Frequently Asked Questions
Frequently Asked Questions

Decoding health insurance-speak and answering your questions.

Health insurance can be complex. At Health New England, we try our best to make it simple. But we know that there are still things that need further explanation.

For example, health care terminology and acronyms aren't always easy to understand. For clarification and definitions, we recommend the health insurance glossary from the U.S. Centers for Medicare & Medicaid Services.

There are also many questions that can come to mind as you think about health insurance coverage and your benefits. We have compiled a list of members' frequently asked questions and answers below that may help you with some of your own questions.

If you still have questions, feel free to call our Member Services at (413) 787-4004 or toll-free at (800) 310-2835. For TTY/TTD, call (800) 439-2370.

Frequently Asked Questions 


How do I change my Primary Care Provider (PCP)?

Changing your PCP is just one of the many things you can do on our secure, interactive member portal. Log into the member portal at my.healthnewengland.org and search for PCPs who participate in your plan. Once you find the doctor you want, you can select your new PCP right online. We'll take care of the rest and update our system. No phone calls, no forms - just a few clicks and you're done.

Or, if you prefer, you can still call Health New England's Member Services at (413) 787-4004 or (800) 310-2835, Monday through Friday, 8 a.m. - 6 p.m., for help. 

I received a bill that I didn’t expect. What should I do?

Is the bill for a copay? A non-covered service? If it is, it's up to you to pay for these.

If you still can't figure out why you got a bill, you can call Member Services at (413) 787-4004 or (800) 310-2835, Monday through Friday, 8 a.m. - 6 p.m.

You can also log into your account on the member portal at my.healthnewengland.org to check what claims we have paid. That's just one of the many things you can do on our secure, interactive member portal.

Do I need a referral from my PCP for specialty care?

No, you do not need a referral from your PCP for specialty care that you receive from an in-plan specialist. Some services do require prior approval. Log into the member portal at my.healthnewengland.org to see prior approval information specific to your plan. That's just one of the many things you can do on our secure, interactive member portal.

Or, if you prefer, call Health New England's Member Services at (413) 787-4004 or (800) 310-2835, Monday - Friday, 8 a.m. - 6 p.m.

What if I'm referred to a provider that doesn't contract with HNE?

Whenever your doctor sends you to another doctor, make sure he or she is a Health New England in-plan provider. Log into the member portal at  my.healthnewengland.org and search for doctors who participate in your plan.

Or, if you prefer, call Health New England's Member Services at (413) 787-4004 or (800) 310-2835, Monday - Friday, 8 a.m. - 6 p.m.

If my children attend college, are they still covered by my plan?

If you are enrolled in a fully funded plan, all dependents are allowed to remain on your plan until their 26th birthday regardless of whether or not they are married, live with the subscriber or are considered an IRS dependent.

All members are covered for emergency care outside our service area, including foreign countries. If your child is seriously ill or injured and needs immediate medical attention, he or she should call 911 or go to the nearest emergency room right away.

If you are enrolled in an HMO or exclusive plan, please keep in mind that you need to call Member Services at (800) 310-2835 to notify Health New England of emergency services that are not received in a hospital emergency room (for example, at a walk-in clinic or doctor's office.)

What if I travel to a foreign country and need medical services?

All plans include coverage for emergency care outside our service area, including foreign countries. If you’re traveling outside the U.S. and need immediate medical attention, seek treatment right away.

Please follow these guidelines:

  • Be sure bills are translated into English.
  • Be sure providers convert charges to the U.S. dollar values in effect on the date of service.
  • If you are treated at a facility other than a hospital emergency room, please call us at (800) 310-2835 at your earliest convenience to report the services.

What should I do if I need emergency medical care?

You are always covered for emergency care. If you believe you are having a life threatening emergency, call 911 or go to the nearest emergency room.

However, the ER is not usually the best place to go for minor injuries or illnesses. Inappropriate ER visits are a key cause of rising health care costs. ERs are often crowded, and patients are treated based on the severity of their condition. That means you may often have a long wait. Since they don’t know you at the ER, you won’t get the same personalized service that you get from your own doctor. The ER doctor won’t be familiar with your medical history, and may not be aware of conditions for which you are being treated. ERs also cost much more than the services you get from your own doctor – both for you and your health plan. For example, your ER copay is most likely much higher than your office visit copay.

Health New England requires your doctor’s office to have 24-hour phone coverage. That way, if you need care after hours, you can call the office. Your doctor or someone covering will help you decide what to do—whether you should get care right away or wait to see your own doctor.

We also have a 24-hour nurse line. If you can’t reach your doctor, call us at (413) 787-4000 or toll-free at (800) 842-4464, choose option 2 ("Member covered by HNE"), then option 5 ("HNE nurse line"). An experienced nurse will listen carefully to your concerns and give you information to help you choose the care that’s right for you.

Are flu shots covered?

Yes, Health New England covers flu shots for all members.

What services require prior approval?

If you are an HMO member, all non-emergency services with out-of-plan providers require prior approval. In addition, a limited number of in-plan services require prior approval.

If you are a POS or PPO member, a limited number of services require prior approval.

Log into the member portal at my.healthnewengland.org to see prior approval information specific to your plan.

Remember: For those services that require prior approval, if you get services out-of-plan without prior approval, your coverage may be reduced or denied.

Does Health New England cover infertility services?

Yes, Health New England covers infertility services in accordance with Massachusetts and Connecticut mandates. Infertility is defined as the inability to conceive for a period of at least one year if under age 35, and six months if over age 35.

What infertility treatments are covered?
Depending on the causes of infertility, there are some first-line treatments that may be appropriate. These do not require prior approval. They may include surgery, drug treatments and/or ovulation induction.

What if the first-line treatments don’t work?
Treatment with one of the Assisted Reproductive Technologies (ART) may be indicated. You must meet eligibility requirements for ART. Prior approval is required for all services.

What are the eligibility requirements for ART?
Complete eligibility requirements for ART are outlined in Health New England's Infertility Protocol. There are residency requirements and individual plan limitations. Other criteria that must be met include:

  • Coverage is only available for individuals under a certain age.
  • You and your partner must be non-smokers.
  • You must seek a nutrition consult and/or participate in a weight loss program if your BMI is 35 or above.

Why are these criteria important?
These requirements support your health status and your ability to conceive. They also decrease risks to both you and your baby.

Who should I talk to about infertility treatment?
Talk to your doctor. If appropriate, he or she may refer you to an infertility specialist. The specialist will perform an assessment and determine whether infertility treatment is appropriate.

Where can I get more information about my coverage for infertility services?
Make sure you are familiar with your plan and your member materials (also referred to as your Member Handbook, Explanation of Coverage or Summary Plan Description). You can find these online when you log into your account on the member portal at my.healthnewengland.org. Or, if you prefer, you can call Member Services at (800) 310-2835 for more information.