Does Highmark Cover LGBTQ Rehab?

Most Highmark commercial plans do cover addiction treatment, and an LGBTQ program or group inside an in-network program is covered the same way as the rest of that program. Coverage typically spans outpatient therapy up through inpatient care, but higher levels of care such as inpatient stays, partial hospitalization and intensive outpatient programs usually need approval first. Your exact benefits depend on your plan, your employer and the state you live in.

Highmark is the Blue Cross Blue Shield company for much of Pennsylvania, Delaware, West Virginia and western New York. Here is how its coverage generally works for LGBTQ rehab and how to check yours.

The short version

• Substance use disorder treatment is a standard part of most Highmark commercial health plans.
• There is no separate LGBTQ benefit. Highmark covers levels of care, and an LGBTQ group is covered as part of the program it belongs to.
• Federal parity law means addiction care cannot have stricter rules or costs than comparable medical care.
• Routine outpatient therapy usually does not need prior authorization. Inpatient, partial hospitalization and intensive outpatient care usually do.
• Some employers carve out behavioral health to a different company, so your mental health benefits may not run through Highmark at all.
• Delaware has its own law that limits approval requirements for addiction treatment on fully insured plans.

Insurers cover levels of care, not populations

Plans pay for treatment of a substance use disorder at a particular level of care: detox, residential, partial hospitalization (PHP), intensive outpatient (IOP) or outpatient. Whether a program runs a group for LGBTQ clients does not change how the claim is handled. What matters is whether the program is in network and whether that level of care is approved.

So start with two questions: which level of care do you need, and does an in-network program at that level offer an LGBTQ group? Our guides to inpatient vs outpatient LGBTQ rehab and LGBTQ-friendly vs LGBTQ-specific rehab can help.

Coverage by level of care

Highmark's provider manual for behavioral health spells out which services need authorization on most commercial products. The table below summarizes it. Always confirm for your plan, since benefits vary by product and employer group.

For an unplanned admission, Highmark's authorization rules say the hospital should seek approval within about 48 hours or once clinical information is available. If you see an in-network provider, that provider is responsible for getting authorization. If you go out of network, Highmark says the member needs to work with the provider to make sure approvals are in place, or the claim may be denied.

Highmark's member page on substance use treatment describes approaches such as cognitive behavioral therapy, motivational interviewing and contingency management, which uses rewards for meeting recovery goals. If withdrawal is a concern, our LGBTQ detox page explains that first step.

Highmark programs that may be part of your benefits

Highmark's guide to behavioral health resources lists several programs that may be available depending on your employer and plan:

• Wayspring, a peer-centered substance use treatment program for adults.
• Bright Heart Health, which offers virtual care for mental health and substance use.
• MAP Care Solutions, which pairs peer recovery support with digital tools for teens and adults.
• Well360 Virtual Health, with virtual therapists and psychiatrists.
• Highmark behavioral health specialists, reached through the member service number on your ID card, who can help find in-network providers.

These programs are not on every plan. Ask member service which ones you can use, and whether any in-network programs near you run a group for LGBTQ clients.

A note for Delaware members

Highmark's provider manual explains that, for fully insured Delaware plans, state law bars precertification and prior authorization for in-network inpatient or residential drug and alcohol treatment. It also limits concurrent review during the early part of inpatient, residential, intensive outpatient and withdrawal management care. The facility still has to notify Highmark soon after admission. Self-funded employer plans may not follow this rule, so ask whether your plan is fully insured. Delaware residents can browse LGBTQ rehab in Delaware.

What you might pay

Even when treatment is covered, you will usually share the cost through your deductible, copays and coinsurance. Under parity, those amounts for addiction care should be in line with what you would pay for similar medical care, such as a hospital stay or specialist visit. Staying in network typically keeps costs lower, and out-of-network care may not be covered at all on some plan types.

Your name and your privacy

Your Highmark ID card and claims use the name on file with the plan. Many programs can use a chosen name and pronouns in day-to-day care, so ask how the program records them and which name appears on paperwork and bills. Our transgender rehab guide lists more questions.

If you are covered as a dependent on a parent's plan, an explanation of benefits may go to the policyholder. Ask Highmark member service whether you can make a confidential communications request. Our confidentiality in rehab guide covers privacy in more depth.

How to verify your Highmark coverage

• Check who manages behavioral health. Highmark notes that some groups have medical coverage through Highmark but behavioral health through another company. Your ID card or HR department can tell you.
• Use the Find a Doctor tool. Search on the Highmark website or app for in-network substance use providers.
• Check the LGBTQ group separately. Our directory lists programs that report a program or group for LGBTQ clients to SAMHSA. That is self-reported, so ask the program whether the group runs at your level of care.
• Call member service. Ask which levels of care are covered, your deductible and copays, and whether a specific program is in network.
• Confirm authorization. Before an IOP, PHP or inpatient admission, ask the program to confirm approval and how many days are approved.
• Read your benefit booklet. Look for "substance use disorder" or "chemical dependency" services.

The Department of Labor notes that you can ask your plan for its medical necessity criteria and the reason for any denial. If Highmark denies care, you can file an internal appeal and then ask for an external review.

Find treatment in Highmark states

Most Highmark members live in Pennsylvania, West Virginia, Delaware or New York. Start with LGBTQ rehab in Pennsylvania, West Virginia or New York, then check each program's network status with Highmark. You can also compare other carriers in our insurance guides.

If you or a loved one is thinking about suicide or in crisis, call or text 988. For a medical emergency, call 911.

Sources

• Understanding Your Mental Health and Substance Use Disorder Benefits (U.S. Department of Labor, EBSA)
• Mental Health and Substance Abuse Health Coverage Options (HealthCare.gov)
• Provider Manual: Behavioral Health Providers (Highmark)
• Provider Manual: Authorizations (Highmark)
• Substance Use Disorder Treatment Programs (Highmark)
• A Guide to Your Behavioral Health Resources (Highmark Blue Cross Blue Shield)

Related guides

• Why LGBTQ-Specific Addiction Treatment Matters | LGBTQ Rehab
• Questions to Ask an LGBTQ Rehab Before You Enroll
• Transgender Rehab: Finding Addiction Treatment That Respects Your Gender
• Minority Stress and Addiction: How Stigma Affects Substance Use
• Family Rejection, Chosen Family and Recovery
• LGBTQ-Friendly vs LGBTQ-Specific Rehab: What's the Difference?

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