Learn About Our Products - Harvard Pilgrim Health Care - Provider (2024)

Harvard Pilgrim offers several different types of standard plans including our Health Maintenance Organization (HMO), Point of Service (POS), Preferred Provider Organization (PPO) plans, as well as our open access versions of the HMO and POS plans and benefit design provider plans including our LP (low-pay) and Flex plans.

Please note these plans may require the member to pay a cost share (deductible, copayment or coinsurance) for covered services. Prior to rendering services at an appointment, please check the member’s eligibility and benefits via HPHConnect, NEHEN, NEHEN Net, or your preferred connection for eligibility services.

• HMO — For our HMO plans, members must select a primary care physician (PCP) in the Harvard Pilgrim network. The PCP coordinates the member’s care and must submit a referral for specialist care. Members utilize providers from our Harvard Pilgrim network across five New England states for most services, with a national network available for when members are out of area and require urgent care.
• POS — Members must select a PCP in the Harvard Pilgrim network. Members can receive care from specialists with or without a PCP referral. Specialist care without a referral incurs a greater member cost share . In addition to Harvard Pilgrim’s provider network, members may choose to see an out-of-network provider, at a higher cost.
• PPO — Members are not required to select a PCP or have referrals for specialist care. Provider coverage includes Harvard Pilgrim’s network in five New England states, and our national network partner, UnitedHealthcare for the remaining states. In addition to the Harvard Pilgrim and UnitedHealthcare networks, members may see an out-of-network provider, at a higher cost.
• HMO Open Access — Members must select a PCP in the Harvard Pilgrim network. Unlike standard HMO plans, in our Open Access HMO plan a PCP referral is not required for specialty care. Members must see providers in Harvard Pilgrim’s network across five New England states for routine care; a national network is available for when members are out of area and require urgent care.
• POS Open Access — Members must select a PCP in the Harvard Pilgrim network. Unlike the standard POS plans, PCP referral is not required for specialty care to receive in-network cost share. In addition to Harvard Pilgrim’s provider network, members may see an out-of-network provider, at a higher cost.
• LP (low-pay) — For some New Hampshire products, members and employers can opt for a low-pay benefit version, in which the member has lower cost sharing when they receive services from a designated “Select LP Provider” general laboratory or ambulatory surgery center provider. Our LP options are offered with Harvard Pilgrim’s HMO, POS, PPO, and HMO Open Access plans. PCP and referral requirements and network availability vary by plan.
• Flex — For some Massachusetts products, members and employers can opt for a Flex benefit option, in which the member has lower cost sharing when they receive services from a designated “Flex” general laboratory or ambulatory surgery center provider. Our Flex options are offered with Harvard Pilgrim’s HMO and PPO plans. PCP and referral requirements and network availability vary by plan.
• SimplyVirtual^SM HMO — Different from our standard HMO plan, adult members must select a PCP through our virtual provider partner, Doctor on Demand. The PCP coordinates the member’s care and must submit a referral for specialist care. Provider coverage is exclusive to Harvard Pilgrim network coverage across five New England states, with a national network available for when members are out of area and require urgent care.
• Virtual Choice^SM HMO — Members must select a primary care physician in the Harvard Pilgrim network. Different from our standard HMO plan, adult members may select a PCP through our virtual provider partner, Doctor on Demand, or an office based PCP through Harvard Pilgrim provider network. The PCP coordinates the member’s care and must submit a referral for specialist care. Provider coverage is exclusive to Harvard Pilgrim network coverage across five New England states, with a national network available for when members are out of area and require urgent care.

Please refer to Harvard Pilgrim’s online provider directory for more information.

Our Limited Network Plans are designed to help employers manage premium costs while still offering comprehensive coverage to their employers. They feature a more limited network of providers in order to manage costs, and members must receive care from providers who participate in the defined network.

These plans may require the member to pay a cost share (deductible, copayment or coinsurance) for covered services. Prior to rendering services at an appointment, please check the member’s eligibility and benefits via HPHConnect, NEHEN, NEHEN Net, or your preferred connection for eligibility services.

• Focus Network MA — Harvard Pilgrim’s Focus Network MA is a Massachusetts plan. in which members must select a participating PCP. The PCP coordinates the member’s care, and must submit a referral to a participating specialist. Authorization is required for care rendered by providers deignated as “Auth Access” in the online provider directory.
• ElevateHealth HMO — Harvard Pilgrim’s ElevateHealth HMO is a New Hampshire sold plan. Members must select a participating PCP. The PCP coordinates the member’s care and must submit a referral to a participating specialist. Authorization is required for care rendered by providers designated as “Auth Access” in the online provider directory.
• NH Local HMO — Harvard Pilgrim’s NH Local HMO is a fully insured product that will be offered in New Hampshire as of Jan. 1, 2023, consisting of the same limited network of providers as NH Local Choice HMO (including PCPs and other provider specialties), but without a tiered structure.

Please refer to Harvard Pilgrim’s online provider directory for more information.

Harvard Pilgrim’s Tiered Network Plans are designed to help employers manage premium costs and educate members on selecting lower cost providers. Member cost share will vary by provider tier designation. Please visit the online provider directory to verify your tier designation, or whom the referring provider is. Tier designation will vary by plan. (For further information, including product-specific FAQs, please refer to our Tiered Network Product Resources page.)

Please note these plans may require the member to pay a cost share (deductible, copayment or coinsurance) for covered services. Prior to rendering services at an appointment, please check the member’s eligibility and benefits via HPHConnect, NEHEN, NEHEN Net, or your preferred connection for eligibility services.

• ChoiceNet HMO and ChoiceNet PPO — Harvard Pilgrim’s ChoiceNet is a tiered Massachusetts sold plan. Massachusetts and New Hampshire hospitals and physician groups are tiered based on cost and quality measures and placed into one of three tier designations. Members will pay less for services rendered at a Tier 1 designated provider. Our ChoiceNet options are offered with Harvard Pilgrim’s HMO and PPO platform. PCP and referral requirements, and network availability vary by plan.
• GIC Harvard Pilgrim Quality HMO and Harvard Pilgrim Explorer — Harvard Pilgrim Quality HMO is a Massachusetts tiered limited-network HMO, which includes a deductible, lower PCP copayment, two copayment tiers for specialist office visits, and two copayment tiers for inpatient admissions to acute care hospitals. The HMO product is available to GIC members residing in Massachusetts (except in Martha’s Vineyard, Nantucket, and Cape Cod). Harvard Pilgrim Explorer POS is a tiered full-network product, open to New England state and municipal employees, that allows members to seek in-network medical care or out-of-network medical services. It includes a deductible, three lower-cost copayment tiers for PCPs, and three copayment tiers for specialist visits and inpatient admissions to acute care hospitals.
• ElevateHealth Options HMO — Harvard Pilgrim’s ElevateHealth Options HMO is a tiered New Hampshire sold plan. Hospitals and physician groups are designated one of two tiers. Members will pay less for services rendered at a Tier 1 designated provider. Members must select a participating PCP. The PCP coordinates the member’s care and must submit a referral to a participating specialist.
• Littleton Options HMO — Harvard Pilgrim’s Littleton Options HMO is a tiered New Hampshire sold plan. Hospitals and physician groups are designated one of two tiers. Members will pay less for services rendered at a Tier 1 designated provider. Members must select a participating PCP. The PCP coordinates the member’s care and submits referrals to participating specialists.
• Maine’s Choice Plus HMO — Harvard Pilgrim’s Maine’s Choice HMO is a tiered Maine sold plan. Hospitals and physician groups are designated one of two tiers. Members will pay less for services rendered at a Tier 1 designated provider. Members must select a participating PCP. The PCP coordinates the member’s care and must submit a referral to a participating specialist.
• Custom Steerage Plans — Harvard Pilgrim has developed custom steerage plans for strategic provider partnerships and key customers, such as Beth Israel Lahey Health and Harvard Medical Faculty Professionals. These plans are designed to steer members to a domestic network within their provider system. Members will pay less for services rendered at a Tier 1 designated provider. Our custom steerage plans are offered with Harvard Pilgrim’s HMO, POS and PPO platforms. PCP and referral requirements, and network availability vary by plan.
• NH Local Choice HMO — Harvard Pilgrim’s NH Local Choice HMO will be offered in New Hampshire as of Jan. 1, 2023 and feature a tiered and limited provider network with two member cost-sharing levels — Tier 1 and Tier 2 — both of which include PCPs and other provider specialties. Tier 1 providers are at a lower cost share, with Tier 2 providers available at a higher cost share.

Please refer to Harvard Pilgrim’s online provider directory for more information.

Harvard Pilgrim’s National Plans are our product offerings in alliance with United Healthcare. These plans are for multi-site and multi-state employers who are based in Massachusetts, New Hampshire and Maine. These plans allow for a seamless network that includes Harvard Pilgrim’s provider network in Massachusetts, New Hampshire, and Maine and UnitedHealthcare’s national network in the remainder of the states.

Please note these plans may require the member to pay a cost share (deductible, copayment or coinsurance) for covered services. Prior to each appointment, please check the member’s eligibility and benefits before rendering services. For Access America Products, utilize HPHConnect, NEHEN, NEHEN Net, or your preferred connection for eligibility services; for Passport and Student Insurance plans, please verify with United Healthcare.

• Access America — Members are not required to select a PCP or have referrals for specialist care. This plan offering is built on Harvard Pilgrim’s systems with Harvard Pilgrim being the servicing issuer. Provider coverage includes Harvard Pilgrim’s network in Massachusetts, New Hampshire, and Maine, and our national network partner, UnitedHealthcare for the remaining states. In addition to the Harvard Pilgrim and UnitedHealthcare networks, members may see an out of network provider, at a higher cost.
• Access America Value — Members are not required to select a PCP or have referrals for specialist care. This plan offering is built on Harvard Pilgrim’s systems with Harvard Pilgrim being the servicing issuer. Provider coverage includes Harvard Pilgrim’s network in Massachusetts, New Hampshire, and Maine, and our national network partner, UnitedHealthcare for the remaining states. Members are required to stay in network with Harvard Pilgrim or UnitedHealthcare and may not see an out of network provider.
• Ocean State Access America – Members are not required to select a PCP or have referrals for specialist care. This plan offering is built on Harvard Pilgrim’s systems with Harvard Pilgrim being the servicing issuer. Provider coverage includes Harvard Pilgrim’s network in Massachusetts, New Hampshire, Maine, and Rhode Island, and our national network partner, UnitedHealthcare for the remaining states. In addition to the Harvard Pilgrim and UnitedHealthcare networks, members may see an out-of-network provider at a higher cost.
• Passport — Members are not required to select a PCP or have referrals for specialist care. This plan offering is built on UnitedHealthcare’s systems with UnitedHealthcare being the servicing issuer. Provider coverage includes UnitedHealthcare’s national provider network and Harvard Pilgrim’s provider network in Massachusetts, New Hampshire, and Maine. Provider relationships and administrative services for members are coordinated by Harvard Pilgrim and UnitedHealthcare. UnitedHealthcare manages member administrative services in all regions, including eligibility, care coordination and claims processing. For provider relationships (including negotiating contract and reimbursem*nt terms, credentialing, enrollment changes, and establishing payment policies), Harvard Pilgrim is responsible in MA, ME, and NH while UnitedHealthcare is responsible in all other areas.
• Student Insurance — This PPO product offering is for students who attend college and universities in Massachusetts and Maine. Members are not required to select a PCP or have referrals for specialist care. Provider coverage includes Harvard Pilgrim’s network in five New England states, and our national network partner, UnitedHealthcare for the remaining states. In addition to the Harvard Pilgrim and UnitedHealthcare networks, members may see an out of network provider, at a higher cost.

Please refer to Harvard Pilgrim’s online provider directory for more information.

Harvard Pilgrim’s Medicare Plans are plans available to Medicare eligible individuals either directly or through their employer. Plans either complement Medicare Parts A and B or provide full coverage (under Medicare Advantage plans). Members must meet certain eligibility requirements to enroll in one of these plans.

Please note these plans may require the member to pay a cost share (deductible, copayment or coinsurance) for covered services. Prior to each appointment, please check the member’s eligibility and benefits before rendering services.

• Medicare Advantage Plans — Medicare Advantage Stride^SM (HMO)/(HMO-POS) is offered to Medicare eligible individuals in New Hampshire. In-network coverage is exclusive to Harvard Pilgrim’s Medicare Advantage Stride^SM contracted providers. Members must select a primary care physician (PCP) in the Harvard Pilgrim Stride^SM network; please refer to Harvard Pilgrim’s online provider directory. The PCP coordinates the member’s care and, when needed, must submit a referral for specialist care. These plans include prescription drug coverage. For additional information, please see our Medicare Advantage webpage for providers.
• Medicare Supplement Plans — These plans are offered to Medicare eligible individuals in Massachusetts (Medicare Supplement Core, Medicare Supplement 1A, Medicare Supplement 1), New Hampshire (Plan A, F, G, M, N) and Maine (Plan A, F, G, M, N). They are also referred to as “Medigap” plans and sold to fill the gaps in Original Medicare coverage. Members must be enrolled in Medicare Parts A and B and are not required to choose a PCP. Medicare Supplement members can receive treatment from any Medicare participating provider. Medicare Supplement Plans do not include prescription drug coverage; a member may purchase a Medicare Part D Pharmacy Drug Plan (prescription drug) separately.
• Medicare Enhance — Medicare Enhance plans offer employer-sponsored coverage for members enrolled in Medicare Parts A and B. Available through employer groups in Massachusetts, New Hampshire and Maine, Medicare Enhance fills in gaps in Medicare coverage. Medicare Enhance is also available with Harvard Pilgrim Prescription Drug coverage or with a Medicare Part D Prescription Drug Plan (PDP), per Harvard Pilgrim underwriting guidelines.

Harvard Pilgrim products and services are available through Health Plans, Inc., a Harvard Pilgrim affiliate. Health Plans Inc. is a regional third-party administrator that offers administrative and consulting services to health and benefit plan sponsors, including self-funded employers, associations of employers and union-negotiated plans. Administrative services, including eligibility verification, care coordination and claims processing are provided by Health Plans, Inc. on behalf of Harvard Pilgrim and its affiliates, including HPHC Insurance Company, Inc. Harvard Pilgrim is responsible for managing provider relationships, such as negotiating contract and reimbursem*nt terms, credentialing and establishing payment policies.

For more information, please visit the Health Plans, Inc. website.

Our portfolio of products and services now include dental and vision products to complement our commercial health plans. These are available to Harvard Pilgrim accounts (of 51 or more members) as well as other commercial plans.

• Point32Health Dental — This PPO product is available to members of large group (51 or more members) Harvard Pilgrim Health Care employer clients in Massachusetts, New Hampshire, Rhode Island, and Maine for plans effective after July 1, 2024. Offered as a complement to our medical health plans, Point32Health Dental provides members with broad coverage for preventive, restorative, and orthodontia services from one of the largest PPO networks nationwide.
• Point32Health Vision — This specialty product is available to members of large group (51+) Harvard Pilgrim Health Care employer clients in Massachusetts, New Hampshire, Rhode Island, and Maine for plans effective after July 1, 2024. Offered as a complement to our medical health plans, Point32Health Vision provides members with comprehensive benefits for exams, lenses, and frames from national retailers, independent practitioners, and leading online providers.