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For many people, deciding to seek help for addiction comes with a mixture of hope and uncertainty. Much of this uncertainty stems from questions related to paying for treatment. Your Highmark insurance plan may cover rehab, aftercare and other services, but there are often restrictions related to medical necessity, prior authorization and location.

In this guide to Highmark rehab coverage, you’ll learn how the company typically processes claims for drug and alcohol rehab. The good news is that your plan may offer both in-network and out-of-network coverage for inpatient care, detox and related services. However, the exact level of coverage depends on what type of plan you have and how it’s designed.

Highmark plans may offer coverage for drug and alcohol rehab, but there are usually some limitations. When you choose an in-network rehab, you typically have to pay less out of pocket. This is because in-network providers have contracts with your insurer.

Out-of-network coverage may be available with point-of-service (POS) or preferred provider organization (PPO) plans. However, out-of-network care usually costs more because the facility hasn’t agreed to accept the company’s discounted reimbursement rates.

The type of plan you have may limit your options when it comes to choosing a rehab. Health maintenance organizations (HMOs) require referrals from a primary care provider. They don’t cover out-of-network care unless it’s an emergency.

POS, PPO and exclusive provider organization (EPO) plans offer more flexibility, but they still have some restrictions. Highmark may require prior authorization or require you to prove that rehab is medically necessary.

Many addiction treatment services are covered under a plan’s behavioral health benefits. Inpatient care includes supervised detox and residential rehab, while therapy and continuing care typically fall into the outpatient category.

Depending on your plan, Highmark may cover:

• Aftercare services
• Supervised medical detox
• Outpatient counseling
• Inpatient/residential rehab
• Medication-assisted treatment (MAT)

Many Highmark plans follow the federal parity guidelines, which require insurers to treat mental health services and medical services the same way. This doesn’t mean they’ll cover every addiction-related service, but it can help you access professional care for your substance use disorder.

Recovery is a series of steps, so it’s common to need more than one type of treatment. Understanding how your benefits apply to each stage can help you feel less overwhelmed.

Medical Detox

If you’re physically dependent on a substance, detox can provide much-needed stabilization. Your plan may cover detox, but you’ll likely need to meet the medical necessity criteria.

During your stay, Highmark may also conduct a length-of-stay review to determine if you’ve made enough progress to move to the next phase. These reviews help match your level of care to your current needs.

Inpatient or Residential Rehab

Inpatient rehab requires you to live at a treatment center. This gives you 24-hour access to trained professionals. It’s also highly structured.

Due to the amount of support available, residential rehab is often the most expensive form of addiction treatment. If your plan covers it, you may have to obtain prior authorization. Highmark may also review your stay periodically.

Medication-Assisted Treatment (MAT)

Medication-assisted treatment (MAT) is sometimes used to help people recover from opioid addiction. Opioids are central nervous system (CNS) depressants that relieve moderate to severe pain.

Opioid addiction often causes strong cravings, so MAT combines medication with behavioral therapies. Medications can reduce your cravings, allowing you to focus on therapy and other services.

Medication claims are usually processed under a plan’s pharmacy benefits. Therapy may be billed under your behavioral health coverage.

Some medications require prior authorization. You may also have to choose a medication that’s on your plan’s formulary, which is a list of medications covered by an insurance plan.

Therapy and Counseling

Your plan may cover cognitive behavioral therapy, dialectical behavior therapy or other evidence-based treatments. A service is evidence-based when the best available research has shown that it works.

Highmark typically allows for ongoing therapy, but it depends on your plan. For example, there may be limitations related to frequency or duration.

Dual Diagnosis Support

It’s common for people with substance use disorders to have other mental health disorders. For example, you may have an addiction accompanied by post-traumatic stress disorder (PTSD), generalized anxiety disorder or depression. This is known as a dual diagnosis.

Not all rehabs offer separate mental health treatment, but they often provide dual diagnosis support. Highmark may cover integrated treatment to help you recover from both conditions, but you might have to meet the medical necessity criteria outlined in your plan documents.

Aftercare and Continuing Support

Recovery continues long after you finish a formal treatment program. Aftercare services can help you adjust to everyday life and maintain your progress.

Your plan may cover continued therapy and medications. In some cases, Highmark’s behavioral health benefits also cover step-down programs. It’s helpful to clarify what’s covered so you can access ongoing support.

The network status of a rehab center has a big impact on your out-of-pocket costs. In-network care is usually less expensive because those providers have contracts with your insurer. These contracts require each facility to accept Highmark’s discounted rates.

Out-of-network providers haven’t agreed to accept those rates, so your out-of-pocket costs will be higher. In some cases, you have to pay a higher coinsurance rate or an additional deductible.

Balance billing is also a concern. This practice involves requiring members to pay the difference between the billed amount and the amount approved by Highmark.

Multiple providers may be involved in your care. Determining if they’re in-network or out-of-network can help you avoid surprise bills later.

Your out-of-pocket costs may depend on these factors:

• Cost-sharing requirements (deductible, co-pays, coinsurance)
• Out-of-pocket maximum
• Admission timing
• Level of care changes
• Pharmacy costs for MAT (if needed)
• Length of stay

Highmark offers a wide range of plans, including:

• Medicare
• Medicaid
• Individual/family
• Employer-sponsored

Your plan may have one of the following designs:

• Health maintenance organization (HMO): This type is the most restrictive. You must get a referral for a primary care provider if you need specialty care, and there’s no coverage for out-of-network care unless it’s an emergency.
• Point-of-sale (POS): POS plans require referrals, but they’re a little more flexible than HMOs. They typically offer out-of-network coverage at a higher cost.
• Exclusive provider organization (EPO): EPOs don’t require referrals, but you must choose an in-network facility if you want to take advantage of your rehab coverage.
• Preferred provider organization (PPO). PPO plans are the most flexible. You don’t need a referral for specialty care, and your plan may cover out-of-network care. However, it’s common for out-of-network services to have a higher coinsurance rate than in-network services

DIY Verification Steps (Member)

You can verify your rehab coverage by following these steps:

1. Call the number on your Highmark ID card.
2. Find out if your preferred facility is in-network or out-of-network.
3. Determine whether you need prior authorization for the required level of care.
4. Ask questions about your deductible, coinsurance and other out-of-pocket costs.
5. Gather information on service limitations, such as length-of-stay reviews, medical necessity criteria and session limits.

Fastest Option: Let a Rehab Verify for You

Letting a rehab verify your coverage is much faster. All you have to do is give the facility your policy name and number. A representative can verify in-network status, coverage limits and out-of-pocket costs.

However, Highmark makes the final call, and verification doesn’t guarantee your plan will cover everything.

Denials and limitations are common, especially if you’re missing required documentation.

Here’s what you can do to overcome these obstacles:

• Get the reason for the denial.
• Ask for information on the appeals process and required documentation.
• Request a peer-to-peer review or a clinical review.
• Find out whether Highmark will allow a single-case agreement.

Single-case agreements are one-time contracts that allow you to receive out-of-network care at in-network rates.

Support is an essential part of addiction recovery. Help.org can give you the support you need to understand your Highmark rehab coverage and verify your benefits.

If you’re ready to get help for a substance use disorder, call or fill out the online form. All we need is your birth date, plan name and policy number.