Does Highmark Include Rehab Treatment Coverage?

July 27, 2024

By Arch Recovery Center

Discover if Highmark insurance covers rehab treatment. Unveil the facts and maximize your coverage for a healthier future.

Understanding Highmark Insurance Coverage

When it comes to rehab treatment coverage, it's important to understand the specifics of your insurance plan. Highmark Insurance, based in Pittsburgh, provides coverage to over 6 million Americans and offers plans under the Affordable Care Act (ACA) that mandate coverage for mental and behavioral health treatment, including inpatient services and substance abuse treatment. Highmark insurance plans cover approximately 5.6 million people in Pennsylvania, Delaware, and West Virginia, with various managed care insurance programs available [2].

Overview of Highmark Insurance

Highmark Insurance offers marketplace insurance plans that comply with the ACA. These plans cover some or all of the costs of drug and alcohol rehab programs, depending on the specific plan, state of residence, in- or out-of-network facilities, length of stay, and insurance plan level. Highmark insurance plans are categorized by metal levels, reflecting the amount paid monthly and at the time of service, rather than the quality of service received.

Benefits of Rehab Coverage

Highmark Insurance recognizes substance abuse as an illness and provides coverage for a variety of recovery programs. These programs may include inpatient and outpatient treatment facilities, individual and group therapy, medically assisted detoxification, and associated services. Coverage may also be available for co-occurring mental illnesses contributing to drug or alcohol addiction [2]. Highmark insurance plans generally offer coverage for substance abuse treatment and mental health care, aligning with the importance of addressing both physical and mental well-being.

To determine the specifics of your coverage, it is crucial to refer to your own plan and policy. This will help you understand which rehabilitation centers are covered and what your out-of-pocket expenses may be. Highmark Insurance policies may provide partial to full coverage for medical detox programs, including medication-assisted treatment. Additionally, copay assistance and prescription discounts may be available for certain members within their coverage area.

Understanding the coverage provided by Highmark Insurance is essential for individuals seeking rehab treatment. By checking the specifics of your plan and policy, you can ensure that you maximize your coverage and receive the necessary support for your recovery journey.

Types of Rehab Treatment Covered

Highmark insurance provides coverage for a range of rehab treatments, ensuring that policyholders have access to the care they need for their recovery journey. The types of rehab treatment covered by Highmark include physical therapy, occupational therapy, speech therapy, and substance abuse treatment.

Physical Therapy and Occupational Therapy

Highmark recognizes the importance of physical therapy and occupational therapy in helping individuals regain their functional abilities and improve their quality of life. Physical therapy focuses on restoring mobility, reducing pain, and improving strength and flexibility. Occupational therapy aims to enhance individuals' ability to perform daily living activities and regain independence.

Whether you require physical therapy to recover from an injury, surgery, or a chronic condition, or occupational therapy to regain skills for daily living and work, Highmark insurance can provide coverage for these essential rehab treatments.

Speech Therapy and Substance Abuse Treatment

In addition to physical therapy and occupational therapy, Highmark insurance also covers speech therapy and substance abuse treatment. Speech therapy is vital for individuals with speech and language disorders, helping them improve their communication skills and overcome speech-related challenges.

Highmark recognizes substance abuse as an illness and provides coverage for substance abuse treatment. This coverage may include inpatient and outpatient treatment facilities, individual and group therapy, medically assisted detoxification, and associated services. Coverage may also be available for co-occurring mental illnesses that contribute to drug or alcohol addiction.

By covering a variety of recovery programs, Highmark insurance aims to support individuals seeking treatment for substance abuse and ensure they have access to the necessary care for their recovery journey.

It's important to note that coverage may vary depending on the specific Highmark insurance plan and individual policy details. To determine the exact coverage for rehab treatment, individuals should refer to the specifics of their own plan and consult with their insurance provider.

Highmark's comprehensive coverage for rehab treatment reflects its commitment to supporting individuals on their path to recovery and ensuring access to the care they need. Whether it's physical therapy, occupational therapy, speech therapy, or substance abuse treatment, Highmark insurance strives to provide coverage for these essential rehab services.

In-Network vs. Out-of-Network Coverage

When it comes to rehab treatment coverage, Highmark insurance offers both in-network and out-of-network coverage options. It's important to understand the advantages and considerations associated with each.

Advantages of In-Network Providers

Utilizing in-network providers can have several advantages for individuals seeking rehab treatment with Highmark insurance. In-network providers have established relationships with Highmark, resulting in negotiated rates and potentially lower out-of-pocket costs for policyholders [4]. By choosing an in-network provider, you can have confidence that the facility and services meet Highmark's quality standards.

Another advantage of in-network providers is the streamlined claims process. Since they have an existing relationship with Highmark, the claims are typically processed more efficiently, reducing the administrative burden for both the policyholder and the provider. This can result in a smoother experience when it comes to billing and reimbursement.

In-network providers offer an added layer of financial protection through Highmark's contractual agreements. These agreements ensure that the provider accepts the negotiated rates, which can help policyholders avoid unexpected out-of-pocket expenses.

Considerations for Out-of-Network Providers

While Highmark does offer coverage for out-of-network providers, there are some important considerations to keep in mind. Out-of-network providers may result in higher costs compared to in-network providers. Policyholders typically pay a higher percentage of the total cost when using out-of-network providers.

Highmark typically pays up to 50% co-insurance for out-of-network providers, although it's important to note that some providers may not accept Highmark insurance [2]. Before beginning treatment, it is advisable to confirm coverage with a Highmark representative and an admission counselor to understand the potential out-of-pocket expenses associated with out-of-network providers.

To ensure the best coverage and minimize financial surprises, it is recommended to review the specifics of your Highmark insurance plan. This will help you determine which rehab facilities are covered and what your out-of-pocket expenses may be.

By carefully considering the advantages of in-network providers and the potential costs associated with out-of-network providers, you can make an informed decision about which option is best for your rehab treatment needs. Remember to consult your Highmark insurance plan details and reach out to Highmark representatives to clarify any uncertainties regarding coverage and costs.

Factors Affecting Coverage Amount

When it comes to rehab treatment coverage, the amount covered by Highmark insurance can vary depending on several factors. Understanding these factors is essential to determine the extent of coverage for rehab treatment. The two main factors that affect the coverage amount are the state of residence and the plan level.

State of Residence and Plan Level

The coverage for rehab treatment provided by Highmark insurance can vary from state to state. Highmark offers insurance plans in Pennsylvania, Delaware, and West Virginia, covering approximately 5.6 million people in these regions [2]. The coverage details may vary based on the state regulations and guidelines.

In addition to the state of residence, the plan level within Highmark insurance can impact the coverage amount. Highmark insurance plans are available through the Affordable Care Act (ACA) and are categorized by metal levels, such as Bronze, Silver, Gold, and Platinum. These metal levels indicate the amount paid monthly and at the time of service, rather than the quality of service received [2]. The higher the metal level, the more comprehensive the coverage is likely to be.

To determine the exact coverage amount for rehab treatment, it is recommended to review the specific insurance plan details provided by Highmark. This will help individuals understand the coverage limits, co-insurance percentages, and any additional requirements or restrictions associated with their specific plan.

Length of Stay and Facility Type

The coverage provided by Highmark insurance for rehab treatment also depends on the length of stay and the type of facility chosen. The duration of a rehab program can vary depending on the individual's needs and the severity of the condition. Highmark typically covers a range of treatment programs, including 28 to 30-day programs, 60-day programs, 90-day programs, and longer programs, with the coverage amount varying based on the plan [2].

The type of facility chosen for rehab treatment is another factor that affects coverage. Highmark covers both inpatient and outpatient treatment facilities for substance abuse rehabilitation. Inpatient programs typically involve residential treatment, where individuals reside at the facility for a specified period, while outpatient programs allow individuals to receive treatment while living at home. The coverage amount may differ between these two types of facilities, with inpatient treatment often having higher coverage limits.

It is important to note that while Highmark generally covers rehab treatment, coverage for out-of-network providers may be different. Highmark typically pays up to 50% co-insurance for out-of-network providers, but it is advisable to confirm coverage with a Highmark representative and an admission counselor before beginning treatment [2].

Understanding the factors that affect rehab treatment coverage provided by Highmark insurance is crucial when seeking treatment. By considering the state of residence, plan level, length of stay, and facility type, individuals can make informed decisions about their rehab treatment options. It is always recommended to review the specific details of the insurance plan and consult with insurance representatives or treatment providers to ensure a clear understanding of the coverage available.

Maximizing Highmark Rehab Coverage

When it comes to maximizing rehab treatment coverage, Highmark provides marketplace insurance plans that cover some or all of the costs of drug and alcohol rehab programs as mandated by the Affordable Care Act (ACA) [2]. To make the most of your Highmark insurance plan for rehab treatment, consider the following strategies:

Utilizing Marketplace Insurance Plans

Highmark offers marketplace insurance plans through the Affordable Care Act (ACA). These plans are categorized by metal levels, indicating the monthly costs and service payments, rather than the quality of service received. By utilizing these marketplace insurance plans, individuals can access coverage for rehab treatment while managing their healthcare expenses.

Marketplace insurance plans from Highmark may cover the costs of both inpatient and outpatient rehab treatment. Inpatient treatment typically involves staying at a rehab facility and may include services such as individual and group therapy, medically assisted detoxification, and associated services. Outpatient treatment, on the other hand, allows individuals to receive treatment while residing at home or visiting a treatment center several times a week. The specifics of coverage and expected costs for outpatient treatment can be obtained by visiting the Highmark website or contacting their toll-free number.

To maximize your Highmark rehab coverage, it is advisable to explore the specific marketplace insurance plans available in your state and select one that aligns with your rehab treatment needs. This ensures that you have access to the necessary services while managing your financial obligations.

Checking Coverage Details

To ensure that you make the most of your Highmark rehab coverage, it is essential to check the coverage details of your specific insurance plan. While Highmark insurance plans generally cover rehab treatment, the extent of coverage may vary depending on factors such as the state of residence, plan level, in- or out-of-network facilities, length of stay, and facility type [2].

To determine which rehabilitation centers are covered by your Highmark insurance plan and understand your out-of-pocket expenses, refer to the specifics of your plan. Highmark insurance plans typically have preferred provider networks, and going to in-network rehab facilities can help optimize coverage. However, out-of-network providers may also be covered, with Highmark often paying up to 50% co-insurance for these providers. It is advisable to confirm coverage with a Highmark representative and an admission counselor before beginning treatment.

By checking the coverage details of your Highmark insurance plan, you can have a clear understanding of the services covered, any network restrictions, and the associated costs. This knowledge empowers you to make informed decisions regarding your rehab treatment and ensures that you maximize the benefits offered by your Highmark insurance plan.

Maximizing your Highmark rehab coverage involves utilizing marketplace insurance plans and checking the coverage details of your specific plan. By taking these steps, you can access the necessary rehab treatment while effectively managing your healthcare expenses. For more information on rehab treatment coverage offered by other insurance providers, check out our articles on does Aetna cover rehab treatment?, does United Healthcare cover rehab?, does Coventry cover rehab treatment?, and does Connecticare cover rehab treatment?.

Authorization and Utilization Management

When it comes to rehab treatment coverage, Highmark requires certain authorization and utilizes management tools to ensure appropriate utilization of services. This section will delve into the prior authorization requirements and utilization management tools implemented by Highmark.

Prior Authorization Requirements

Prior authorization is a process where Highmark requires authorization for certain services, procedures, and/or Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) prior to performing the procedure or service. The authorization is typically obtained by the ordering provider. It's important to note that some authorization requirements may vary depending on the member's contract with Highmark [5].

The specific authorization requirements for rehab treatment coverage may vary based on the member's benefit plan and eligibility at the time of service review and approval. Benefit plans can vary widely and are subject to change based on the contract effective dates. Providers are responsible for verifying member eligibility and covered benefits before proceeding with rehab treatment [5].

Utilization Management Tools

Highmark has implemented utilization management tools to facilitate the authorization process and ensure appropriate utilization of rehab treatment services. One such tool is the Predictal Auth Automation Hub, which allows offices to submit, update, and inquire about authorization requests. This tool streamlines the process and enhances efficiency for healthcare providers.

In addition, Highmark has partnered with eviCore healthcare for utilization management of physical medicine services. For Post-Acute Care for Medicare Advantage members, Highmark contracts with Home & Community Care Transitions. These partnerships and utilization management tools help Highmark ensure appropriate utilization of rehab treatment services while maintaining quality care and cost-effectiveness.

For more detailed information on authorizations and utilization management, providers can refer to Chapter 5 (Care & Quality Management) of the Highmark Provider Manual.

Understanding the authorization and utilization management requirements is essential when seeking rehab treatment coverage with Highmark. By adhering to the prior authorization process and utilizing the available tools, healthcare providers can ensure smooth and efficient access to rehab treatment services for their patients.