Benefits & Programs

Maximize Your Benefits

Having the benefits of a Highmark Wholecare Medicaid membership allows you access to better health plan solutions. So let us take care of your health, while you focus on everything else life throws at you.

Member Benefits, Rights, and Responsibilities

A co-payment is the amount you pay for some covered services. It is usually only a small amount. You will be asked to pay your co-payment when you receive the services, but you cannot be denied a services if you are not able to pay a co-payment at that time. If you did not pay your co-payment at the time of the service, you may receive a bill from your provider for the co-payment.
The following services do not require a co-payment

Tobacco cessation services
Antipsychotic medications
Antidiabetic medications, including insulin
Antineoplastic medications (cancer drugs)
Antiparkinson medications
Antiglaucoma medications
Antihypertensive medications
Anticonvulsant medications
Cardiovascular medications (antiarrhythmics, antianginals, anticoagulants, lipid lowering agents)
HIV/AIDS medications
Naloxone
Influenza, pneumonia and zoster vaccines

Additional services can be found in the Member Handbook. You can find the Co-payments in "Section – 2 Rights and Responsibilities".

The following benefits are covered by Medicaid under federal law:

Inpatient hospital services
Outpatient hospital services
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
Nursing facility services
Home health services
Physician services
Rural health clinic services
Federally qualified health center services
Laboratory and X-ray services
Family planning services
Nurse midwife services
Certified Pediatric and Family Nurse Practitioner services
Freestanding Birth Center services (when licensed or otherwise recognized by the state)
Transportation to medical care
Tobacco cessation counseling for pregnant women

States may choose to cover the following services:

Prescription drugs
Clinic services
Physical therapy
Occupational therapy
Speech, hearing and language disorder services
Respiratory care services
Other diagnostic, screening, preventive and rehabilitative services
Podiatry services
Optometry services
Dental services
Dentures
Prosthetics
Eyeglasses
Chiropractic services
Private duty nursing services
Personal care
Hospice
Case management
Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
State Plan Home and Community Based Services- 1915(i)
Self-Directed Personal Assistance Services- 1915(j)
Community First Choice Option- 1915(k)
TB Related Services
Inpatient psychiatric services for individuals under age 21
Health Homes for Enrollees with Chronic Conditions – Section 1945

As a Highmark Wholecare Member, you have the right:

To be treated with respect, recognizing your dignity and need for privacy, by Highmark Wholecare staff and network providers.
To get information in a way that you can easily understand and find help when you need it.
To get information that you can easily understand about Highmark Wholecare, its services, and the doctors and other providers that treat you.
To pick the network health care providers that you want to treat you.
To get emergency services when you need them from any provider without Highmark Wholecare’s approval.
To get information that you can easily understand and talk to your providers about your treatment options, risks of treatment, and tests that may be self-administered without any interference from Highmark Wholecare.
To make all decisions about your health care, including the right to refuse treatment. If you cannot make treatment decisions by yourself, you have the right to have someone else help you make decisions or make decisions for you.
To talk with providers in confidence and to have your health care information and records kept confidential.
To see and get a copy of your medical records and to ask for changes or corrections to your records.
To ask for a second opinion.
To file a grievance if you disagree with Highmark Wholecare’s decision that a service is not medically necessary for you.
To file a complaint if you are unhappy about the care or treatment you have received.
To ask for a Department of Human Services (“DHS”) Fair Hearing.
To be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it easier for the provider, or to punish you.
To get information about services that Highmark Wholecare or a provider does not cover because of moral or religious objections and about how to get those services.
To exercise your rights without it negatively affecting the way DHS, Highmark Wholecare, and network providers treat you.
To create an advance directive.
To make recommendations about the rights and responsibilities of Highmark Wholecare’s members.

As a Highmark Wholecare Member you have a responsibility to:

Provide, to the extent you can, information needed by your providers.
Follow instructions and guidelines given by your providers.
Be involved in decisions about your health care and treatment.
Work with your providers to create and carry out your treatment plans.
Tell your providers what you want and need.
Learn about Highmark Wholecare’s coverage, including all covered and non-covered benefits and limits.
Use only network providers unless Highmark Wholecare approves an out-of-network provider or you have Medicare.
Get a referral from you Primary Care Physician (“PCP”) to see a specialist.
Respect other patients, provider staff, and provider workers.
Make a good-faith effort to pay your co-payments.
Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.

Si desea una copia de los derechos y responsabilidades de los miembros del Plan de Salud Highmark Wholecare, llame al 1-800-392-1147.
Derechos y Responsabilidades de las Miembros Declaracion.

Member Programs

For our Medicaid members, help is always just a phone call away. Call 1-855-805-9408 with your questions about:

A recent diagnosis, treatment options or surgery
Current symptoms
Medication side effects
Self-care home treatments
When to go to the doctor
When to go to the Urgent Care Center or Emergency Room
Preventive care and lab tests

A professional nurse is available 24 hours a day, 7 days a week. If you experience an emergency, please call 911.

Also available to all our Medicaid members, is our wellness coaching program. You have access to several wellness coaches, including:

Certified Rehabilitation Counselor - Help prevent or reduce falls. This Wellness Coach will ask some questions about your risk for falling and do a home safety checklist. Your coach will also give you tips to help your balance and strength.
Registered Dietitian Nutritionist - Get answers to your questions about healthy eating from a food expert. This Wellness Coach will work with you to help manage any medical conditions or your overall health.
Certified Diabetes Care and Education Specialist - Take control of your diabetes. This Wellness Coach will help you learn about taking medicines and lowering your risk of diabetes-related complications. You can set goals for moving more. If you are looking for help with food and nutrition information only, reach out to our Registered Dietitian Nutritionist Wellness Coach!

When you make the right choices, you deserve a reward. Healthier lifestyle decisions are no exception. The Goodness Rewards Programs gives Highmark Wholecare members a reloadable gift card, good at over 100 locations. Every time you complete an eligible health activity, you get a reward!

Contact Goodness Rewards for more information.

Review Frequently Asked Questions here.

Call: 1-800-539-5722

TTY: 711

Monday - Friday, 7 a.m. to 7 p.m.

We have a special program for pregnant women called MOM Matters®. This program gives you the education and support to help you have a healthy pregnancy. Our Maternity Team members are here to answer questions and help you every step of the way. They can help you:

Find a doctor and set up your appointments for prenatal care. Call us as soon as you find out you are pregnant!
Answer questions, direct you to community services, and guide you throughout your pregnancy.
Arrange a home visit by a nurse when needed.
Provide resources for transportation to and from important doctor appointments.
Connect you to the smoking quit line at 1-800-784-8669 or 1-800-QUIT-NOW.
Earn rewards for going to all your prenatal and postpartum care doctor visits!

Free Cell Phone Service - Talk, Text and Data Every Month! Highmark Wholecare is proud to be working with SafeLink Wireless to offer PA Medicaid members this special Lifeline program at no cost.

View the flyer to learn more about this program.

Enrolled in the Boys & Girls Clubs programming or want to enroll?

You can have the cost of monthly membership dues paid by Highmark Wholecare!

IN ORDER TO QUALIFY:

A current Highmark Wholecare member:
Between the ages of 6-18 for the Olivet Boys and Girls Clubs in Reading
Between the ages of 5-24 for the Boys & Girls Clubs of Western Pennsylvania
Live near one of the clubhouse locations

For more information call Member Services.

IN ORDER TO QUALIFY FOR THIS VALUE ADDED BENEFIT, YOU MUST:

Be a current Highmark Wholecare member
Be at least 17 years old
Be a PA resident
Not enrolled in any other school program

Many jobs now require a high school diploma or GED and getting your GED gives you the chance to earn at least $9,000 more a year! Don’t miss the opportunity to take your GED test at NO COST.

If you are interested in this program contact Member Services at 1-800-392-1147. (TTY# 711 for hearing impaired)

Questions?

If you need help or support with your Medicaid coverage, please call our Call Center
at 1-800-392-1147 from 8am-8pm, Monday through Friday. TTY users call 711.

This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.