Better understand your plan and how to get the most out of it.
Learn more about the latest state regulations and how upcoming changes may affect your coverage.
Massachusetts
Fully insured commercial Massachusetts plans
Abortion and abortion-related care
In accordance with Massachusetts law, effective January 1, 2023, all fully insured commercial Massachusetts plans will provide coverage for abortion and abortion-related care without cost sharing under the Voluntary Termination of Pregnancy benefit.
If you are covered under a High-Deductible Health Plan under the federal internal revenue code that is offered with a federally qualified Health Savings Account (HSA plan), your plan is designed to comply with the requirements of the Internal Revenue Service and the Deductible will apply to these services. If you are covered under a PPO or POS plan and you use Out-of-Network benefits, standard Out-of-Network cost sharing will apply.
Please note, abortion and abortion-related care services may not be covered when your employer is a church or church-controlled organization, as allowed by law.
Individual and group fully insured commercial Massachusetts plans
An act addressing barriers to care for mental health
In accordance with Massachusetts law, all individual and group fully insured commercial Massachusetts plans will:
- Provide coverage for:
- an annual mental health wellness examination performed by a licensed mental health professional or a primary care provider (as part of an annual preventive visit). The exam will be covered with no patient cost sharing. If you are covered under a PPO or POS plan and you use Out-of-Network benefits, standard Out-of-Network cost sharing will apply.
- mental health or substance use disorder services that are delivered through the psychiatric collaborative care model.
- medically necessary emergency services programs (ESP) including behavioral health crisis assessment, intervention, and stabilization services through (i) mobile crisis intervention services; (ii) emergency service provider community-based locations; and (iii) adult community crisis stabilization services.
- medically necessary mental health acute treatment, community-based acute treatment (CBAT) and intensive community-based acute treatment (ICBAT) and will not require a preauthorization before obtaining treatment.o medically necessary mental health acute treatment, community-based acute treatment (CBAT) and intensive community-based acute treatment (ICBAT) and will not require a preauthorization before obtaining treatment.
- Shorten the expedited appeal notification timeline to 2 business days if the expedited review affirms the denial of coverage or treatment.
- Allow disabled dependents to remain on coverage after the age of 26.
- Define “licensed mental health professional”, to include: a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed certified social worker, a licensed mental health counselor, a licensed supervised mental health counselor, a licensed psychiatric nurse mental health clinical specialist, a licensed psychiatric mental health nurse practitioner, a licensed physician assistant who practices in the area of psychiatry, a licensed alcohol and drug counselor I, as defined in section 1 of chapter 111J, a licensed marriage and family therapist within the lawful scope of practice for such therapist, a clinician practicing under the supervision of a licensed profession and working towards licensure in a clinic license under chapter 111.
Fully insured Medicare Enhance Massachusetts plans
An act addressing barriers to care for mental health
In accordance with Massachusetts law, all fully insured Medicare Enhance Massachusetts plans will:
- Provide coverage for:
- an annual mental health wellness examination performed by a licensed mental health professional or a primary care provider (as part of an annual preventive visit). The exam will be covered with no patient cost sharing.
- mental health or substance use disorder services that are delivered through the psychiatric collaborative care model.
- medically necessary emergency services programs (ESP) including behavioral health crisis assessment, intervention, and stabilization services through (i) mobile crisis intervention services; (ii) emergency service provider community-based locations; and (iii) adult community crisis stabilization services.
- medically necessary mental health acute treatment provided in an inpatient facility
- Shorten the expedited appeal notification timeline to 2 business days if the expedited review affirms the denial of coverage or treatment.
- Define “licensed mental health professional”, to include: a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed certified social worker, a licensed mental health counselor, a licensed supervised mental health counselor, a licensed psychiatric nurse mental health clinical specialist, a licensed psychiatric mental health nurse practitioner, a licensed physician assistant who practices in the area of psychiatry, a licensed alcohol and drug counselor I, as defined in chapter 111, a licensed marriage and family therapist within the lawful scope of practice for such therapist, a clinician practicing under the supervision of a licensed profession and working towards licensure in a clinic license under chapter 111.
Maine
Fully insured commercial Maine plans
An act to provide access to fertility care
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will cover fertility diagnostic care, fertility treatment and fertility preservation services.
An act to promote better dental care for cancer survivors
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will cover medically necessary dental procedures to reduce the risk of infection, eliminate infection or to treat tooth loss or decay for Members diagnosed with cancer before and after undergoing treatment.
An act to improve outcomes for persons with limb loss
In accordance with Maine state legislative changes effective January 1, 2024, for Members under 18 years of age, Harvard Pilgrim will cover a second prosthetic device that is determined by the Member’s provider to be the most appropriate model that meets the medical needs of a Member for sports or recreational purposes.
An act to require private insurance coverage for donor breast milk
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will provide coverage for medically necessary pasteurized donor breast milk provided to an infant.
An act to remove barriers to abortion coverage in private insurance
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will not impose any deductible, copayment, coinsurance or other cost sharing requirement for the costs of abortion services performed by an in-network provider.
This does not apply to high-deductible health plans as defined in the federal Internal Revenue Code, Section 223(c)(2).
An act regarding insurance coverage for diagnostic and supplemental breast examinations
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will not impose any deductible, copayment, coinsurance or other cost sharing requirement for the costs of screening mammograms, diagnostic breast examinations, supplemental breast examinations, breast ultrasounds or breast MRIs performed by an in-network provider.
This does not apply to high-deductible health plans as defined in the federal Internal Revenue Code, Section 223(c)(2).
Fully insured Maine Medicare Enhance plans
An act to promote better dental care for cancer survivors
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will cover medically necessary dental procedures to reduce the risk of infection, eliminate infection or to treat tooth loss or decay for Members diagnosed with cancer before and after undergoing treatment.
An act regarding insurance coverage for diagnostic and supplemental breast examinations
In accordance with Maine state legislative changes effective January 1, 2024, Harvard Pilgrim will not impose any cost sharing requirement for the costs of screening mammograms, diagnostic breast examinations, supplemental breast examinations, breast ultrasounds or breast MRIs performed by a provider.
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