Using Harvard Pilgrim for Behavioral Health Treatment

Harvard Pilgrim Insurance company is based out of Massachusetts and has been operational for over 50 years. The timely and effective treatment and rehabilitation of persons experiencing substance abuse problems is a critical service. As per the Affordable Care Act (ACA), it has been mandated that the vast majority of health plans in the United States, including Harvard Pilgrim plans, cover at the very least a portion of the costs of addiction treatment. Rehabilitation is considered a treatment for substance use disorder (SUD). So, according to the ACA, it falls under the classification of mental and behavioral health services, which are both regarded as essential health benefits. The vast majority of insurance companies, as a result, must provide some degree of coverage for this treatment type.

What is A “Harvard Pilgrim Approved Rehab?”

A healthcare provider, facility, or center that provides treatment of addiction and rehabilitation services while also accepting Harvard Pilgrim health policies is “Harvard Pilgrim Approved.” Facilities that accept Harvard Pilgrim plans allow policyholders to access partial or complete coverage for the specific program or treatment they need.

Differences in Coverage for In-Network vs. Out-Of-Network Facilities

The issue of a healthcare provider being “in-network,” or “out-of-network” has a substantial impact on the final cost of treatment with them. Though it appears intricate and confusing, this process is straightforward. Facilities and healthcare providers often have established agreements with insurance providers. These agreements make them a part of that insurance’s “network.” Consequently, the costs of care at these facilities are typically lower, and therefore, the out-of-pocket expenses are markedly reduced. Out-of-network facilities can end up costing significantly more. It is critical to note that simply because a provider is an out-of-network facility does not mean your insurance policy won’t be accepted. Regardless, if possible, it is always better to opt for a facility or healthcare provider that is within your insurance’s network.

What are the Tiers of Harvard Pilgrim Plans?

Tiers of Harvard Pilgrim Plans

Depending on your particular needs, as it relates to mental health and behavioral issues, as well as substance abuse treatment, Harvard Pilgrim policies operate as follows:

  • Mental/behavioral health in-network outpatient services: $20 copay/visit
  • Mental/behavioral health out-of-network outpatient services: 20% coinsurance
  • Mental/behavioral health in-network inpatient services: No charge
  • Mental/behavioral health out-of-network inpatient services: Deductible, then 20% coinsurance
  • Substance Use Disorder in-network outpatient services: $20 copay/visit
  • Substance Use Disorder out-of-network outpatient services: 20% coinsurance
  • Substance Use Disorder in-network inpatient services: No charge
  • Substance Use Disorder out-of-network inpatient services: Deductible, then 20% coinsurance

Multiple factors can influence the type and level of coverage you will experience, varying among persons. The network status of your provider, which state you are in, the length of stay your treatment requires, and the specific nuts and bolts of your policy.

Harvard Pilgrim Substance Abuse Treatment Options

Insurance operates via systems that can feel overly complex to the uninitiated. Some questions come up habitually around what treatment options may be accessible. “Will my Harvard Pilgrim policy cover medical detox?” “Can I get dual diagnosis treatment with Harvard Pilgrim?” “Is medication-assisted treatment possible with Harvard Pilgrim?” “Can Harvard Pilgrim insurance cover residential treatment?” “Does Harvard Pilgrim cover aftercare services or sober living?” That’s just a tiny sample of the questions people commonly pose. Let’s break down, in the most straightforward way possible, the answer to the overarching question of what Harvard Pilgrim plans to cover treatments for SUD:

Medical Detox

In the early stages of detoxing from substance addiction, the process can be quite painful and requires 24/7 support. The presence of an experienced and professional clinical team is a requirement for this phase.

Medication-Assisted Treatment (MAT)

Medication-Assisted Treatment is a highly effective avenue for battling addiction, combining FDA-approved medications with therapy. This method has been proven and tested in its efficacy for treating persons suffering from SUD.

Inpatient Treatment

In severe cases, patients may need intensive care to overcome addiction. In cases like this, inpatient treatment can be a highly effective option. Including professional physician oversight and 24/7 monitoring for the entire duration of treatment, this treatment variety is proven to yield high degrees of success.

Partial Hospitalization Programs (PHPs)

It is common to look at PHPs as step-downs from inpatient programs. It is common in these programs for the patient to spend the bulk of the day at the facility and return to their home at night.

Outpatient Treatment

Less acutely intensive, outpatient care traditionally involves visits to the provider’s facility for the patient on some regularized schedule. This schedule can be set to as little as once or twice per week, depending on the specifics of the condition and case.

Intensive Outpatient Programs (IOP)

More intensive than standard outpatient programs but not as all-encompassing as an inpatient treatment plan, IOPs lie somewhere in the middle and are essentially outpatient programs with a greater frequency of visits and sessions.


Treatment plans focus on the support and sustenance of the patient’s sobriety after they have gone through detox, and psychological treatments and therapy are classed as Aftercare. They are a critical component of sobriety that lasts. These programs include support groups, therapy, and even community programs.

What are the States Serviced By Harvard Pilgrim?

What are the States Serviced By Harvard Pilgrim

Harvard Pilgrim provides healthcare benefits to over 1 million people across the United States in the states of New Hampshire, Massachusetts, Maine, and Connecticut.

Premiums And Deductibles

Premiums and Deductibles are an inherent part of the insurance system. How does all of this work, though? Essentially, the premium is the monthly payment towards the policy. The deductible is the out-of-pocket costs that you as the patient must bear before the insurance kicks in to cover your treatment. The relationship between these two things is generally simple enough. If your policy has a higher premium, it typically means that the deductible you pay out-of-pocket is smaller. If you choose to pay a lower monthly premium, you can expect to pay a higher amount on the deductible. If you’re willing to pay more out-of-pocket when you need to access healthcare, you can opt for a lower premium with smaller monthly payments.

Features Of Approved Harvard Pilgrim Rehab Programs

Healthcare providers have wildly varying specifics and details. When it comes to finding a high-quality facility, several factors and considerations generally indicate whether or not a provider can be trusted for effective and worthwhile programs and treatments. A crucial step before engaging a treatment facility is to research their track record, practices, and general modus operandi. If you remain aware of the following factors, you will likely make a more informed decision:


Reputable facilities operate by having their therapy and programs run by qualified and trained staff. Medical practitioners with advanced certifications can usually be trusted to be adequately vetted whose methods are based on science-backed techniques and practices. If the qualifications of the staff you are expected to trust with treatment are difficult for you to find out, that’s usually a red flag.


High-quality treatment facilities, in addition to meeting state-mandated requirements, often undergo the process of accreditation. The granting of “accredited” status to a facility or healthcare provider means that they went through an extensive and standardized service quality evaluation by an authorized third-party body. The Joint Commission Accreditation for Addiction Treatment (JCAHO) and the Commission on Accreditation of Rehab Facilities (CARF) are two of the most trusted accreditation bodies. A grant of endorsement by either of these bodies generally means that the provider has satisfied that they operate and uphold a high standard of healthcare. It is only possible for facilities to become and remain accredited by offering a very high quality of care. The burden of proof lies on the facility to show that its staff is appropriately trained and qualified and that the facility operates at high safety standards, is HIPAA-compliant, culturally sensitive, and more. You can generally trust that you are in good hands with an accredited facility.


You can tell a provider is reputable if you encounter transparency around pricing and a willingness to exert efforts in service of helping you access treatment, regardless of any potential financial limitations. Indeed, the facility may not be able to divulge every detail around the cost of the treatment. Still, they should generally be open to assisting you with understanding your coverage and any other financial aid options that may be accessible to you. Persons of all socioeconomic standing grapple with addiction like this and deserve treatment and access to rehabilitation. A facility that acknowledges financial restrictions their patients may be living with and works to help them figure a way out beyond the addiction is likely to be an advocate for proper treatment methods.



Unique, custom treatment plans that cater to each individual’s needs should be considered a necessary component of effective treatment. Quality treatment focuses on the reality that there are almost always multiple components to a habit of substance addiction, which include but are not limited to any associated psychological, environmental, medical, or social issues. Bespoke treatment plans typically offer various services required to treat the patient. Dual-diagnosis patients, for example, may need treatment for depression AND substance use disorder. A high-quality facility will usually conduct an extensive evaluation before admittance of the patient and create a detailed plan of action that accounts for any stressors, supports, circumstances, environmental and historical factors.


Many of the factors that affect the mind and body due to SUD can be subtle in advance of the withdrawal phase. Professional medical teams must address any physical and mental health issues that manifest due to physiological dependence and the withdrawal symptoms from being deprived of it. Care in the detoxing stage is critical for managing opioids and alcohol withdrawal as the patient will likely experience severe discomfort, pain, and the potential exists for medical complications.


A reputable provider should have the overall, perpetual goal of treatment that the patient can live a fulfilling, satisfying and successful life post-care. The reality is that specific life skills must be developed (or sharpened) to assist the patient in re-emerging into everyday life and building resiliency for coping with the stressors of life that can and do rear their heads. A high-quality treatment center will always offer skill-building to some degree or another. The patient might gain essential knowledge and proficiency in skills that allow them to live.


Depending on the case’s specifics, social and environmental triggers can put the patient at risk of relapse in the post-treatment world. During the early stages of recovery, removing as many triggers as realistically possible can be essential to facilitate the patient’s focus on their journey without distraction or stumbling blocks. Serene environmental surroundings can offer an opportunity to connect with the beauty of nature; however, while location can be essential, the fact remains that many highly-rated, effective and proven rehab programs exist that do not feature an overabundance of exotic or expensive amenities and environments but still manage to provide a high quality of service. The main focus should always be the treatments and programs.


Aftercare should not be considered optional. It is a necessary component of treating addiction properly. A good healthcare provider will focus a great deal of time and effort on generating and executing a comprehensive aftercare plan for each patient. Usually, a qualified and certified member of staff is responsible for developing that plan and assisting with the execution and running of it in the post-acute-treatment phase. These plans can include:

  • Individual or group therapy sessions
  • Continuous and sustained outpatient treatment
  • Step-down program from inpatient care to an external living environment. This is usually done on a gradual basis
  • 12-step programs or another recovery support group

Without a targeted aftercare plan for most patients, the risk of relapse and readdiction can be even greater. A facility that does not account for this may be offering lower-quality healthcare.

Find Lasting Recovery with Harvard Pilgrim Coverage at Pathfinders

For over 20 years, we at Pathfinders have been treating and helping persons struggling with substance abuse and addiction. Our expert medical team and holistic care professionals are qualified, capable, and ready to work with you or your loved one as you begin and navigate the process of detoxing, healing from the psychological trauma which contributed to the descent into substance abuse, as well as the crucial function of aftercare that serves to better set our patients up for success in life on the other side.

A life of fulfillment is our goal for every person who walks through our doors, and our results speak volumes on their own. Suppose you or someone you love is experiencing difficulties with addiction or substance abuse issues. In that case, we can tell you that hope exists… Contact us today for more information or a no-cost consultation!


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