Does Highmark Cover Mental Health Treatment in Pennsylvania?
If you have Highmark insurance in Pennsylvania and are exploring mental health or addiction treatment, your plan covers behavioral health services. Highmark — one of Pennsylvania’s two dominant health insurance carriers — is required under both federal and Pennsylvania state law to cover mental health and substance use disorder treatment on equal terms with medical care. From outpatient therapy to Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP), Highmark members in Pennsylvania have meaningful, protected coverage for the full continuum of behavioral health care.
Highmark operates as Highmark Blue Cross Blue Shield in western Pennsylvania and as Highmark Blue Shield in central and eastern Pennsylvania. Together, Highmark plans serve millions of Pennsylvanians through employer-sponsored, individual, Medicare Advantage, and Medicaid programs. Provive Wellness in Wayne, PA and Scranton, PA accepts Highmark insurance at both locations as an in-network provider, meaning your Highmark benefits apply at in-network rates when you receive care at either facility.
Key Takeaways
- Highmark covers mental health and substance use disorder treatment under all ACA-compliant and employer-sponsored plans
- Pennsylvania Act 106 provides additional state-level mental health parity protections beyond federal law for Highmark members
- PHP, IOP, outpatient therapy, psychiatric care, and medication-assisted treatment are all covered behavioral health benefits
- Prior authorization is required for PHP and IOP through Highmark’s behavioral health review process
- Provive Wellness in Wayne, PA and Scranton, PA accepts Highmark as an in-network behavioral health provider
Table of Contents
- Does Highmark Cover Mental Health Treatment?
- What Mental Health Services Does Highmark Cover?
- Does Highmark Cover PHP and IOP in Pennsylvania?
- Highmark Plan Types and Mental Health Benefits
- Does Highmark Require Prior Authorization for Mental Health Treatment?
- In-Network vs. Out-of-Network Coverage
- How to Verify Your Highmark Mental Health Benefits
- How to Use Your Highmark Benefits at Provive Wellness
- Frequently Asked Questions
Does Highmark Cover Mental Health Treatment?
Yes. Highmark is required by both federal and Pennsylvania law to cover mental health and substance use disorder treatment. Under the Mental Health Parity and Addiction Equity Act (MHPAEA), Highmark cannot impose more restrictive limits on behavioral health benefits than it applies to equivalent medical and surgical benefits. This means no lower visit limits, no stricter prior authorization standards, and no higher cost-sharing for mental health care than for comparable physical health care.
Pennsylvania also has its own mental health parity statute — Pennsylvania Act 106 — which applies to state-regulated insurance plans and provides an additional layer of consumer protection specific to Pennsylvania residents. Under Act 106, Highmark’s state-regulated plans must provide mental health and substance use disorder benefits that are equal in scope, duration, and cost-sharing to physical health benefits. This dual layer of federal and state protection makes Pennsylvania one of the stronger states in the country for mental health insurance rights.
The practical reality for Highmark members is that mental health treatment — including PHP, IOP, therapy, and psychiatric care — is a covered benefit. What varies between plans is your specific cost-sharing: your deductible, copay amounts, coinsurance percentage, and out-of-pocket maximum. Our admissions team will verify your specific Highmark benefits at no cost before treatment begins. Call (610) 947-0800 to get started.
What Mental Health Services Does Highmark Cover?
Highmark covers a comprehensive range of behavioral health services under its plans. The following are generally included as covered benefits for Highmark members in Pennsylvania:
- Individual outpatient therapy and counseling sessions
- Group therapy programs
- Psychiatric evaluations and diagnostic assessments
- Psychiatric medication management and prescriptions
- Intensive Outpatient Programs (IOP) for mental health and substance use
- Partial Hospitalization Programs (PHP) for higher-intensity structured care
- Medication-assisted treatment (MAT) for opioid and alcohol use disorders
- Telehealth behavioral health services
- Inpatient psychiatric care when medically necessary
- Dual diagnosis treatment for co-occurring mental health and substance use conditions
Highmark members in eastern and central Pennsylvania can access these services at Provive Wellness in Wayne, PA on the Philadelphia Main Line and Scranton, PA in northeastern Pennsylvania. Our admissions team verifies your Highmark benefits before you begin treatment and handles all prior authorization with Highmark’s behavioral health review process. Call (610) 947-0800 for a free, confidential benefits check.
Does Highmark Cover PHP and IOP in Pennsylvania?
Yes. Highmark covers both Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP) in Pennsylvania when medically necessary and provided by an in-network facility. Both levels of care require prior authorization before treatment begins. Provive Wellness accepts Highmark at both its Wayne and Scranton locations for PHP and IOP.
Partial Hospitalization Program (PHP)
PHP at Provive Wellness provides structured daytime treatment 5 to 7 days per week over 4 to 6 weeks. It includes daily individual therapy, group therapy sessions, psychiatric care, medication management, and holistic programming. PHP is designed for individuals who need intensive clinical support throughout the day but can return home each evening. It is the highest level of outpatient care and a step below inpatient hospitalization. Highmark covers PHP when prior authorization is obtained and the clinical criteria for medical necessity are satisfied. Our team handles all documentation and submission directly with Highmark’s behavioral health reviewers.
Intensive Outpatient Program (IOP)
IOP at Provive Wellness runs 3 to 6 days per week over 8 to 12 weeks. It offers structured group and individual therapy in a flexible schedule that allows individuals to maintain work, school, and family responsibilities while receiving consistent clinical support. IOP is the most commonly used step-down level of care after PHP and is also appropriate as a first level of structured care for those who do not require PHP intensity. Highmark covers IOP when medically necessary and prior authorized. Telehealth IOP is available and covered under most Highmark plans. Our admissions team coordinates all IOP authorizations with Highmark before your first session.
Highmark Plan Types and Mental Health Benefits
Highmark offers several plan types across its product lines. Each covers mental health and substance use disorder treatment, but cost-sharing and network requirements vary by plan type.
Highmark PPO
PPO plans offer the broadest network access and flexibility, allowing both in-network and out-of-network coverage. In-network care at Provive Wellness is covered at the lower in-network rate as defined in your plan’s benefits summary. PPO plans do not require a primary care physician referral for behavioral health services, making access to PHP, IOP, and therapy straightforward for members who know the level of care they need.
Highmark HMO and EPO
HMO and EPO plans require care from in-network providers and may restrict or eliminate out-of-network coverage except in emergencies. Behavioral health services at in-network facilities like Provive Wellness are fully covered at your plan’s in-network cost-sharing rate. These plan types typically carry lower monthly premiums in exchange for their network restrictions. Our team will confirm your in-network status with Highmark before your treatment begins.
Highmark Medicare Advantage
Highmark offers Medicare Advantage plans in Pennsylvania — including Freedomblue, Security Blue, and Signature 65 — with behavioral health coverage at least equivalent to Original Medicare and often with expanded benefits. Prior authorization requirements for PHP and IOP apply. Our admissions team can verify your specific Highmark Medicare Advantage behavioral health benefits directly before you commit to treatment.
Employer-Sponsored Highmark Plans
Many Pennsylvania employers offer Highmark as their group health insurance carrier. Employer-sponsored Highmark plans are subject to ERISA and the Mental Health Parity and Addiction Equity Act, with mental health benefits required at parity with medical benefits. The specific cost-sharing for behavioral health services — deductibles, copays, coinsurance — varies by employer plan design. Provive Wellness will verify your employer Highmark plan benefits directly with Highmark’s behavioral health team before your treatment begins.
Does Highmark Require Prior Authorization for Mental Health Treatment?
Yes. Highmark requires prior authorization for PHP, IOP, and typically inpatient psychiatric care. Prior authorization is the process of submitting clinical documentation — including your diagnosis, current symptom severity, treatment history, and clinical rationale for the requested level of care — to Highmark’s behavioral health reviewers before treatment begins. Authorization must be in place before your first day of treatment for coverage to apply.
At Provive Wellness, our admissions and clinical team manages the entire prior authorization process with Highmark on your behalf. We prepare and submit all documentation, follow up with Highmark’s reviewers, and ensure authorization is confirmed before you begin. If Highmark requests additional information or issues a denial, we respond and appeal as needed. You should not have to manage any part of this process on your own — we handle it so you can focus on getting the care you need.
In-Network vs. Out-of-Network Coverage
Receiving care at an in-network facility like Provive Wellness is always the most cost-effective way to use your Highmark behavioral health benefits. In-network providers have negotiated rates with Highmark, and your cost-sharing — deductible, copay, and coinsurance — applies at the lower in-network rate defined in your benefits summary. This results in significantly lower out-of-pocket costs compared to out-of-network care.
Out-of-network care is considerably more expensive under PPO plans and typically not covered at all under HMO and EPO plans, except in emergencies. Selecting in-network care at Provive Wellness in Wayne, PA or Scranton, PA maximizes your Highmark benefits and protects you from unexpected balance billing. Our admissions team confirms your in-network status during your initial benefits verification call before any treatment commitment is made.
How to Verify Your Highmark Mental Health Benefits
Before starting treatment, confirming your specific Highmark coverage, deductibles, copay amounts, and prior authorization requirements protects you from financial surprises. You can verify your behavioral health benefits through any of the following:
- Call the member services number on the back of your Highmark insurance card and ask specifically about behavioral health benefits, PHP coverage, IOP coverage, outpatient therapy, and prior authorization requirements
- Log in to your Highmark member account at highmarkbcbs.com or highmarkblueshield.com to review your benefits summary and search for in-network behavioral health providers near Wayne or Scranton, PA
- Call Provive Wellness at (610) 947-0800 — our admissions team will contact Highmark directly to verify your specific benefits, confirm your in-network status, and obtain prior authorization before treatment begins, all at no cost to you
Our benefits verification call is free, confidential, and typically completed within 24 hours. We will explain your financial responsibility in plain language so you know exactly what to expect before you begin. Same-day appointments are available most times at our Wayne and Scranton locations.
How to Use Your Highmark Benefits at Provive Wellness
Provive Wellness accepts Highmark insurance at both its Wayne, PA and Scranton, PA locations. Here is the process from first call to first day of treatment:
- Call (610) 947-0800 to reach our admissions team
- Share your Highmark member ID from your insurance card so we can verify your coverage and in-network status
- Our team contacts Highmark to obtain prior authorization for the appropriate level of care
- Complete a clinical assessment to confirm the right program — PHP, IOP, outpatient, or telehealth
- Begin treatment at your Provive Wellness location with your Highmark coverage confirmed and all authorizations in place
Provive Wellness is a JCAHO-accredited behavioral health provider with locations in Wayne, PA on the Philadelphia Main Line and Scranton, PA in northeastern Pennsylvania. We treat anxiety, depression, PTSD, bipolar disorder, OCD, substance use disorders, and co-occurring conditions using evidence-based therapies including CBT, DBT, and EMDR, alongside holistic programming such as equine therapy, sound healing, and breathwork. Our team navigates Highmark authorizations every day and will make the process as clear and smooth as possible for you.
Frequently Asked Questions
Does Highmark cover therapy in Pennsylvania?
Yes. All ACA-compliant and employer-sponsored Highmark plans cover outpatient individual therapy and group therapy. Your cost-sharing depends on your specific plan tier and whether you see an in-network provider. Provive Wellness is an in-network Highmark provider at both its Wayne and Scranton, PA locations. Call (610) 947-0800 to confirm your Highmark therapy coverage.
Does Highmark cover IOP in Pennsylvania?
Yes. Highmark covers Intensive Outpatient Programs (IOP) in Pennsylvania when medically necessary and prior authorized. Our admissions team coordinates the prior authorization process with Highmark’s behavioral health reviewers before treatment begins at our Wayne or Scranton location. You do not need to manage this process on your own.
Does Highmark cover PHP in Pennsylvania?
Yes. Partial Hospitalization Programs (PHP) are covered under Highmark plans when medically necessary and prior authorized. Provive Wellness handles all PHP authorization paperwork with Highmark’s behavioral health team on your behalf, so your coverage is confirmed before your first day of treatment.
What is Pennsylvania Act 106?
Pennsylvania Act 106 is Pennsylvania’s state-level mental health parity law, which requires state-regulated insurance plans — including many Highmark plans — to provide mental health and substance use disorder benefits equal in scope, duration, and cost-sharing to physical health benefits. It applies in addition to the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and reinforces your right to behavioral health coverage at true parity with medical coverage.
Does Highmark cover addiction treatment in Pennsylvania?
Yes. Highmark covers substance use disorder treatment as an essential health benefit, including medication-assisted treatment (MAT), individual and group addiction counseling, PHP, IOP, and outpatient programs for alcohol, opioid, and other substance use disorders. Provive Wellness accepts Highmark for all levels of addiction treatment at its Wayne and Scranton, PA locations.
What if Highmark denies my prior authorization?
Denials can be appealed. You have the right to an internal appeal with Highmark and, if needed, an independent external review under both Pennsylvania and federal law. Pennsylvania’s Insurance Department offers consumer assistance for insurance disputes and denials. Provive Wellness will provide clinical documentation and advocacy support throughout your appeal, and many prior authorization denials are successfully overturned.
Take the Next Step
If you have Highmark insurance and are considering mental health or addiction treatment, Provive Wellness is ready to help. Our admissions team will verify your Highmark benefits at no cost, handle all prior authorization paperwork, and guide you from the first call through your first day of treatment.
We have two Pennsylvania locations: Wayne, PA on the Philadelphia Main Line serving Chester, Delaware, and Montgomery Counties, and Scranton, PA in northeastern Pennsylvania serving Lackawanna, Luzerne, and Wyoming Counties. Same-day appointments are available most times and all treatment is fully confidential.
Call (610) 947-0800 today to speak with our admissions team. Recovery is possible, and it starts with one call.
