Medicare is a federal insurance plan for people aged 65 and older. Original Medicare Part A covers hospital, skilled nursing facility care, and hospice, and Part B pays for medically necessary care to diagnose and treat conditions, and some preventive services.

Medicare Part C, also called Medicare Advantage, offers plans that combine original Medicare (parts A and B) coverage. Medically approved companies, such as Harvard Pilgrim Health Care, administer the plans.

According to the Kaiser Family Foundation (KFF), more than 24 million United States citizens enrolled in Medicare Advantage in 2020. The plans provide the same benefits as original Medicare and may also offer additional benefits.

This article looks at the Harvard Pilgrim Health Care Advantage plans, availability, coverage and benefits, and costs.

Glossary of Medicare terms

We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:

  • Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
  • Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
  • Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
  • Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
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Harvard Pilgrim Health Care can be a good healthcare option for people in Massachusetts, New Hampshire, and Maine.

Doctors founded Harvard Pilgrim Health Care (Harvard Pilgrim) in 1969. The company provides Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Medicare Advantage plans to more than 3 million people in Massachusetts, New Hampshire, and Maine.

The company is accredited by The National Committee for Quality Assurance (NCQA). A person can check Harvard Pilgrim’s overall rankings for consumer satisfaction, prevention and treatment using this online tool.

Harvard Pilgrim plans are location specific and offer Advantage plans in three states:

  • Maine
  • Massachusetts
  • New Hampshire

A person can use this online plan finder tool to compare Medicare Advantage plans.

Harvard Pilgrim offers two types of Medicare Advantage plans, called Medicare Advantage Stride HMO and HMO-POS.

Harvard Pilgrim HMO plans

With HMO plans, healthcare providers in the plan’s network provide healthcare services. A person chooses an in-network primary care doctor, who then coordinates the person’s healthcare.

However, if a person uses a provider outside the plan network, such as in an emergency, they may have to pay extra costs.

Harvard Pilgrim offers four HMO plans, including:

  • Stride Basic Rx
  • Stride Value Rx
  • Stride Value Rx Plus
  • Stride Gain Rx

The various plans offer basic benefit level to full coverage.

Harvard Pilgrim HMO-POS plans

HMO Point-of-Service (HMO-POS) plans are similar to HMO plans, but a person can get some types of healthcare outside the plan’s network. However, if a person chooses to do that, there may be higher copays or coinsurance.

Harvard Pilgrim offers one HMO-POS plan, the Harvard Pilgrim Stride Choice Rx.

A person can enroll in a Harvard Pilgrim Medicare Advantage plan during several Medicare enrollment periods, including:

  • Initial enrollment period (IEP): When a person is first eligible for Medicare, they can enroll in the plan 3 months before their 65thbirthday, during their birthday month, and for up to 3 months afterward.
  • General enrollment period (GEP): If a person missed their IEP, they can also enroll from January 1 to the end of March. The coverage starts the month after a person has enrolled.
  • Fall open enrollment period (OEP): From October 15 through December 7, an individual can change from original Medicare to a Medicare Advantage plan or switch between Medicare Advantage plans.
  • Special enrollment periods (SEPs): A person may also qualify to enroll at other times, depending on special circumstances such as moving homes, qualifying for Extra Help or Medigap, or moving to an institution.

There are several options to get detailed information about Harvard Pilgrim’s Advantage plans, including calling the Harvard Pilgrim client care number at 1-866-843-3186 (TTY: 711), available from 8am to 8pm or using the online portal.

Specific rules and exclusions

If a person is eligible for original Medicare, they can enroll in a Harvard Pilgrim Advantage plan.

If a person moves away from the three states in which Harvard Pilgrim offers Advantage plan coverage, they may be excluded from their Advantage plan and will need to find a new plan in the new location.

This online tool may be useful in finding a new plan.

When an individual enrolls in a Harvard Pilgrim Advantage plan, they must pay various healthcare costs, including deductibles, copays, and coinsurance.

For example, if a person gets medically approved surgery as an outpatient, copays in 2021 may range from $225 to $300. However, the coinsurance for durable medical equipment is a standard 20% across all plans.

A person may also pay a plan premium, although the Harvard Pilgrim Stride Basic Rx HMO plan does not have a monthly premium.

The Harvard Pilgrim website tool may help a person find the approximate costs of their healthcare plans.

Cost examples

Costs vary depending on a person’s location and the plan, and the costs in Maine may be different from in Massachusetts, or in New Hampshire.

For example, for a person living in Cumberland County, the premiums in 2021 average:

  • Stride Basic Rx: $0
  • Stride Value Rx: $30
  • Stride Choice Rx: $34

Extra, optional benefits

Harvard Pilgrim Advantage plans include the following benefits:

  • prescription drug coverage
  • preventive dental care
  • periodontics
  • vision care
  • hearing care and hearing aids
  • annual physical exams
  • over-the-counter medication
  • transportation for non-emergency care

The plans may also include such benefits as

  • comprehensive dental care
  • acupuncture and other alternative therapies
  • fitness benefits through Silver Sneakers
  • emergency and urgent care while outside of the U.S.

The coverage provided by a Harvard Pilgrim plan varies by individual plan and location. All Medicare Advantage plans must offer the same coverage as original Medicare.

Standard coverage includes:

  • appointments with primary care physicians or specialists
  • laboratory tests
  • diagnostic tests
  • preventive care
  • inpatient stays at hospitals
  • short-term stays at skilled nursing facilities
  • emergency care and transportation by ambulance
  • outpatient visits to psychiatrists or other mental health professionals
  • occupational and physical therapy
  • durable medical equipment such as walking canes and wheelchairs
  • telehealth services
  • hearing and vision exams

If a person lives in Massachusetts, New Hampshire, or Maine, they can choose a Harvard Pilgrim Health Care Advantage plan. The plans offer the same coverage as original Medicare, plus additional benefits such as dental, vision, and hearing care.

Plan costs vary by location and offered benefits, and all benefits may not be available in all locations.