Focus: State Law Requirements

Your Highmark plan may be subject to certain state law requirements. Select your state below to learn more about one or more state law requirements that are highlighted and may apply to your Highmark plan issued in that state.

Applicable legal requirements listed for each state may be included in your current Highmark coverage. Please note this is not a complete listing of all state law requirements that may apply to your Highmark plan and may only highlight one or a few requirements. Remember to check your plan documents to confirm your plan’s benefits and coverage details. Coverage may be subject to deductibles and coinsurance. To determine the availability of services under your health plan, please review your member materials for details on benefits, conditions and exclusions or call the number on the back of your ID card.

Delaware

In 2025, your benefits may include:

• Coverage for annual screening tests for women at risk for ovarian cancer and expanded monitoring tests subsequent to treatment for ovarian cancer.
• Coverage for diagnostic breast examinations and supplemental breast screening examinations.
• Coverage for annual mammograms for the purpose of early detection for women age 40 or older with or without a referral from a health-care provider.
• Coverage for speech therapy for children diagnosed with certain speech-language disorders; and
• Coverage for over-the-counter non-emergency contraceptives.

HAIR PROSTHESIS BENEFITS REMINDER: You may also have continued coverage of up to $500 per year for scalp hair prosthesis expenses when hair loss is a result of alopecia areata caused by an autoimmune disease.

West Virginia

West Virginia Prior Authorization Requirements:

West Virginia law requires that all prior authorization requests and related communications to be submitted via an electronic portal.  Your health care provider has access to this portal.  Certain services may be bundled together as part of an episode of care.  Health care providers who meet the state requirements for frequency, performance, and approval may qualify for a “gold card” exemption for a limited period of time.  A gold card exemption means the provider is not required to request prior authorization approval while they hold an active gold card.  Our goal in meeting the state requirements is to enhance timely prior authorization reviews.

Some types of health care services and supplies require prior authorization from Highmark before you can receive them. This means your provider needs our approval before they can provide these services to ensure that:

• Your benefit plan covers the service: Service preapproval is based on the member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits.
• You receive the most appropriate care: We review your provider's request to make sure the service is medically necessary and aligns with your health needs.
• Your care is cost-effective: We work to ensure that the services you receive are both effective and affordable. 
  

What You Need to Do:

• Talk to your provider: Your provider is responsible for checking if a service requires prior authorization. They have access to Highmark’s prior authorization list on the Provider Resource Center, and the ability to check your benefits via Availity, our provider portal.
• Be prepared: If your provider determines that a service requires prior authorization, they will initiate the process. 

If you have any questions or need assistance, please call Member Services using the number on the back of your Member ID card.

New York

Annual Colorectal Cancer Screening Coverage notification

Federal and New York state laws requires coverage of colorectal cancer screenings recommended by the American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF) for average-risk adults 45 years and older ( 45+ years).

Regular screenings with either a high-sensitivity stool-based test (FIT test) or visual (structural) exam (screening colonoscopy).

A diagnostic colonoscopy performed within one year of a positive USPSTF or ACS mandated colon cancer screening test is also covered. 

Specific details on the recommendation and requirements can be found at the links below:

USPSTF: Colorectal Cancer: Screening - Learn More

ACS: American Cancer Society Colorectal Cancer Screening Guidelines - Learn More