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.
Changing your PCP is just one of the many things you can do on our secure, interactive member portal. Log into your account on the member portal at my.healthnewengland.org. Click on "Change my PCP" in the left hand navigation menu after you log in and follow the prompts. You will be able to search for PCPs who participate in your plan and then select a new PCP.
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.
Is the bill for a copay? A non-covered service? If it is, it's up to you to pay for these.
You can review your claim history and details by logging into your member portal account at my.healthnewengland.org. Just click “Claims” at the top of the page after you log in. From there, you can view claim details and check what claims we have paid.
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.
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 by clicking on “Provider Search” at the top of the page.
In the provider search tool, be sure to adjust the search based on the type of plan you are enrolled in (Fully Funded HMO, Medicare Advantage, Be Healthy, etc.).
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 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.)
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:
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. ERs also cost much more than the services you get from your primary care provider (PCP) – both for you and your health plan. For example, your ER copay is most likely much higher than your office visit copay.
For non-emergency medical issues, always contact your PCP first. Health New England requires your PCP’s office to have 24-hour phone coverage. That way, if you need care after hours, you can call the office. Your PCP or the physician covering will help you decide what to do—whether you should get care right away or wait to see your PCP..
We also have a 24-hour nurse line, which is a free health information line to help answer your questions whenever they come up. Licensed nurses and clinicians will listen carefully to your concerns and give you information to help you choose the care that’s right for you. The Nurse Line is available 24 hours a day, 7 days a week at (866) 389-7613. Interpretation services are also available for your call.
In addition, as a Health New England member, you have access to Teladoc® for non-emergency medical issues. If you are ever unable to reach your PCP, you have access to U.S. board-certified physicians 24/7/365 through Teladoc. Learn more at healthnewengland.org/teladoc.
You can view coverage for a specific medication using Health New England's formulary look up tool on healthnewengland.org. Just click "Find A Drug" at the top of the page. You can also find more information by logging into your account on the member portal at my.healthnewengland.org and clicking on “Look up drugs & pharmacies” in the left hand navigation menu.
Please note: Some medications require prior authorization, have quantity limits, or require that you try a less expensive medication before you are able to fill them (a process called step therapy). If your medication is subject to any of these processes, it will be noted on the formulary look up tool. If your provider feels you should have an exception to any of these protocols, there will be a link to the appropriate authorization request form that can be completed and submitted for review.
Flu Shots: Yes, Health New England covers flu shots for all members.
You can also call our Member Services Department at the number listed on your ID card. We are available Monday through Friday, 8:00 a.m. to 6:00 p.m.
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.
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:
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.
You have 180 days from the date of denial notice to request a standard or expedited appeal. For urgent care situations, expedited external review may occur at the same time as the internal appeal process.
You may file an appeal. You also may appoint someone to file an appeal for you. We call this person your authorized representative. The authorized representative may be anyone you choose including an attorney.