How to Use your Medical Plan

Health insurance is important to have – but it's not always easy to understand. Harvard Pilgrim recognizes that there are a lot of health insurance terms for you to keep straight, so we encourage you to take the time to understand how your plan works. Here are some key things to know as you get started.

Know how your plan works.

Each insurance plan has different rules for using health care benefits. You should become familiar with your specific Harvard Pilgrim plan benefits and limitations when you first sign up—especially if the plan requires you to receive your care from certain doctors and hospitals. Your benefits, costs and limits are outlined in the Schedule of Benefits and Benefit Handbook.

The Schedule of Benefits (SOB) is a summary of benefits covered under your health insurance plan, along with the associated fees and service limits. SOBs are provided so you can be informed about which services and treatments are covered and which are not. For a detailed summary of your plan benefits, cost sharing and limits, you can access your SOB by visiting the My Account tab above and view Plan Documents.

Your Benefit Handbook works in conjunction with the SOB and will provide greater detail on your covered benefits and services as well as any exclusions. The Benefit Handbook is also available from your Member Dashboard by visiting the My Account section and viewing Plan Documents.

Understand the referral rules of your plan.

Many HMO plans require a referral from your primary care provider (PCP) for specialty visits. If you are on a POS plan, referrals are required for specialty care in order for services to be covered at the in-network (lower cost) benefit level. PPO plans do not require a referral for specialty care services.

If you need to see a specialist and require a referral, you must contact your PCP for one prior to the appointment. In most cases, a referral will be given to a specialist who is affiliated with the same hospital as your PCP or who has a working relationship with their practice.

Choose a PCP.

Individuals with health insurance typically have a PCP who oversees their medical care. A PCP may be a physician, a physician assistant or a nurse practitioner specializing in one or more of the following specialties: internal medicine, adult medicine, adolescent medicine, geriatric medicine, pediatrics or family practice.

You’ll want to check that your PCP is in the Harvard Pilgrim network and listed in your member profile before scheduling an appointment. You can change your PCP though your member account or by calling Member Services at (888) 333-4742. If you don’t already have a PCP, or if your current provider is not part of your new insurance plan, you can refer to “Tips for Choosing a PCP” for some helpful information on finding the right provider.

Visit Harvard Pilgrim’s provider directory to find providers in your plan’s network.

The provider directory identifies PCPs, specialists, hospitals and other plan providers that are in your network. It can help you search for providers by state and town, specialty and languages spoken.

If you have a Limited Network or Tiered Plan (which will be stated in your Schedule of Benefits), the provider directory will list only those providers who participate in your network, including their tier level if applicable, You may access the provider directory from your Member Dashboard. The provider directory is accessible from your Member Dashboard by clicking the Find a Provider link.

Become familiar with your urgent care options.

If you have an injury or illness that is not life-threatening, and your primary care physician’s office is closed, you have lower cost urgent care options that can save you both time and money; while avoiding a visit to the emergency room (ER).

Urgent care options available through your Harvard Pilgrim plan:

  • Have a virtual visit with Doctor On Demand: You see a board-certified doctor for a visit within minutes—using your mobile device. Visit or download the free app.
  • Find a clinic near you: Locate convenience care clinics and urgent care centers. More information on your Urgent Care options are available from your Member Dashboard by selecting ‘Tools & Resources’.

Learn about the many tools and services available to help you save money.

Your plan may include different cost sharing options based on the location where you receive medical services. It’s important for you to know the out-of-pocket costs that different service locations may have (e.g., hospital vs. physician’s office) before deciding along with your PCP where to get treatment. Details about your plan and how it works may be found in your SOB and Benefit Handbook.

To learn about additional savings options, visit Tools & Resources as well as Discounts & Savings from your Member Dashboard.