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      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.

      Pennsylvania

      In 2026, your benefits may include:

      • Highmark complies with applicable Pennsylvania requirements.  For more information about your coverage, please refer to your plan documents or contact the number on the back of your ID card.
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      Delaware

      In 2026, your benefits may include:

      • Coverage for prostate screenings for men at risk of prostate cancer beginning at ages that are in accordance with American Cancer Society guidelines.
      • Coverage for doula services when provided by a doula certified by the Delaware Certification Board, including at least 3 prenatal visits up to 90 minutes each, 3 postpartum visits up to 90 minutes each, attendance through labor and birth, and additional postpartum visits with a recommendation from a Title 24 licensed practitioner or clinician acting within their scope of practice.
      • Coverage for at least 1 early egg allergen introduction dietary supplement and at least 1 early peanut allergen introduction dietary supplement prescribed to an infant under the age of 1 year.
        You need to submit the following documents for potential reimbursement:
        1. completed paper Claim Form. Under section DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, write “early egg allergen introduction dietary supplement” and/or “early peanut allergen introduction dietary supplement”;
        2. a receipt showing payment for the early egg and/or early peanut allergen introduction dietary supplement; and
        3. provider prescription for the early egg and/or early peanut allergen introduction dietary supplement.
      • Coverage for services related to the termination of pregnancy.
      • Coverage for FDA-approved drugs prescribed to treat the associated conditions of metastatic cancer without requiring that an insured first fail to successfully respond to a different drug or drugs, or prove a history of failure of a different drug or drugs, where use of the prescribed drug is consistent with best practices for the treatment of the associated conditions of metastatic cancer and is supported by national clinical guidelines, national standards of care, or peer reviewed medical literature.

      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.

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      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. 

      Important Information for West Virginia Medicare Supplement Policyholders: New Guaranteed Issue Rights

      Effective on and after June 1, 2026, or at any time thereafter when any term of thepolicy, contract, or plan is changed, or any premium adjustment is made, West Virginia House Bill 4869 introduces new guaranteed issue rights for eligible Medicare Supplement policyholders. These new rights provide opportunities for individuals to enroll in or switch Medicare Supplement plans under specific circumstances without medical underwriting. 

      Please review the information below to understand how these changes might affect you.

      1. Guaranteed Issue for Existing Highmark Medicare Supplement Members

      If you are an existing Highmark Medicare Supplement policyholder in West Virginia, you may gain new guaranteed issue rights around your birthday.

      • Eligibility: To qualify, you must have maintained continuous coverage under your Highmark Medicare Supplement policy for at least 24 months. Each replacement policy issued pursuant to this new guaranteed issue right is subject to the same 24 month continuous coverage requirement before it may be replaced.
      • Your Right: During your "birthday" application period, you will have a guaranteed right to purchase another Highmark Medicare Supplement policy with the same or lesser standardized benefits than your current plan.
      • Application Period: This special enrollment period begins on the first day of your birth month and extends for 60 days. During this period, Highmark cannot deny your application, impose medical underwriting, or apply pre-existing condition exclusions.

      2.  Guaranteed Issue for Individuals from a non-Highmark Carrier

      Individuals insured by another carrier may also qualify for a guaranteed issue right to switch to a Highmark Medicare Supplement plan under specific circumstances.

      • Eligibility: This right applies if your previous carrier (or its affiliate) has not accepted applications for a Medicare Supplement policy offering the same or lesser standardized benefits as your current coverage for a period of at least 12 months. You also must have maintained continuous coverage for at least 24 months with your previous Medicare Supplement carrier.
      • Your Right: You can purchase a Highmark Medicare Supplement policy with the same or lesser standardized benefits as your current plan. You cannot purchase a policy with greater benefits than the one being replaced.
      • Application Period: This special enrollment period begins on the first day of your birth month and extends for 60 days. Highmark cannot deny your application, impose medical underwriting, or apply pre-existing condition exclusions.

      3. Guaranteed Issue Upon Loss of Medicaid Eligibility

      If you are a West Virginia resident aged 65 or older and lose your Medicaid eligibility, you may have a guaranteed right to enroll in a Medicare Supplement plan.

      • Eligibility: You must be 65 years of age or older, lose your Medicaid eligibility, and be entitled to Medicare. This right applies regardless of whether you were previously enrolled in a Medicare Supplement policy or were eligible for/enrolled in Medicaid when you first became entitled to Medicare.
      • Your Right: You will have a guaranteed right to purchase any Medicare Supplement policy actively offered by Highmark to new enrollees.
      • Application Period: This guaranteed issue period begins on the date your Medicaid eligibility ends and continues for 63 days thereafter. Highmark cannot deny your application, impose medical underwriting, or apply pre-existing condition exclusions.

      Next Steps and Important Considerations:

      If you believe you may qualify for one of these new guaranteed issue rights, please contact Highmark Member Services for assistance or apply online at Medicare.Highmark.com.

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

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      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

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      We’re here for you

      If you have questions about your benefits, please call the number on the back of your member ID card or log in to your account.