Highmark Rehab Insurance Coverage

Highmark insurance provides health insurance for all the health care needs that have been deemed essential by the Affordable Care Act, including treatment for substance use disorders. Learn how costs can vary among plans, which treatments are covered, and what to expect in rehab.

Highmark Health is a national blended health insurance organization providing coverage to millions. It may be headquartered in Pittsburgh, with Highmark focusing heavily on the region, including Pennsylvania, Delaware, West Virginia, and eastern and northwestern New York, but the company serves individuals and businesses in all 50 states and the District of Columbia.

Highmark Health includes one of the U.S.’s largest Blue Cross Blue Shield insurers, and it’s part of a growing regional hospital and physician network. They also offer options to supplement Medicare coverage.

When people look into rehab for drug or alcohol addiction, questions like cost or will insurance cover treatment are probably two of the most pressing concerns. While rehab isn’t cheap, broad coverage, including with something like Highmark’s BlueCard, with 1.7 million providers and 95% of all hospitals nationwide accessible via the plan, can make a tough, emotionally fraught decision easier to manage.

Affordable Care Act

The Affordable Care Act (ACA) made substance abuse treatment and mental health care into essential benefits, so most folks with health insurance should have some degree of coverage. The kind of plan one has, however, will determine exactly where they can seek treatment as well as what the copays, deductible, and coinsurance requirements will be.

Whether an addiction treatment facility offers more standard care or luxury rehab, that also will factor into costs.

It’s always a good idea to do research ahead of time, to avoid surprises. Your insurance provider can answer a lot of questions about coverage, copays, and other costs. They’ll also be able to tell you if treatments or services require prior approval. Rehab centers can provide answers, too. They work very closely with insurers and can give information about their services and what the costs will be.

Getting treatment (or any care, for that matter) from in-network doctors, clinics, and hospitals is also a good way to save money.

Highmark Levels of Care

Highmark Health offers several levels of care, including:

  • Gold: Premiums are higher but out-of-pocket costs are low. Gold plans tend to be good for people who need to utilize healthcare services more often. There even are Gold options with $0 deductibles. Copays and coinsurance vary plan by plan.
  • Silver: These have middling premiums and middling out-of-pockets costs. Highmark’s Silver plans don’t qualify for advance premium tax credits. Deductibles and co-pays differ among plans.
  • Bronze: These have low premiums with high out-of-pocket costs. Bronze can work well for the person who wants to keep monthly premiums low, or who rarely goes to the doctor. Deductibles and copays fluctuate among plans.
  • Extra Savings Silver: This Highmark offering includes cost-sharing reductions. Some people choose this option to help balance premiums with out-of-pocket costs.
  • Catastrophic: These plans have a very low premium with high out-of-pocket costs. They’re available to people under 30 or those with a qualifying hardship. Catastrophic coverage is suggested primarily for emergency-only cases. An individual catastrophic plan might have an in-network $8,700 deductible and $0 costs once that is met, including for inpatient hospitalization.

In shopping for plans it’s a good idea to consider how often you may need to see a doctor or specialist if you might need surgery or other special care, and whether you have regular prescriptions.

Highmark offers access to the essential benefits (as outlined by the ACA) including hospitalization, emergency care, pregnancy/maternity/newborn care, and preventive services. Mental health and substance use disorder services are also among those essentials.

Most plans recommend staying in-network to save money. That applies to Highmark, too, but some options like their BlueCard permit some out-of-network access to emergency or urgent care treatment, but it’s always a solid idea to confirm what your plan explicitly allows.

Drug and Alcohol Rehab

Does Highmark Health insurance cover drug and alcohol rehab? Substance abuse treatment and behavioral health are covered. It can include emergency care and detoxification, inpatient treatment, intensive outpatient treatment, therapy, and counseling. It will depend on patient needs and what medical experts suggest. Many procedures will need prior authorization, especially where residential treatment is concerned.

The type of plan will determine how much of the costs you are responsible for. Gold plans will mean smaller deductibles and a lower coinsurance requirement, while for Bronze plans the reverse is true.

Length of Treatment

The length of treatment Highmark Health insurance allows tends to vary.

The National Institute on Drug Abuse (NIDA) suggests considering a patient’s health history, how long they’ve used drugs or alcohol, and how frequently, along with other factors like age, gender, ethnicity, and more as a treatment plan is prescribed. A longer stay in rehab (three months, or longer, if possible) usually makes for better patient outcomes.

Rehab centers also work hand-in-hand with insurers, to secure needed care (or extra treatment time) for patients who may not be ready to exit rehab.

Mental Health

Does Highmark Health also cover mental health? Mental health care is one of the essential benefits lined up by the ACA, so Highmark does offer its subscribers mental health coverage.

That can be helpful because mental health conditions and substance use disorders frequently overlap. When a person is diagnosed with both, that’s a case of co-occurring disorders. Treating both can lead lead to more successful outcomes.

Mental health care can take on many forms, including counseling and therapy, inpatient and outpatient care, and medications to keep symptoms more under control.

Inpatient Rehab

Highmark Health insurance inpatient rehab is usually recommended for people who are undergoing alcohol or drug addiction treatment. Stays for inpatient programs usually last from 30 to 90 days, though some programs may require people to stay longer.

Inpatient rehab involves several stages, including:

  • Assessment. The patient is examined so staff gets a full picture of their health. That’ll be used to shape a treatment plan for any pressing health needs and to begin treating any mental health disorders if they’ve been undiagnosed or overlooked.
  • Detoxification. Many patients must undergo detox when they first enter rehab. The body will be rid of drugs or alcohol (or both). Severe opioid, alcohol, or benzodiazepine addiction can be extremely dangerous to quit full stop, so medical oversight ensures patient safety and comfort. It also helps minimize nausea, insomnia, vomiting, and other conditions that manifest during detox.
  • Treatment. This includes behavioral (or talk) therapies like cognitive-behavioral therapy to determine the root causes of addictive behaviors. Patients will become familiar with the reasons why they use and learn healthier coping mechanisms. Sometimes holistic therapies are part of the program, teaching the patient how to relax and reduce stress. Support groups provide camaraderie and provide insights and advice.
  • Aftercare. Here, the patient is prepared for life after rehab. Regular check-ins may be scheduled to monitor progress. Challenges and wins may be discussed. The patient will more than likely be connected with support groups and counselors closer to home, so they can continue with their recovery journey and avoid relapse.

The more intensive and longer-term treatment approach helps people stay off substances for longer periods, which can help with longer-term recovery. Inpatient rehab tends to offer fewer outside distractions and more time to focus on recovery.

Prior authorization is typically required for inpatient hospitalization.

Outpatient Services

Highmark Health insurance outpatient services allow patients to follow rehab plans without requiring them to stay at the facility. That can be helpful if they are unable to do so. A center will develop a care plan that a client follows during the day, sometimes several times a week. That can include therapy and other treatment protocols. Then they may go home or to a sober living facility at night.

Suboxone Treatment

Suboxone is often used to treat opioid use disorder. The generic version is a blend of buprenorphine and naloxone.

It’s usually part of a medication-assisted treatment (MAT) program, which blends behavioral therapies with medicine. They’re safe to use long-term and MAT has been found to keep people in treatment longer, reduce illicit opioid use, and prevent relapse.

Suboxone (and its generic equivalent) have a longer half-life so it can help treat short-acting opioids like heroin or oxycodone. The longer half-life and reduced intensity mean the effect will not rapidly wear off, leaving someone scrambling to take more (possibly dangerous amounts) to avoid withdrawal.

Suboxone, or the generic equivalent of buprenorphine-naloxone, is covered by Highmark Health plans.

Methadone Treatment

Methadone is another drug that’s approved to treat opioid use disorders. It’s also part of MAT care.

Methadone is an opioid agonist that has a long half-life. It reduces cravings and minimizes withdrawal symptoms because the effects are less intense. That can help prevent relapse.

Does Highmark Health insurance cover methadone treatment? It is covered under Highmark, but the exact copay and formulation will vary by plan.

Paying for Rehab

Addiction rehab, especially if hospitalization, detoxification, and inpatient care are involved, can be pricey. Some people may fear even considering treatment out of fear that it’ll be expensive.

Insurance can help considerably, however. Knowing your plan and going in-network for care can make rehab a lot less costly.

Deductibles and coinsurance obligations are a given, so when researching treatment it’s a smart idea to find out what deductibles, copays, and coinsurance will be.

Insurance companies can answer these questions as well as tell you which rehab facilities would be in your network. They’ll also clear up what needs authorization ahead of time.

Addiction centers can also provide answers and help the approval process along.

For services not covered by Highmark Health insurance policies, many rehabs can set up installment plans so paying deductibles and other costs becomes easier to manage. Financing may be an option as well.

Sources

Medical disclaimer:

Sunshine Behavioral Health strives to help people who are facing substance abuse, addiction, mental health disorders, or a combination of these conditions. It does this by providing compassionate care and evidence-based content that addresses health, treatment, and recovery.

Licensed medical professionals review material we publish on our site. The material is not a substitute for qualified medical diagnoses, treatment, or advice. It should not be used to replace the suggestions of your personal physician or other health care professionals.

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