highmark insurance works can help you make informed decisions during what might be a challenging time. This guide will walk you through key aspects of Highmark's mental health coverage, helping you navigate the complexities while focusing on your wellbeing.

Highmark's Commitment to Mental Health Parity

Highmark adheres to mental health parity laws, which require that coverage for mental health and substance use disorders cannot have more restrictive or less favorable terms than coverage for medical and surgical benefits. This means that financial requirements (such as copayments, coinsurance, and deductibles) and treatment limitations for mental health services should be comparable to those for physical health services.

Highmark's approach acknowledges that mental health conditions deserve the same level of care and coverage as physical health conditions. Through their behavioral health programs, they aim to provide members with access to a diverse national network of mental health providers, timely appointments, and both in-person and virtual care options.

Mental Health Services Typically Covered by Highmark

Highmark insurance typically covers a wide range of mental health services, though specific coverage details depend on your individual plan. Understanding the types of services that are generally included can help you begin planning your care journey.

Outpatient Mental Health Services

Most Highmark plans provide coverage for various outpatient mental health services. These typically include individual therapy with licensed providers, psychiatric evaluations to establish accurate diagnoses, medication management with psychiatrists or other prescribers, and group therapy sessions that provide therapeutic support in a structured environment.

Highmark has also expanded its telehealth options in recent years, allowing members to access mental health care through virtual appointments. Their Mental Well-Being program, powered by Spring Health, offers digital tools for daily wellness, one-on-one care navigation, and virtual therapy sessions, making mental health support more accessible to members.

Intensive Treatment Options

For those requiring higher levels of care, Highmark typically covers more intensive mental health services. These may include Intensive Outpatient Programs (IOPs) that provide structured treatment several days per week, Partial Hospitalization Programs (PHPs) that offer comprehensive daytime treatment, and inpatient mental health treatment for acute conditions requiring 24-hour care.

Highmark also provides coverage for dual diagnosis treatment, addressing both mental health disorders and substance use disorders simultaneously. This integrated approach recognizes that many individuals face multiple challenges that require coordinated care.

Mental Health Conditions Covered

Highmark covers treatment for a wide range of mental health conditions. Under Delaware mandates, for example, Highmark covers "serious mental illness" which includes conditions like schizophrenia, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, and other conditions as defined by the current Diagnostic and Statistical Manual (DSM).

Additionally, Highmark provides coverage for substance use disorders, reflecting their understanding that addiction often requires professional treatment. Coverage typically extends to both crisis intervention for acute episodes and ongoing treatment for chronic mental health conditions.

Navigating Insurance Verification and Payment Processes

Understanding how to verify your Highmark mental health benefits and navigate the payment process is crucial for accessing care efficiently and minimizing unexpected costs.

Verifying Your Coverage

To verify your Highmark insurance coverage for mental health services, start by reviewing your Summary of Benefits and Coverage document, which outlines the specifics of your plan. Look for sections addressing behavioral health or mental health services.

For personalized information about your coverage, consider these verification steps:

• Call the Member Services number on the back of your Highmark ID card

• Log into the Member Portal on Highmark's website

• Use the My Highmark mobile app to access your plan details

• Ask your healthcare provider to verify your benefits before starting treatment

• Check if the provider you want to see is in-network with Highmark

When verifying coverage, ask specific questions about mental health benefits, including copayment amounts, whether you need referrals, and if there are any session limits or prior authorization requirements for certain services.

Understanding Costs and Payment

The cost of mental health services with Highmark varies depending on your specific plan. Most plans involve some form of cost-sharing, which may include copayments (fixed amounts paid at each visit), coinsurance (a percentage of the total cost), and deductibles (amounts you must pay before insurance coverage begins).

For in-network providers, Highmark has negotiated rates that typically result in lower out-of-pocket costs. Your provider will bill Highmark directly, and you'll be responsible for your portion of the cost based on your plan's terms. If you choose an out-of-network provider, your costs may be higher, and you might need to pay upfront and submit claims for reimbursement.

Highmark's mental health parity commitment means that financial requirements for mental health services should be comparable to those for medical services. For example, if your plan has a $25 copay for primary care visits, your copay for outpatient mental health visits should not be substantially higher.

Authorization Requirements and Coverage Limitations

Like most health insurance providers, Highmark has certain authorization requirements and limitations for mental health coverage. Understanding these before starting treatment can help you plan effectively and avoid unexpected denials.

Prior Authorization Process

Highmark often requires prior authorization (also called preauthorization) for certain mental health services. This means that the service must be approved by Highmark before treatment begins to ensure coverage. Services that typically require prior authorization include inpatient hospitalizations, residential treatment programs, partial hospitalization programs, and sometimes intensive outpatient programs.

The authorization process generally involves your provider submitting clinical information to Highmark to demonstrate that the requested services are medically necessary for your condition. For outpatient therapy, Highmark may not require prior authorization for the initial sessions but might require it for continued treatment beyond a certain number of visits.

For ongoing treatment, requests for reauthorization should typically be submitted at least 24 hours before the expiration of the original authorization period. This ensures continuity of care and prevents gaps in coverage.

Coverage Limitations

While Highmark offers comprehensive mental health coverage, there are some limitations to be aware of. Common limitations may include session limits for certain types of therapy, network restrictions (coverage may be limited to in-network providers), and medical necessity requirements (services must be deemed medically necessary for your diagnosed condition).

Some Highmark Medicare plans may have lifetime limits for inpatient psychiatric hospitalizations. Additionally, coverage might be more limited for services addressing general life problems like grief counseling, couples therapy, or career counseling when not related to a diagnosed mental health condition.

It's important to note that coverage limitations vary significantly between different Highmark plans, so checking your specific policy is essential. Some plans may offer more comprehensive coverage than others, particularly for specialized mental health services.

The Insurance Approval Process: What to Expect

Navigating the insurance approval process for mental health treatment with Highmark follows a specific pathway. Understanding what to expect can help reduce stress and prepare you for each step.

Initial Assessment and Treatment Planning

With Highmark, the mental health treatment process typically begins with an initial assessment by a qualified provider. During this assessment, the provider will evaluate your symptoms and mental health history, establish a clinical diagnosis if appropriate, develop a treatment plan based on your specific needs, and determine the appropriate level of care.

This initial assessment forms the foundation for your treatment plan and helps determine what services will be covered by Highmark. The assessment findings, including your diagnosis and treatment recommendations, may be shared with Highmark if authorization is needed for certain services.

Ongoing Care and Care Management

Throughout your treatment, your provider may need to communicate with Highmark about your progress and ongoing needs. Highmark may conduct "concurrent reviews" for certain services to assess continued medical necessity and determine whether an extension of previously authorized services is appropriate.

For most outpatient services, your provider will handle the necessary paperwork and authorization requests. For higher levels of care, such as inpatient treatment, Highmark may be more actively involved in reviewing your care and participating in discharge planning to ensure appropriate follow-up care.

Appeals Process for Denied Claims

If Highmark denies coverage for mental health services that you and your provider believe are necessary, you have the right to appeal this decision. The appeals process typically begins with an internal review by Highmark, during which additional clinical information can be submitted to support the medical necessity of the requested services.

If the internal appeal is unsuccessful, you may have the right to an external review by an independent third party. Throughout the appeals process, your provider can be a valuable advocate, providing clinical documentation to support your need for treatment.

Remember that mental health parity laws protect your right to equitable coverage for mental health services. If you believe Highmark's denial violates parity requirements, you may have additional recourse through state insurance regulators.

Benefits of Choosing a Facility that Accepts Highmark

Selecting a treatment facility that accepts Highmark insurance offers several advantages for individuals seeking mental health care.

Financial Benefits and Streamlined Billing

Working with an in-network Highmark provider can substantially reduce your out-of-pocket expenses. In-network providers have agreed to Highmark's negotiated rates, resulting in lower costs for covered services. Additionally, in-network providers handle most of the insurance paperwork, submitting claims directly to Highmark on your behalf.

This streamlined billing process minimizes your administrative burden during treatment, allowing you to focus on your recovery rather than managing insurance paperwork. In-network providers are also familiar with Highmark's authorization requirements and coverage policies, which can help prevent unexpected denials or gaps in coverage.

Access to Quality Care and Coordinated Services

Highmark maintains a diverse network of mental health professionals, including psychiatrists, psychologists, licensed therapists, and specialized treatment facilities. These providers must meet Highmark's credentialing standards, ensuring a baseline level of quality care.

Through their Mental Well-Being program, Highmark offers members access to care navigators who can guide you to the right level of care based on your specific needs. This care navigation service helps ensure you receive appropriate treatment while maximizing your insurance benefits.

Additionally, Highmark's integrated approach may facilitate better coordination between your mental health providers and other healthcare providers, supporting comprehensive care that addresses both physical and mental health needs.

How to Determine if Your Specific Highmark Plan Covers Needed Treatment

Highmark offers various plans with different levels of coverage, so determining exactly what your specific plan covers is essential for effective treatment planning.

Reviewing Plan Documents and Using Online Tools

Start by carefully reviewing your Highmark plan documents, including your Evidence of Coverage and Summary of Benefits. These documents outline your mental health benefits, including copayments, deductibles, coinsurance, and any coverage limitations.

Highmark also provides online tools and resources for members to understand their benefits. By logging into the Highmark member portal or using the My Highmark mobile app, you can access personalized information about your coverage, find in-network providers, and check if specific services require authorization.

When reviewing your plan, pay particular attention to:

• Mental health and substance abuse treatment benefits

• In-network vs. out-of-network coverage differences

• Prior authorization requirements

• Visit or session limitations

• Inpatient and higher levels of care coverage

• Telehealth benefits for mental health services

Direct Verification Methods

For the most accurate and personalized information about your coverage, contact Highmark Member Services directly using the number on your insurance card. A representative can explain your specific mental health benefits and answer questions about coverage for particular services or conditions.

When speaking with Highmark representatives, be specific about the types of treatment you're considering, as coverage may vary for different services. Ask about both in-network options and any coverage for out-of-network providers if you have a preferred provider who doesn't accept Highmark.

Many mental health providers also offer insurance verification services and can help you understand your specific coverage for their programs. They can check your benefits before you begin treatment, helping you make informed decisions about your care.

Recent Developments in Highmark's Mental Health Coverage

Highmark has implemented significant enhancements to its behavioral health services in recent years, reflecting the growing recognition of mental health's importance and the evolving landscape of mental health care.

Expansion of Telehealth and Digital Mental Health Resources

One of the most notable recent developments is Highmark's expansion of telehealth options for mental health care. Their Mental Well-Being program offers virtual therapy sessions, making mental health support more accessible to members who may face barriers to in-person care, such as transportation challenges, busy schedules, or mobility limitations.

Beyond traditional telehealth appointments, Highmark has developed digital mental health resources to support members between appointments. These resources include wellness apps, online self-assessments, and digital tools for stress management, meditation, and sleep improvement. These digital offerings complement traditional therapy, providing additional support for members working on their mental health.

Focus on Timely Access and Preventive Care

Highmark has also emphasized improving timely access to mental health care. Their behavioral health program aims to provide fast access to therapy and psychiatry, typically within five days or less. This commitment to timely care recognizes that delays in treatment can exacerbate mental health conditions and lead to poorer outcomes.

Additionally, Highmark has increased its focus on preventive mental health care and early intervention. By providing behavioral health screenings and resources for managing stress and building resilience, Highmark aims to help members address mental health concerns before they become severe. This preventive approach aligns with Highmark's broader commitment to supporting whole-person health and wellness.

The Patient Journey with Highmark Insurance

Understanding what to expect throughout your treatment journey with Highmark can help you navigate the process with greater confidence and less stress.

Starting Your Mental Health Care Journey

When beginning your mental health treatment journey with Highmark, you have several entry points. Many members start by discussing mental health concerns with their primary care physician, who can provide initial support and referrals to specialized mental health services. Alternatively, you can contact a mental health provider directly or use Highmark's provider directory to find an in-network specialist.

Before your first appointment, verify that the provider accepts your Highmark plan and check if you need a referral or authorization. At your initial appointment, the provider will conduct an assessment to understand your needs and develop a treatment plan. Be prepared to share your mental health history, current symptoms, and treatment goals.

Common steps in starting mental health care with Highmark include:

1. Recognizing when you need support for your mental health

2. Checking your Highmark coverage for mental health services

3. Finding an in-network provider through Highmark's directory

4. Scheduling an initial assessment appointment

5. Participating in the development of your treatment plan

6. Understanding your financial responsibility for services

7. Beginning regular therapy sessions or recommended treatment

Ongoing Treatment and Support Resources

Throughout your treatment, maintain open communication with both your provider and Highmark about your care. If your treatment needs change—for example, if you need to transition to a different level of care or add medication management—work with your provider to ensure proper authorization if required.

Highmark offers additional resources to support your mental health journey beyond formal treatment. These include online educational materials about mental health conditions, self-help tools, and community resources. Many of these resources are available through Highmark's website or member portal.

Remember that recovery and mental health improvement often take time. Be patient with yourself throughout the process, and don't hesitate to advocate for your needs if your current treatment isn't meeting your expectations. Your Highmark coverage is a valuable tool to support your mental health journey, and understanding how to maximize your benefits can help you receive the care you deserve.

Finding Treatment Facilities That Accept Highmark

When you're ready to find mental health treatment using your Highmark insurance, several resources can help you locate appropriate providers.

Our Treatment Facility Directory

Our mental health treatment directory offers a convenient way to find facilities that accept Highmark insurance. You can search for providers by location and specialty, filter results to show only Highmark-accepting facilities, and view detailed program information to find the right fit for your needs.

Ready to find mental health treatment covered by your Highmark insurance? Browse our directory of Highmark-accepting facilities in your area today.

Taking the Next Step in Your Mental Health Journey

Navigating mental health insurance can feel overwhelming, especially when you or a loved one is already struggling with behavioral health challenges. However, with Highmark's comprehensive coverage options and commitment to mental health parity, accessing quality mental health treatment is within reach.

Remember that seeking help is a sign of strength, not weakness. Mental health conditions are highly treatable, and with proper support, recovery and improved quality of life are achievable goals. Your Highmark insurance provides a valuable resource for accessing the care you need.

Whether you're taking the first step toward treatment or continuing your mental health journey, understanding your insurance coverage empowers you to make informed decisions about your care. By working with providers who accept Highmark, you can focus on what matters most, your wellbeing and recovery.

Don't wait to get the support you deserve. Explore our directory of mental health treatment facilities that accept Highmark insurance and take the next step toward healing today.

References

[1] "Mental and Behavioral Health with Medicare" Highmark Wholecare. https://www.highmark.com/wholecare/medicare/benefits-programs/benefit-list/mental-behavioral-health

[2] "Mental Health Parity" Highmark. https://www.highmarkhealthoptions.com/mental-health-parity.html

[3] "Behavioral Health Support" Highmark Insurance. https://www.highmark.com/employer/care-management/behavioral-health

[4] "Behavioral Health Care" Highmark. https://www.highmark.com/because-life/mental-health

[5] "Authorization Guidance" Highmark. https://providers.highmark.com/claims-and-authorization/authorization-guidance