HMO residency requirements

[Pinsarein]

Vermont

I am covered by Harvard Pilgrim Healthcare through a plan that I get from my employer, a Massachusetts company. A few months ago the nature of my work changed which has allowed me to move to Vermont, where I have owned a house for a few years. Vermont is now where I vote and file my federal income taxes from. My primary care physician is still in the HMO's network and is in the Boston area.

Harvard Pilgrim recently sent me letter stating that they are going to drop me from the plan since my residence is not in Massachusetts, Maine or Rhode Island.

It does state in the member service agreement that my permanent residence has to be withing their coverage area. When I asked the reason for this I am told "because". I have no idea what difference it makes to them. I told them I would file my federal income taxes in MA but they said that that my body had to be in the coverage area for 9/12 months. I asked, "What about someone who travels for business?" They said they would have different plan. I pointed out that they would not know this. This requirement is arbitrary, inconsistently enforced and makes no difference to their bottom line.

This is a good plan and if I have to get other coverage it will cost me thousands more.

I noticed that in 1999 when they pullled out of Rhode (subsequently they have come back in) Island they allowed some members of their insolvent Rhode Island division to switch to Primary care physicians in MA and still keep their coverage. I would like to know how my situation is different?

Does anyone know of anyway I can force them to continue my coverage?

[cbg]

No. They are entitled to require that you be within their coverage area. There is no law that will force them to violate that requirement. The fact that they made exceptions for a few employees when they left a coverage area does not obligate them to provide coverage to someone in an area that they do not and have not covered.

[ecmst12]

It most likely means that the plan doesn't have any doctors contracted outside of their area of coverage. That means even if they let you keep the plan, you'd have to go back to MA to go to the doctor, since HMOs only provide coverage when using contracted providers (except for emergencies of course). So you're better off getting a plan that's supported where you live.