What You Need to Know
Highmark plans differ by state and even by county in Pennsylvania.
While membership benefits vary by state, universal extras include telemedicine and gym discounts on many individual and family plans.
The customer complaint index in Pennsylvania and West Virginia is below average. The complaint index in Delaware is above average.
Highmark Blue Cross Blue Shield serves three states: Pennsylvania, West Virginia and Delaware. It currently operates in 42 counties of western, northeastern and eastern Pennsylvania.1 Coverage in West Virginia and Delaware is statewide.
Who is Highmark Blue Cross Blue Shield?
Highmark, Inc. is among the top 10 largest health insurers in the United States. It was formed in 1977 and in the 1990s with the consolidation of two Pennsylvania Blue Cross Blue Shield partners, Highmark began its journey of covering individuals and families in multiple states.2
Highmark Blue Shield covers 21 counties of central Pennsylvania and Lehigh Valley. It also provides services in conjunction with a separate health plan (Independence Blue Cross) in southeastern Pennsylvania.3
Each of these companies has an independent contract with the Blue Cross Blue Shield Association, which sells insurance in all 50 states, Washington, D.C., and Puerto Rico. They’re also part of the Highmark Health enterprise, a diversified health, and wellness system based in Pittsburgh.6
Basics on Highmark Blue Cross Blue Shield
During the Great Depression of the mid-1930s, Pennsylvania established two separate insurance companies to help residents cover hospital expenses. The first was Blue Cross of Western Pennsylvania and shortly thereafter, the Pennsylvania Medical Society backed the founding of Pennsylvania Blue Shield. The companies collectively introduced historical innovations, including the first children’s health insurance program, which later helped formulate the national CHIP program that exists today. The companies also developed an insurance program for seniors, which actually predates Medicare.7
The two companies were consolidated in November 1996 and formed Highmark, Inc. The company split its operations, conducting business in Western Pennsylvania as Highmark Blue Cross Blue Shield and in the rest of Pennsylvania as Pennsylvania Blue Shield, partnering with three Blue Cross plans to provide complete coverage throughout the state.8
In West Virginia, Highmark formed a partnership with Mountain State Blue Cross Blue Shield in 1999 and became the primary administrator. In January 2011, Mountain State Blue Cross Blue Shield changed its name to Highmark Blue Cross Blue Shield West Virginia.9
Blue Cross Blue Shield of Delaware partnered with Highmark in 2010. In 2012, Blue Cross Blue Shield of Delaware became Highmark Blue Cross Blue Shield Delaware.10
Today there are a total of 5.6 million Highmark insureds in three states. It’s the fourth largest Blue Cross Blue Shield affiliate and the largest insurance carrier in Pennsylvania, with 4.7 million members.11
Highmark has a number of network providers based on location and plan type. It participates in the national Blue Cross Blue Shield program called BlueCard®. Nationwide, more than 96% of hospitals and 91% of professional providers contract with the BlueCard® System.12
Beginning in January 2021, Highmark began participating in a new national network of higher-quality providers called Blue High Performance Network (Blue HPN). More than 185 million Americans in more than 55 major markets will have access to Blue HPN across the country, including Pennsylvania and Delaware.13
What Health Insurance Does Highmark Blue Cross Blue Shield Offer?
Individual & FamilyPlans
Highmark individual and family coverage are Affordable Care Act (ACA) plans (also known as Obamacare) offered on Pennie, the Pennsylvania Health Insurance Marketplace, Choose Health Delaware, the state’s health exchange, and healthcare.gov for West Virginians. Individuals with income between 100-400% of the federal poverty guidelines could be eligible for a financial subsidy to help lower the cost of the monthly premium. You can use this ACA subsidy calculator to estimate your potential health plan savings.
ACA plans meet the 10 essential mandated requirements of the healthcare law, which include:
- Preventive care covered at 100%
- Wellness checks covered at 100%
- Dental coverage for children covered at 100%
- Prescription drugs, mental health coverage, surgeries and hospitalizations covered after deductible and coinsurance.
It’s important to remember that outside of preventive care paid at 100%, you must typically meet your deductible before the insurance company will cover a portion of your medical bills.
Employer-sponsored group health insurance is available in several forms. Highmark offers exclusive provider organization (EPO) plans and preferred provider organization (PPO) plans in Pennsylvania and Delaware. EPO plans are generally more cost-effective than PPO plans. That said, if you have a EPO plan and go outside of your network, you could be responsible for 100% of the costs (except in an emergency). A PPO monthly plan premium is typically more expensive than an EPO plan, but it has a larger network. If you have a doctor you prefer, he or she might be part of Highmark’s PPO network.
Highmark offers both Medicare Advantage and Medicare supplemental coverage (Medigap). This coverage is for anyone 65 years or older, or under 65 with qualifying disabilities. There are differences to consider when deciding between Medicare Advantage or Medigap plans.
When you opt for Medicare Advantage, you no longer have Original Medicare. Instead, you get coverage from a private insurer that is a package deal—doctors, hospitals and prescription drug coverage are part of the plan, in addition to extra benefits like dental. There are no decisions to make. The plan benefits are federally regulated and do not differ. However, the doctor and hospital network can be more limiting than Original Medicare.
Medigap, or Medicare Supplement, policies cover deductibles and excess charges Original Medicare doesn’t cover. The provider network is typically larger than a Medicare Advantage network.
Highmark sells dental insurance standalone, so having a Highmark health policy is not required to obtain coverage. Benefits can include 100% coverage for cleanings, X-rays and exams. Depending on the level of coverage you obtain, major services like root canals, crowns and other oral surgeries can be partially, if not completely covered.
Dental and vision coverage is available on group employer plans.
What Are Member Benefits for Highmark Blue Cross Blue Shield?
On many Highmark health plans, extra benefits can include:14
- $0 copay Tier 1 prescription drugs
- $0 telemedicine visits
- Discounts on select gym memberships
How Do You Enroll in Coverage with Highmark Blue Cross Blue Shield?
You can shop for individual health plans on the Highmark website and enroll online or over the phone by calling 1-866-488-7469. An insurance broker licensed with Highmark can also talk through your options and help you apply for a plan. You can also complete this form to have a Highmark representative contact you about their health plans.
If you live in Pennsylvania, there are three satellite locations in Pittsburgh, Johnstown and Erie you can visit in person.
How Do You File Claims with Highmark Blue Cross Blue Shield?
Filing a claim with Highmark will depend on your state and location. It’s best to look at the back of your ID card for the correct address to send your claims. Highmark also recommends that you ask your provider to handle claim filings, which will help ensure faster payment. Here are the claim contacts based on region:
- Pennsylvania Central, Eastern and Northeastern Regions Only
- Pennsylvania Western Region
- Highmark West Virginia
- Highmark Delaware
How is Highmark Blue Cross Blue Shield Rated?
Financial standings are an excellent tool for judging a company’s internal strength and commitment to the insureds it serves. Here’s where Highmark Blue Cross Blue Shield stands:
A.M. Best: Rated “A” (Excellent)
Standard & Poor’s: “A” (Stable)
When it comes to customer satisfaction, it varies by state.
National Association of Insurance Commissioners
According to the National Association of Insurance Commissioners (NAIC), there were 49 complaints filed by West Virginians in 2019.15 The top five complaints were for:
- Denial of claim – 11
- Delays – 5
- Out-of-network benefits – 4
- Essential health benefits – 4
- Unsatisfactory settlement – 3
There were 29 complaints submitted to the NAIC from Pennsylvania in 2019.16 The top five complaints were:
- Denial of claim – 6
- Premium notice/billing – 3
- Premium & rating – 2
- Unsatisfactory settlement – 2
- Out-of-network benefits – 2
In Delaware, the NAIC received 64 NAIC complaints in 2019.17
- Claim handling – 30
- Policyholder services – 30
- Underwriting – 4
Highmark has a 2.5 rating out of 5 stars on Consumer Affairs. There are a total of 33 reviews.18
Better Business Bureau
- In Pennslyvania, Highmark does not have a Better Business Bureau accreditation, and received 1 out of 5 stars from one review. Thirteen complaints have been closed in the last 12 months.
- In Delaware, Highmark has an A+ accreditation, and 1.5 out of 5 stars from two customer reviews. Four complaints have been closed in the last 12 months.
- There are no reviews for Highmark Blue Cross Blue Shield in West Virginia.19
In 2020, Highmark paid more than $100 million in rebates to insureds in Pennsylvania because of lower claims due to the COVID-19 pandemic.20 That same year, the company rebated policyholders in Delaware more than $21.5 million.21 There was no immediate data for West Virginia rebates.
What Are Strengths of Highmark Blue Cross Blue Shield?
Highmark Blue Cross Blue Shield has a long history as a top insurer in all three states it serves. Its financial ratings indicate internal strength. The company is also held accountable by the Blue Cross Blue Shield Association and must live up to its mission and values.
What Are Weaknesses of Highmark Blue Cross Blue Shield?
According to consumer complaints, claims disputes are the primary reason for dissatisfaction with the company. Keep in mind these disputes vary by state. When considering a Highmark health plan, it’s important to look at reviews to see how the plan performs in your state.
When considering a health plan from Highmark, keep these factors in mind before you decide on a plan:
- What can you afford monthly in premium, and do you qualify for a financial subsidy?
- What deductible amount can you pay if an unexpected illness occurs?
- Are doctor office visit co-pays important to you?
- Do you need a plan with a robust prescription drug program?
Prioritize your healthcare wishes to make sure you get the best plan for your health and budget.
If you’re interested in learning more about Blue Cross Blue Shield plans offered by Highmark in Pennsylvania, Delaware and West Virginia, visit their website to get started or call its customer service line to find out what plans are available in your area.
The views and opinions expressed are those of the authors and do not necessarily reflect the official policy or position of HealthCareInsider.com or HealthCare, Inc.