Transitioning Your Health Care FAQs

Moving Your Health Care When You Choose a New Plan

What are the first steps I should take to transition (move) my health care to a new health insurance plan?

If you need to change health care providers (such as doctors and hospitals you use) under your new plan, you may want to:

  • Make sure you have enough refills on your prescriptions to last until your new plan starts and your new doctor can write you a prescription.

  • Ask your current doctor or health plan for copies of your medical records, including any prior authorizations or referrals for other providers that you have right now. In some cases, you may be able to download this information from your current plan’s member website. This will help your new doctors give you the best care.

  • If your current doctor or hospital is not in your new plan’s network, contact your new plan to ask for a new in-network provider. If you have a plan with a HMO network, you may need to have a primary care provider before you can get referrals to other providers.
  • Your new plan will have a member website. You should sign up on their member website as soon as possible so you can get your plan information.

What if I already scheduled surgery, tests, or doctor visits for after my new plan starts?

If you have health care services planned after the start date of your new plan, call your doctor to discuss your options. Your current referrals or authorizations for care may or may not be valid (allowed) with your new plan. You should also call your new plan to ask how any of your ongoing care needs will be handled.

What if my doctor or hospital is not covered through my new plan’s network?

If a health care service is medically necessary for you and covered by your plan, but you can’t find an in-network provider for the care, or if you have already scheduled care with a particular provider, call your new health insurance company’s customer service phone number for help.

The health insurance company’s customer service staff will work with you to see if there is a doctor or hospital in their network who can treat you.  In most cases, they will require that you see an in-network medical provider.

If there is no in-network provider who can give you the care, your new plan may sometimes arrange for you to see an out-of-network provider. However, if there is a provider in the network who can give you the care, your new plan will require you to change providers.

If there is an emergency: Your new plan cannot require you to pay more than the in-network cost if you get emergency care from an out-of-network hospital’s emergency room.  If you go to an out-of-network hospital for emergency care, remember to call your health insurance company and tell them as soon as possible.

What if my medication is not covered through my new plan?

If you switch plans and need a medication that is not on the list of prescription medications covered by your new plan (also called a “formulary”), you can contact your health plan’s customer service hotline to ask about their prescription drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan.

Every plan must have a prescription drug exceptions process that allows you to request coverage of a prescribed drug not covered by your plan. While the process will be different for each plan, usually your doctor will send a request to your plan that the non-covered drug is clinically appropriate for your medical condition. You should contact your new health plan to learn more about its process.

What should I do when my new plan starts?

Your new plan will send you a new ID card. Show that new card to any providers you are keeping. In the meantime, if you change plans, call your doctor’s office and let them know. That way, they can help you avoid any billing issues and ensure any new referrals or approvals are in place for your care.

Related: When will I get my new member ID card?

What if I followed these steps, but am having trouble accessing health care in my new plan?

If your health plan denies coverage, you have a right to appeal the health plan’s decision. Your denial letter from the insurance company should explain the services the health plan is denying and why. You have the right to ask your insurance company to reconsider this decision through an “internal appeal” with your health plan. If your insurance company denies your internal appeal, you have the right to an “external appeal” with an independent decision-maker.

Contact your health plan to learn more about your appeal rights. You can also learn more by reading the Evidence of Coverage booklet from your health plan.

How can I contact my new health plan with questions?

You can call your new health plan’s customer service hotline to work with them to determine how to transition your care from one health plan to another. Your new plan may also have helpful resources on its website. Here is a list of contact information for the insurers that offer plans through the Health Connector.

Health Insurer Customer Service Center
Ambetter from Celticare Health 877-687-1186
Monday–Friday, 8:00 a.m.–5:00 p.m.

Helpful Information:
Ambetter From Celticare Health Member Resources  

Blue Cross Blue Shield of Massachusetts 800-262-2583
Monday–Friday, 8:00 a.m.–6:00 p.m.

Helpful Information:
Blue Cross Blue Shield of Massachusetts Health Connector Plans  

Boston Medical Center HealthNet Plan Pre-Enrollment Questions
888-566-0010 and 888-566-0012
Monday–Friday, 8:00 a.m.–6:00 p.m.

Enrolled Members
800-792-4355
Monday–Friday, 8:00 a.m.–6:00 p.m.

Helpful Information:
Boston Medical Center HealthNet Plan New Member Frequently Asked Questions  

Fallon Health Plan Pre-Enrollment Questions
866-345-2486
Monday–Friday, 8:00 a.m.–5:00 p.m.

Enrolled Members
800-868-5200
Monday, Tuesday, Thursday, Friday, 8:00 a.m.–6:00 p.m.
Wednesday, 10:00 a.m.–6:00 p.m.

Helpful Information:
Fallon Health Plan New Member Welcome Page  

Harvard Pilgrim Health Care 888-333-4742
Monday, Tuesday, Thursday 8:00 a.m.–6:00 p.m.
Wednesday, 10:00 a.m.–6:00 p.m.
Friday, 8:00 a.m.–5:30 p.m.

Helpful Information:
Harvard Pilgrim Health Care Frequently Asked Questions  

Health New England 888-310-2815
Monday–Friday, 8:00 a.m.–6:00 p.m.

Helpful Information:
Health New England Frequently Asked Questions  

Minuteman Health Pre-Enrollment Questions
855-428-2382
Monday–Friday, 8:00 a.m.–6:00 p.m.
Saturday, 8:00 a.m.–12:00 p.m.

Enrolled Members
855-644-1776
Monday–Friday, 8:00 a.m.–6:00 p.m.

Helpful Information:
Minuteman Health Resources  

Neighborhood Health Plan 866-414-5533
Monday–Friday, 9:00 a.m.–6:00 p.m.
Thursday 8:00 a.m.–8:00 p.m.

Helpful Information:
Neighborhood Health Plan Medical Benefits Information  

Tufts Health Plan Direct Pre-Enrollment Questions

888-257-1985
Monday–Friday, 8:00 a.m.–5:00 p.m.

Enrolled Members
888-257-1985
Monday–Friday, 8:00 a.m.–5:00 p.m.

Helpful Information:
Tufts Health Plan Direct Plan Year 2017 Information  

Tufts Health Plan Premier 617-972-9400
Monday–Thursday, 8:00 a.m.–7:00 p.m.
Friday, 8:00 a.m.–5:00 p.m.

Helpful Information:
Tufts Health Plan Premier Plan Year 2017 Information  

Tuesday, November 29th, 2016|