Back to Insights and Updates for ProvidersMay 2023

GIC product updates effective July 1

Harvard Pilgrim Health Care Commercial

Effective July 1, 2023, Point32Health is updating our Commercial Group Insurance Commission (GIC) product offerings. For the 2023-2024 plan year, we will offer two custom Commercial Harvard Pilgrim Health Care/GIC products in New England for active GIC or eligible municipal enrollees, retired GIC enrollees not eligible for Medicare, retired municipal teachers, and certain other government retirees:

Harvard Pilgrim Quality HMO — Harvard Pilgrim Quality HMO (formerly Primary Choice HMO) is a tiered limited-network HMO, open to Massachusetts residents (except in Martha’s Vineyard, Nantucket, and Cape Cod). This plan includes a deductible, lower PCP copayment, two copayment tiers for specialist office visits, and two copayment tiers for inpatient admissions to acute care hospitals.

Harvard Pilgrim Explorer POS — Harvard Pilgrim Explorer POS (formerly Independence Plan POS) is a tiered full-network product, open to Massachusetts state and municipal employees, that allows members to seek in-network medical care (from their PCP or from Harvard Pilgrim participating providers with a PCP referral) or out-of-network medical services (from non-participating providers or Harvard Pilgrim participating providers without a PCP referral). Harvard Pilgrim Explorer POS offerings include a deductible, three lower-cost copayment tiers for PCPs, and three copayment tiers for specialist visits and inpatient admissions to acute care hospitals.

Providers received letters in early March informing them of their inclusion in the products and tier assignments.

2023-2024 tiering methodology
Tier assignments are the same for both plans with some exceptions; however, because Harvard Pilgrim Quality HMO is a limited-network product, some of Harvard Pilgrim’s contracted providers do not participate in this network. It is important to confirm network participation before a Harvard Pilgrim Quality HMO member receives treatment.

Please note that for the 2023-2024 plan year, we’ve updated the methodology used to assign tier classifications, which are based on quality and cost performance, as measured by health-status-adjusted total medical expenses and relative prices, and select Quality and Health Equity measures. If applicable quality measures were unavailable, tiers were based solely on health-status-adjusted total medical expenses or relative prices, or both. Providers outside of Massachusetts were not included in the tiering analysis, and default to Tier 2 for both products.

For more information about our tiering methodology, refer to the Fast Facts for Hospitals and Professional Providers document on Point32Health’s provider website.

Tufts Health Plan Spirit and Tufts Navigator retiring
As we’ve detailed in our Point32Health Integration FAQ, Tufts Health Plan’s Commercial members have begun migrating to Commercial Harvard Pilgrim products as Point32Health’s Commercial markets move toward a more unified product portfolio, with transitions occurring on products’ renewal dates. As a reminder, this includes Tufts Health Plan’s Commercial GIC products, Tufts Health Plan Spirit and Tufts Navigator — members of these plans will automatically be enrolled in the corresponding Harvard Pilgrim Commercial GIC HMO or POS product as of July 1, 2023.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Jesse Salvato, Stephen Wong,

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Production Coordinator

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Graphic Designer