Highmark are a private insurance company that offer older adults various insurance policies, including Medigap and Medicare Advantage plans.
Original Medicare includes Part A, which covers hospital care. It also includes Part B, which covers outpatient services and limited prescription medications.
Individuals eligible for original Medicare can opt for a Medicare Advantage plan instead. Private insurance companies, such as Highmark, administer Medicare Advantage plans.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Advantage plans include the benefits of original Medicare and often provide coverage for prescription drugs and other services, such as dental care.
The federal government oversees Medicare and also regulates Medicare Advantage plans. Different plans are available, and they are designed to fit various budgets and individual needs.
Unlike original Medicare, Medicare Advantage plans have an out-of-pocket maximum, which is a cap on the amount a person will pay themselves.
Types of Medicare Advantage plans
There are four main types of Medicare Advantage plans:
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Private Fee-for-Service (PFFS)
- Special Needs Plans (SNP)
Health Maintenance Organization Point-of-Service (HMO-POS) plans are also available, but these are less common.
Each plan has different rules that may, for example, require a person to use in-network healthcare providers, choose a primary care physician (PCP), and obtain referrals to visit a specialist.
Highmark license with Blue Cross Blue Shield (BCBS), meaning that they can offer plans in specific BCBS service areas. However, they offer many of the same benefits as BCBS.
Highmark can use the BCBS licensed marks, but they remain an independent company.
Highmark claim to be the fourth largest BCBS-affiliated organization, with the company providing healthcare coverage for more than 5.6 million people in Delaware, Pennsylvania, and West Virginia.
Currently, Highmark Medicare Advantage plans are not available everywhere in the country. The company only offer Advantage plans to people in the following states:
- Delaware
- Pennsylvania
- West Virginia
Highmark Medicare Advantage plans include:
HMO
Those with this plan must use an in-network provider. The plan may have lower out-of-pocket expenses than others, but individuals must use an in-network provider, or they will typically pay more for services.
PPO
This plan allows a person to use out-of-network providers, giving more flexibility to their healthcare. The costs are generally higher than those of an HMO.
HMO-POS
This type of plan is a combination of an HMO plan and a PPO plan. Usually, HMO-POS plans offer a more comprehensive network of healthcare providers than an HMO plan, with the cost often lower than that of a PPO plan.
The cost of a Highmark Medicare Advantage plan may vary by area and coverage level. The cost of monthly premiums may also vary. For example, some plans have no monthly premium, whereas others do.
All plans have coinsurance, copayments, and deductibles.
The table below provides a general idea of how costs may differ. It includes examples of 2021 costs in Lackawanna County, Pennsylvania, for PPO and HMO Highmark Medicare Advantage plans.
| Community Blue Medicare HMO | Freedom Blue PPO basic | |
| Monthly premium | $0 | $66 |
| Out-of-pocket max | $7,550 | $5,900 |
| PCP copay | $0 | $0 |
| Specialist copay | $20 | $35 |
| ER copay | $90 | $90 |
| Inpatient hospital copay | $250 | $340 |
Standout benefits and services
Some Highmark Medicare Advantage plans may offer the following additional benefits:
- dental care
- hearing aids
- fitness programs
- chiropractic care
- routine vision screenings
- prescription drug coverage
Some of the perks and services include:
- Blues On Call: This 24-hour nursing service provides answers by phone to medical questions.
- AIS home visit program: This program provides additional support at home for those with serious medical conditions.
- People Able to Lend Support (PALS): The PALS program includes volunteers supporting Highmark members in need.
- Medication Therapy Management (MTM) Program: This service helps individuals with chronic conditions better manage their medications.
- Highmark House Call: This is a yearly home visit from a healthcare provider to review a person’s medical history and prescribed drugs and to address any questions.
- Silver Sneakers: This fitness program is available to adults aged 65 years and over.
When comparing Highmark Medicare Advantage plans, individuals should consider several features, including:
- copayments
- coinsurance
- monthly premiums
- provider networks
- deductibles
Medicare’s plan comparison tool may be useful when looking for a Medicare Advantage plan.
Advice
State Health Insurance Assistance Programs offer impartial advice and assistance in selecting an Advantage plan.
Medicare’s helpful plan comparison tool may be useful when looking for a Medicare Advantage plan.
Highmark Medicare Advantage plans are available in Delaware, Pennsylvania, and West Virginia.
Coverage includes the services that original Medicare provides, plus some additional services, such as dental care, fitness programs, and 24-hour on-call nursing advice.
The costs and coverage of individual plans vary by location, plan type, and plan provider.