What You Need to Know
Harvard Pilgrim Health Care is a not-for-profit health services company based in New England. The insurance company focuses on Maine, New Hampshire, Connecticut and Massachusetts.
In January 2021, the company announced a merger with Tufts Health Plan.
The company offers a variety of member benefits aimed at improving wellness, cutting healthcare costs, and making behavioral and mental health treatment accessible.
Who is Harvard Pilgrim Health Care?
Founded by doctors about 50 years ago, Harvard Pilgrim Health Care provides health plans and services to more than 3 million customers, primarily in New England (Massachusetts, Maine, New Hampshire, and Connecticut) but offer national plans for group insurance as well.1 The provider network includes more than 80,000 doctors and other clinicians, and 183 participating hospitals.
The local, not-for-profit company invests in the communities it serves through the Harvard Pilgrim Health Care Foundation, whose programs and sponsorships provide millions of dollars in grants to nonprofits in the area.2
The company was originally the Harvard Community Health Plan in 1969. In 1977, it became a federally qualified health maintenance organization (HMO), and in 1980 reached the 100,000-member mark.
In 1981, Pilgrim Health Care and the Pilgrim Foundation began.
In 1995, Harvard Community and Pilgrim Health Care merged to become Harvard Pilgrim Health Care and the following year reached 1 million members. Later, the company expanded to Maine, Connecticut, and New Hampshire.3
In January 2021, Harvard Pilgrim Health Care merged with Tufts Health Plan. The joint company has no new name yet, and the two are operating independently for now.4
The company has few complaints to the National Association of Insurance Commissioners, much lower than the national average.
What Health Insurance Plans Does Harvard Pilgrim Health Care Offer?
Harvard Pilgrim Health Care offers individual and family plans in three states:5
- New Hampshire has HMO plans.6
- Maine has HMO and cost-sharing reduction (CSR) plans.7
- Massachusetts has HMO, preferred provider organization (PPO), and connector plans.8
The company also offers large and small group employer-sponsored plans, including HMO, PPO, limited network, deductible/consumer-directed health plans, and Medicare enhance options.9 The premiums and deductibles for these (and all) plans depend on which one you choose and who is covered.
Medicare plans include a HMO/HMO-POS Medicare Advantage plan called “Stride,” which includes dental and eye examinations and care, Medicare Supplement and Medicare Advance.
The company also has a program to help members plan for a healthy retirement, called Celebrating 65.10
International travelers visiting the U.S. can take advantage of Harvard Pilgrim’s visiting family coverage through a partnership with International Medical Group (IMG). This coverage has two options at different price points.11
Diverse Network Options
Harvard Pilgrim offers HMOs, PPOs, CSRs and more.
What Are Member Benefits for Harvard Pilgrim Health Care?
In addition to health coverage and a strong network of doctors, hospitals and other care providers, Harvard Pilgrim Health Care has several programs, including preventive services to help keep you in good health.
- Wellness support programs: These provide personal health coaching, mindfulness, meditation hotline, reimbursement for expenses like dues to fitness clubs, vision coverage, and healthy eating and diet programs and resources to help manage health conditions, including acupuncture, chiropractic, and more for chronic pain.
- Preventive care: Most preventive services, like annual physicals, screenings, and immunizations like an annual flu shot, are covered at no cost to you.12
- Special discounts: Members save money on items that help them live more healthily, such as smoking cessation programs and eye exams
- Emergency care: Options help you avoid the emergency room.
- “Reduce My Costs:” This member savings program encourages elective procedures at lower-priced facilities.13
- Behavioral health care: This provides support for emotional, psychological, and mental health concerns, including depression, anxiety, stress, addiction, and eating disorders.
- Prescription drugs: Coverage may include one of seven prescription drug plans; members can go to harvardpilgrim.org/rx to check if a drug is covered and what it will cost.14 Members can order medications used to treat chronic conditions through a specialty pharmacy program, which aims to reduce costs.15
- Telehealth: These visits are available through “Doctor on Demand.”16
- Other programs: Access to additional services may include tools such as mental health apps, therapy (including psychiatric care), medication, nurse care managers, and other resources.17
How Do You Enroll in Coverage with Harvard Pilgrim Health Care?
After choosing your state, you’ll see a guide to available plans. Get health insurance quotes and enroll.
How Do You File a Claim with Pilgrim Health Care?
Generally, your healthcare providers will file claims on your behalf, but if you need to make claims, you’ll find the forms you need on Harvard Pilgrim’s website.
How Is Harvard Pilgrim Health Care Rated?
Consumer ratings of Harvard Pilgrim Health Care are mixed.
- The Complaint Index: This “member satisfaction” index from the National Association of Insurance Commissioners (NAIC) rates Harvard Pilgrim at 0.44, which was less than half of what’s expected in the market. (The complaint index is 1, so a company with half the expected claims would have a complaint index of 0.5, while a company with double the expected complaints would have an index of 2.) In 2020, with only 15 filings against Harvard Pilgrim, this accounted for just 0.4% of all the complaints against insurance companies in the U.S. market. Ten of these were complaints about group plans, while five were related to individual plans.19
- NCQA: The National Committee for Quality Assurance (NCQA) accredits the company’s commercial and exchange plans. The company evaluates plans based on the quality of care, patient satisfaction, and the plans’ efforts to continue to improve.20
- Better Business Bureau: The company has an A+ rating from the Better Business Bureau (BBB), but it is not BBB accredited (to be accredited by BBB, a business or organization applies, pays a fee, and affirms that it meets and will abide by certain ethical standards). Seven customer reviews average 1.14 stars out of 5. (BBB ratings do not take customer reviews into account.)21
- Weiss Ratings: From an investment standpoint, Weiss gives the overall organization a C+ rating, citing fair profitability, good stability and liquidity, and a decline in enrollment in 2019.22
- Hospital safety: Check the safety ratings of the provider’s hospitals in the area you live by searching online.
What Are the Strengths and Weaknesses of Harvard Pilgrim Health Care?
While the star ratings on the Better Business Bureau are low, these averages are based on a very small number of reviews. The company has few complaints to the National Association of Insurance Commissioners, much lower than the national average, indicating high customer satisfaction.
Another strength is the company’s offerings, such as visiting family coverage, behavioral health services and support, plus member savings and wellness programs that can improve health and cut healthcare costs.
The main weakness of Harvard Pilgrim is that the offerings are concentrated in a small number of states; only individuals in three states are eligible to purchase individual or family plans. Also, implications are not yet known about the merger with Tufts Health Plan, which is ongoing.
To learn more about the merger with Tufts Health Plan, visit this information site.
If you are in Massachusetts, Maine or New Hampshire and want more information about the variety of individual or family plans, go here.
If you are an employer interested in group health plans, you can find more information here.
Buying health insurance is a big decision; before making any choices, carefully study the options and consider your individual needs to find the right fit for you. Then examine the options in your area along with the health insurance companies providing them.
The views and opinions expressed are those of the authors and do not necessarily reflect the official policy or position of HealthCareInsider.com or HealthCare, Inc.