We understand health care can be confusing. At Highmark, we're listening.
Here is what you're asking right now.
Click on the questions below to reveal their corresponding answers.
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:
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.
Yes. We offer two convenient options in-store to help answer your customer service questions:
Other convenient ways to access customer service include:
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.
Please bring with you:
If you are under 65:
If you are Medicare eligible:
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.
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.
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.
30 to 60 minutes.
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.
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.
Once you enroll, you can review your benefit booklet online at the My Benefits page on the website.
You will receive your insurance ID card(s) after you make your first month’s premium payment.
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.
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.
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.
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.
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.
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?
There are lots of things you can do to improve your health, become an educated health care consumer and help control health care costs.
Community Blue offers nearly 60 community and specialty hospitals and over 10,300 doctors in the 29 counties in Western Pennsylvania (as of January 1, 2015). You will also receive exceptional provider choices, close-to-home – including cancer care, rehabilitation services, behavioral health, emergency care, women’s health and children’s careFreedom and flexibility. Plan members don’t need a referral to see a specialist. Coverage for preventive care services, like physical exams, health screenings and vaccines. For everyone, at every stage of life, preventive care is a critical part of staying healthy.
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.
In case of emergency, you’re covered at the higher level of benefits for emergency care received in or outside the PPO provider network.
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.
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.
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.
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.
Your premium depends on the plan you select. View premium options by completing the 3 simple steps to finding the right insurance.
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.
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.
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.
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.
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.
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.
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.
Under the new health care reform law, health plans must provide coverage for adult dependents under-age 26 on their parents policies.
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.
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.