Frequently Asked Questions
 

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What is Highmark Direct?

What are Highmark Direct Stores?

In our stores, licensed associates offer personalized assistance to people searching for the right health insurance policy — for themselves or for their families. Since the first Highmark Direct location opened in 2009, more than 330,000 people have visited our stores. We offer a personalized way to shop for health insurance; Here are some of the services that our Highmark Direct stores offer:

  • One-on-one consultations with licensed associates to discuss health insurance options and receive assistance in applying for and purchasing coverage
  • Highmark plans for individuals without employer health coverage, such as students, recent graduates, or people who are self-employed, between jobs, or retiring early
  • Medicare products for seniors
  • Group plans for companies with 50 or fewer employees
  • Health insurance for travelers and expatriates from GeoBlue®^
  • Medicare information seminars for seniors

 

 

Are the health plans offered at Highmark Direct the same as the health plans offered online?

Yes.  For information regarding health insurance plans offered by Highmark, prior to visiting Highmark Direct, please visit Discover Highmark.  At Discover Highmark you find tools and resources that will help you understand your options.

 

I’m a current member; can I visit a store if I have questions about my claims and benefits?

Yes.  We offer two convenient options in-store to help answer your customer service questions:

  • Customer Service Self Service Kiosks -- At these kiosks we will help you access your Highmark member website as well as help connect you to a Highmark customer service rep directly via phone, bypassing wait time.
  • Video conference capability -- If you prefer to speak to someone “face to face”, Highmark Direct’s Video conference capability can help! Connect with a customer service rep from one of customer service walk-in centers to have your questions answered.
  • In-Store Customer Service Representatives -- Exclusively at our Highmark Direct stores in Erie and Allentown we offer in-store Customer Service.  A Customer Service Representative can help answer your customer-service inquires.  They can assist you with:
    • Better understanding your claims, benefits and enrollment
    • Using Member Advocacy Services
    • Taking premium payments; We accept checks, money orders, Visa® and Mastercard®
    • Utilizing the tools and services available to you through the Highmark Member website

Other convenient ways to access customer service include:

  1. Call the Member Service/Benefits Questions phone number listed on the back of your ID card.
  2. Log into your Highmark Member website. To access your site, select the service region noted on your member ID card.
  3. Visit a Highmark Member Service walk-in center; to find locations, visit your Member website and click on “Contact Us.”
 

Do I need an appointment?

No, but appointments are recommended. Walk-ins are welcome but subject to availability of licensed associates and previously scheduled appointments.  Wait times for walk-ins vary.

 

What do I need to bring with me to a consultation?

Please bring with you:

  1. Name, birthdates, and Social Security numbers (or document numbers for legal immigrants) for everyone in your family who needs health coverage
  2. Employer and income information (e.g., pay stubs, W-2 forms — Wage and Tax Statements)
  3. Health insurance policy numbers for anyone in your family who currently has health coverage
  4. If losing group coverage, a letter showing proof of cancelation
  5. Valid email address 
 

Do you take all forms of payment in the stores?

We accept check, money order, Visa, MasterCard, Discover, and American Express for in-store payments.  We are unable to accept payments over the phone or cash.

 

Is there a plan that will cover me immediately even if I do not have creditable coverage?

Yes.  We offer a variety of plans to help cover your needs regardless if you have creditable coverage or not.  We have Short Term coverage that can cover you the very next day as long as you can complete a short questionnaire.   However, it is important to note, that Short Tem coverage does not cover pre-existing conditions and is not a qualified Affordable Care Act (ACA) health plan, which means you could potentially incur a monetary penalty.

 

Where are the stores located? What are the hours of operation?

We have ten Highmark Direct stores located throughout western and central Pennsylvania.  Our stores are open Monday through Saturday from 9am to 6pm.  Visit our store locator for addresses, phone numbers, and directions.

 

Typically how long is a consultation?

30 to 60 minutes.

 

Can I get a quote over the phone through the Highmark Direct store?

No.  We cannot provide quotes over the phone.  To receive a quote you must meet with one of our Highmark Direct licensed associates.  However, if you wish to receive a quote over the phone, please call 1-800-876-7639.

 
 

New to Highmark?

Do I need a referral for any services?

PPO plans do not require members to receive initial care through a primary care physician. You can decide for yourself where to obtain care. You can use network providers, including specialists, and receive a higher level of coverage, or go to out-of-network providers and receive a lower level of coverage – and pay more -- for covered services. The choice is yours.

 

How do I get a benefit booklet?

Once you enroll, you can review your benefit booklet online at the My Benefits page on the website.

 

When will I receive my insurance ID cards?

 You will receive your insurance ID card(s) after you make your first month’s premium payment.

 
 

The Basics

Why do I need health care coverage?

With the new laws established by the Affordable Care Act (ACA), it’s more important than ever to find a health plan that is right for you.  If you or your dependents don’t have insurance that qualifies as minimum essential coverage you may have to pay a penalty.  You will also have to pay for all of your medical expenses.  For more information regarding penalties please visit Healthcare.gov's "What if I dont have Health Coverage?"

In addition to avoiding penalties and paying for all of your health care expenses, one of the smartest things you can do is to protect yourself and your family with the right health care coverage, even if you are healthy.  The cost of medical care is increasing every day -- and getting treatment for an illness or injury could mean thousands of dollars of debt – even bankruptcy – if you don’t have health care coverage.

And what about staying healthy?  Regular check-ups, vision care, maternity care and well-child care visits are important ways to take care of yourself and your family.  With health care coverage that includes preventive care, you don’t have to think twice about scheduling regular check-ups.
 

 

 

How does health care coverage work?

Some individuals get health care coverage for themselves and their families through their employer as part of their benefits package.  Other individuals and families purchase coverage directly from a health insurance company.

When you go to a health care provider, your health insurance identification card shows the provider which plan you have and the payment you are expected to make for the service.  The provider then sends a claim (a bill for the services provided) to your insurance company, and, if the service is covered, the insurance company pays the provider for the service.  You receive an Explanation of Benefits (EOB) statement from the insurance company that tells you the amount the insurance company paid for the service and any remaining amount that you owe the provider.  If you did not pay at the time you received care, you will receive a bill from the provider for the amount you owe.

 

What are the costs for health coverage?

In addition to your premium, which is the series of payments to a health plan for your coverage, you may have to share the costs of the services you receive.

·         A deductible is the specified dollar amount you must pay each year for your health care expenses before your plan begins to pay.

·         A coinsurance is the specified percentage amount of the provider’s reasonable charge for covered services that you are required to pay for care after you have met your deductible.  For example, if the health insurance company pays 80 percent of the cost for a service, you would pay 20 percent coinsurance.

·         A copayment is a specific, upfront dollar amount that you pay every time you receive certain services or care, such as $20 for every doctor’s visit.  The health insurance company pays the remaining cost.  Copayments do not count toward your deductible.

 

What is a PPO plan?

A Preferred-Provider Organization (PPO) gives you access to a network of participating doctors, hospitals and other health care providers.  If you receive care from a network provider, you pay a lower share of the cost.  You can also choose to go to a doctor or hospital out of the network and pay a higher share of the cost for your care. You do not need to have a primary care physician to coordinate your care.

Some “qualified” PPOs are offered in conjunction with a Health Savings Account (HSA) as defined by the Internal Revenue Service.  Your HSA can be used to fund your out-of-pocket medical expenses using tax-free dollars.

 

What are provider networks?

A provider is any doctor, specialist, hospital or rehabilitation facility, for example, where you get health care.

Network providers are doctors, hospitals and other health care professionals and suppliers that have signed an agreement with a health plan to accept the amount that the company will pay for covered services as payment in full less any cost-sharing you’re responsible for.  They also file claims for you.

Out-of-network providers do not have an agreement with a health plan.  If you are treated by an out-of-network provider or facility, you’ll have to pay a greater share of the costs for your care.  You may also be responsible for paying any difference between the amount your plan pays and the provider’s charge for the service, and you may have to file your own claims. 

 

What should I consider when choosing a health care plan?

When selecting a health care coverage plan, you will want to research specific details about the plans you are considering, including:

Covered services – Most plans cover doctor visits, hospital stays, surgery and emergency care.  But if you want coverage for prescription drugs, vision or behavioral health, make sure the plan offers it.

Deductible – How much of your health care expenses are you responsible for paying before the plan begins to cover your care?  If you are covering family members too, do you need to meet more than one deductible?  Or do expenses for all covered family members count toward a single deductible?

Cost-sharing – What portion of the cost for services is paid by the plan and how much will you be responsible for?  Are those costs within your budget?

Network – Does the plan’s provider network include the doctors and hospitals you want?  If you use providers outside of the network, how much more will you pay for care?

Preventive care – This usually includes yearly check-ups, mammograms, Pap tests, prostate exams, immunizations and well-child visits. What kind of preventive care is covered?  Are there limitations on that care, such as the number of visits per year?

Maximums – Are there limits on how much the plan will pay for your care?

Health Savings Account – To enjoy the tax advantages of a Health Savings Account, should you consider enrolling in a qualified high-deductible health plan?

 

How can I be smart about my health care?

There are lots of things you can do to improve your health, become an educated health care consumer and help control health care costs.

  • Exercise, eat right, maintain a healthy weight and control stress. Enroll in wellness classes to help you meet your goals.
  • Select a provider by researching their credentials, their service costs and their quality performance ratings.
  • Get your preventive care, so a condition can be treated before it becomes serious.
  • Be sure to discuss possible medication side effects and interactions with your doctor and your pharmacist and keep both of them informed of all the medications you take.
  • Research treatment options. Talk to your doctor about alternative treatments to determine the option that is appropriate for you.
  • Learn about tests, procedures, surgeries and their costs, so you can communicate more effectively with your doctors.
  • Ask your doctor to prescribe generic drugs when possible. They’re usually less expensive.
  • Review your Explanation of Benefits (EOBs) to make sure the services you received are listed correctly.
  • Track your health care spending. Use this information to choose health care coverage that suits your needs and budget.
  • Read information about health topics and stay informed about changes in the health care industry.
 
 

In-Network or Out?

What is Community Blue?

With a Community Blue plan, you’ll have access to the region’s leading health care providers, including those that are a part of the Allegheny Health Network. These plans usually have lower premiums and provide access to nearly 720,000 providers in the Blues network across the country.  View "Community Blue: Quality Care in your Neighborhood... and Beyond" (Get Adobe® Reader®)  for more information, including a list of local hospitals that accept Community Blue.  You should always check with your doctors to verify what plans are accepted, before choosing a health plan.

 

Is my current doctor or hospital in the plan’s network?

With more providers than competitive plans, chances are good that your current physician and hospital are part of our extensive provider network.  Find a Doctor, Hospital or Medical Provider to see if your provider is in our network.

 

How is emergency care coverage handled?

In case of emergency, you’re covered at the higher level of benefits for emergency care received in or outside the PPO provider network.

 

Am I covered outside the plan’s service area?

Your PPO Plan has you covered no matter where you are. You can locate thousands of participating Blue Plan providers by calling BlueCard Access at 1-800-810-BLUE.

 

Am I covered when I travel outside the country?

Your PPO Plan is a Blue Plan. That means you enjoy all the services of BlueCard Worldwide. Your coverage travels with you through a worldwide network of care providers.

 
 

Understanding Costs

Do I qualify for financial assistance?

To help make health coverage more affordable, the government offers a new type of tax credit called an Advance Premium Tax Credit (APTC), or “Premium Tax Credit.” If you qualify, a Premium Tax Credit could help lower your monthly insurance cost. The amount of a Premium Tax Credit is based mostly on family size and income.

Tax credit savings may only be used to purchase a metal level plan for an individual or family through the Health Insurance Marketplace.

Cost Sharing is also based on household size and income.  If you qualify, you must choose a Silver level plan, but the deductible, coinsurance and copays will be lowered.

Visit your local Highmark Direct store or Healthcare.gov for additional information.

 

What is my out-of-pocket max?

If your plan does not have set copays, services will be subject to your in-network deductible. Once the deductible has been met, services will then be considered at a set percentage of the allowance (80% for example). You will be responsible for the remaining 20% until you have reached your out-of-pocket maximum for the calendar year. Once the out-of-pocket maximum has been met, services will then be considered at 100% of the allowed amount for the rest of the calendar year.  For all new plans that meet the ACA requirements, your OOP max includes your deductible, coinsurance and any copays you have paid.

 

What is my premium?

Your premium depends on the plan you select. View premium options by completing the 3 simple steps to finding the right insurance.

 

What is my deductible or coinsurance?

Your deductible or coinsurance depends on the plan you select. View the deductible or coinsurance by completing the 3 simple steps to finding the right insurance.

 

What is my copay for a doctor’s visit?

Your copay, if any, depends on the plan you select and if you are seeing your primary care physician or a specialist. Compare benefits including copays by completing the 3 simple steps to find the right insurance.

 

How much will my medication cost? Is my medication covered?

Prescription drug coverage varies based upon your health insurance plan.  If you are current Highmark member and have questions regarding your medication costs, please contact customer service (reference the back of your ID card for contact details) or if you are shopping for insurance, speak to an associate at your local Highmark direct store for more information.

 

How much will my medical procedure cost?

In order to obtain this information, we will need the following information: the procedure code, the in-network provider’s tax ID and provider’s charge. Once you have this information, you can contact member service for the medical procedure cost.

 
 

What is Covered?

Do you offer Dental and Vision coverage? Is it included in your plans?

We offer a Standalone Dental policy through United Concordia*.  Our Dental plans take effect the first of the following month after the application is completed and first month’s premium is received.  At this time we do not offer a Standalone Vision plan, however vision is included in most of our policies.

 

I have pre-existing conditions; will you be able to help me?

Yes.  Due to the new Affordable Care Act (ACA) law, all pre-existing conditions are covered under a qualified ACA health insurance plan.  Please note:  Short Term coverage does not cover pre-existing conditions.

 

What is eligible under my routine benefits?

There are many services that are eligible as part of your preventive benefits package. Eligibility of services will be based on age, gender, and when the last service date was. It is best to contact member service at the time of your visit with a list of services that your health care provider will be performing or check the Preventive Schedule on our website.

 

Will my adult child be allowed to stay on my health care plan?

Under the new health care reform law, health plans must provide coverage for adult dependents under-age 26 on their parents policies.

 

How many physical therapy visits do I have for the year?

Your number of visits depends on your selected plan. View available plans and compare benefits including physical therapy visits by completing the 3 simple steps to finding the right insurance and selecting the More Details button.

 

Are gym memberships covered?

Gym memberships are not a covered benefit under the terms of your health insurance policy. However, you may be entitled to receive a discount through our member wellness discount program.

 
 
^GeoBlue is a trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross Blue Shield Association. GeoBlue is a separate company and is solely responsible for its health insurance plans and services for individual expatriates and short-term international leisure and business travelers.