Frequently Asked Questions

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 health insurance store 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 health insurance 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

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

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

• In-Person Customer Advocates -- We now offer in-store customer service at all of our Highmark Direct health insurance store locations.  A Customer Advocate can help answer your customer service inquiries.  They can assist you with:
• Finding a doctor and making appointments
• Answering your claims, benefits and enrollment questions
• Transferring medical records
• Using Member Advocacy Services
• Taking premium payments; We accept checks, money orders*, Visa®, Mastercard®, Discover®*, and American Express®* 
• Utilizing the tools and services available to you through the Highmark member website
• 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”, the Highmark Direct health insurance store video conference capability can help! Connect with a customer service rep from one of customer service walk-in centers to have your questions answered.

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.”

All of the details of what you need to bring to a consultation are included on our "What to Bring" page.

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.

*not accepted at our Williamsport, Bartonsville, or Dickson City locations

We have 13 Highmark Direct health insurance stores located throughout Pennsylvania.  At all locations, excluding Williamsport, Dickson City and Bartonsville locations, our stores are open Monday through Saturday from 9 am to 6 pm.  Our Williamsport, Dickson City and Bartonsville stores are open Monday though Friday from 9 am to 5 pm.  Visit our store locator for addresses, phone numbers, and directions.

30 to 60 minutes.

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 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 insurance 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 insurance 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 insurance coverage that includes preventive care, you don’t have to think twice about scheduling regular check-ups.
 

Some individuals get health insurance 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 (ID) 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 will 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, the amount you pay each month for your health insurance, you may have to share the costs of the services you receive.

·         A deductible is the specified dollar amount you must pay each benefit period (usually a year) for your health care expenses before your plan begins to pay.

·         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.

·         Copayment (Copay) is a fixed, 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. Can be before or after deductible.

• Out-of-Pocket Maximum is the highest amount you will need to pay each benefit period (usually a year) for covered in-network care before your insurance company pays 100% of covered in-network services.

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.

• 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.

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.

As a Highmark member, you enjoy all the services of BlueCard Worldwide. Your coverage travels with you through a worldwide network of care providers. For more details, please ask your local Highmark Direct health insurance store associate.

To help make health insurance more affordable, the government offers two types of financial help to eligible households - depending on your household income and other factors.

Advanced Premium Tax Credit (APTC). If you qualify, a Premium Tax Credit may be applied (in advance) to lower what you pay in monthly premiums on any Health Insurance Marketplace plan. The amount of a Premium Tax Credit is based mostly on family size and income.*

Cost-Sharing Reductions (CSR) will lower your out-of-pocket costs that you may pay at the time of service for doctor's visits, lab tests, drugs and other covered services.  You can only get these savings if you enroll in a Marketplace Silver Metal Level plan.**

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

* Eligibility for financial help can only be determined by requesting an eligibility verification through the Health Insurance Marketplace at Healthcare.gov. 

** American Indian and Alaska Native Cost-Sharing Reductions apply to individual plans at any Metal Level through the Marketplace.

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. This does not include any services not covered by your plan.

Your premium depends on the plan you select. Your premium is the amount you pay each month for your health insurance. A Highmark Direct health insurance store licensed associate will be able to walk you through plan options to help you understand your benefits and find a plan that fits your needs.

Your deductible or coinsurance depends on the plan you select. A Highmark Direct health insurance store licensed associate will be able to walk you through plan options to help you understand your benefits and find a plan that fits your needs.

Your copay, if any, depends on the plan you select and if you are seeing your primary care physician or a specialist. A Highmark Direct health insurance store licensed associate will be able to walk you through plan options to help you understand your benefits and find a plan that fits your needs.

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 health insurance 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.

If you have specific questions, please contact your local Highmark Direct health insurance store.

Yes.  Due to the Affordable Care Act (ACA), 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 Affordable Care Act (ACA), health insurance plans must provide coverage for adult dependents under age 26 on their parents' policies.

Your number of visits depends on your selected plan. A Highmark Direct health insurance store licensed associate will be able to walk you through plan options to help you understand your benefits and find a plan that fits your needs.

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.