Harvard Pilgrim Health Care
Standard High Gold
Plan ID36046MA0750211
Plan year2026Sold on Massachusetts Health Connector
Plan typeHMOReferral needed for specialists
Metal levelGoldNot HSA-eligible
Sold inEvery countyStatewide
These are the plan's 2026 details. Massachusetts's 2027 plan details are not public yet, so prices, benefits or doctors may change for 2027. Check Massachusetts Health Connector before you enroll.
Deductible$1,000$2,000 family
Out-of-pocket max$7,000$14,000 family
CoinsuranceNoneafter the deductible
Having a baby$1,700CMS example
Monthly premiums are not shown: they depend on age, county and income. NPI Profile does not sell insurance; Massachusetts Health Connector lists premiums and handles enrollment.
Doctor search is not available for this plan
Harvard Pilgrim Health Care does not send its provider directory to CMS, so we cannot show which doctors are in this plan's network. Call Harvard Pilgrim Health Care or the doctor's office.
What you pay with this plan
Which services this plan covers, from the plan files Massachusetts Health Connector sends to CMS. Those files do not include copays; the plan's Summary of Benefits and Coverage from Harvard Pilgrim Health Care or Massachusetts Health Connector lists them.
Doctor visits
- Primary care visit
- Covered
- Specialist visit
- Covered
- Nurse practitioner or PA visit
- Covered
- Preventive care and vaccines
- Covered
- Urgent care
- Covered
Prescription drugs
- Generic drugs
- Covered
- Preferred brand drugs
- Covered
- Non-preferred brand drugs
- Covered
- Specialty drugs
- Covered
Tests and imaging
- Lab work
- Covered
- X-rays
- Covered
- MRI, CT and PET scans
- Covered
Emergencies and hospital
- Emergency room
- Covered
- Ambulance
- Covered
- Hospital stay
- Covered
- Outpatient surgery (facility)
- Covered
Mental health
- Therapy and counseling visits
- Covered
- Inpatient mental health care
- Covered
Pregnancy
- Prenatal and postnatal care
- Covered
- Delivery and hospital stay
- Covered
Other care
- Physical and occupational therapyLimit: 60 visits a year
- Covered
- Chiropractic care
- Covered
- Eye exam for childrenLimit: 1 exam a year
- Covered
- Glasses for childrenLimit: 1 item a year
- Covered
- Adult dental
- Not covered
$1,700Having a baby (CMS example)
$1,300Managing type 2 diabetes for a year
$1,000A simple fracture
Every service in the plan file (88)
| Service | You pay | Limits and notes |
|---|---|---|
| Abortion for Which Public Funding is Prohibited | Covered | |
| Accidental Dental | Covered | Any treatment after 3 days is not covered. All services are excluded, except for the following: Extraction of the teeth damaged in the injury when needed to avoid infection, Reimplantation and stabilization of dislodged teeth, Repositioning and stabilization |
| Acupuncture | Covered | |
| Allergy Testing | Covered | |
| Bariatric Surgery | Covered | |
| Basic Dental Care - Adult | Not covered | |
| Basic Dental Care - Child | Covered | Not covered for Members age 19 and older. |
| Bone Marrow Transplants for Treatment of Breast Cancer | Covered | |
| Cardiac Rehabilitation | Covered | |
| Chemotherapy | Covered | |
| Childbirth Classes | Covered | In excess of 1 initial Childbirth Course or 1 refresher course per pregnancy will not be covered |
| Chiropractic Care | Covered | |
| Clinical Trials | Covered | |
| Congenital Anomaly, including Cleft Lip/Palate | Covered | Excluded for Members age 18 and older |
| Contraceptive Services | Covered | |
| Cosmetic Surgery | Not covered | |
| Delivery and All Inpatient Services for Maternity Care | Covered | |
| Dental Check-Up for Children | Covered | 2 exams a year Not covered for Members age 19 and older. |
| Diabetes Care Management | Covered | |
| Diabetes Education | Covered | |
| Dialysis | Covered | |
| Durable Medical Equipment | Covered | |
| Early Intervention Services | Covered | Not covered for Members age 3 and older. |
| Emergency Room Services | Covered | |
| Emergency Transportation/Ambulance | Covered | |
| Eye Glasses for Children | Covered | 1 item a year |
| Fitness Club Reimbursement | Covered | Excludes coverage for fees or costs that you pay for country clubs, tennis clubs, social clubs (such as ski, riding or hiking clubs), gymnastics facilities, pool-only facilities, sports teams or leagues, spas, instructional dance studios and martial arts |
| Gender Affirming Care | Covered | |
| Generic Drugs | Covered | |
| Habilitation Services | Covered | 60 visits a year |
| Hearing Aids | Covered | $2,000 every 3 years Excluded for Members age 22 and older. |
| Home Health Care Services | Covered | |
| Hormone Replacement Therapy (HRT) | Covered | |
| Hospice Services | Covered | |
| Human Leukocyte Antigen Testing | Covered | |
| Hypodermic Syringes or Needles | Covered | |
| Imaging (CT/PET Scans, MRIs) | Covered | |
| Infertility Treatment | Covered | |
| Infusion Therapy | Covered | |
| Inherited Metabolic Disorders - PKU | Covered | |
| Inpatient Hospital Services (e.g., Hospital Stay) | Covered | |
| Inpatient Physician and Surgical Services | Covered | |
| Inpatient Rehabilitation Services | Covered | 60 days a year |
| Laboratory Outpatient and Professional Services | Covered | |
| Long-Term/Custodial Nursing Home Care | Not covered | |
| Low Protein Foods | Covered | |
| Major Dental Care - Adult | Not covered | |
| Major Dental Care - Child | Covered | Not covered for Members age 19 and older. |
| Mental/Behavioral Health Inpatient Services | Covered | |
| Mental/Behavioral Health Outpatient Services | Covered | |
| Minor Dental Care - Child | Covered | Not covered for Members age 19 and older. |
| Non-Preferred Brand Drugs | Covered | |
| Nutrition/Formulas | Covered | |
| Nutritional Counseling | Covered | |
| Off Label Prescription Drugs | Covered | |
| Orthodontia - Adult | Not covered | |
| Orthodontia - Child | Covered | Not covered for Members age 19 and older. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | Covered | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | Covered | |
| Outpatient Rehabilitation Services | Covered | 60 visits a year |
| Outpatient Surgery Physician/Surgical Services | Covered | |
| Preferred Brand Drugs | Covered | |
| Prenatal and Postnatal Care | Covered | |
| Preventive Care/Screening/Immunization | Covered | |
| Primary Care Visit to Treat an Injury or Illness | Covered | |
| Private-Duty Nursing | Not covered | |
| Prosthetic Devices | Covered | |
| Radiation | Covered | |
| Reconstructive Surgery | Covered | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | Covered | 60 visits a year |
| Rehabilitative Speech Therapy | Covered | |
| Retail Health Clinics | Covered | |
| Routine Dental Services (Adult) | Not covered | |
| Routine Eye Exam (Adult) | Covered | 1 exam a year |
| Routine Eye Exam for Children | Covered | 1 exam a year |
| Routine Foot Care | Covered | Excluded for all diagnosis, except for the treatment of Diabetes. |
| Skilled Nursing Facility | Covered | 100 days a year |
| Specialist Visit | Covered | |
| Specialty Drugs | Covered | Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered. |
| Substance Abuse Disorder Inpatient Services | Covered | |
| Substance Abuse Disorder Outpatient Services | Covered | |
| Transplant | Covered | |
| Treatment for Temporomandibular Joint Disorders | Covered | No dental care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment. |
| Urgent Care Centers or Facilities | Covered | |
| Weight Loss Programs | Covered | 3 months a year All Weight Loss Programs are excluded, except for Weight Watchers |
| Well Baby Visits and Care | Covered | |
| Wigs | Covered | 1 item a year All types of wigs are excluded, except for a synthetic monofilament wig |
| X-rays and Diagnostic Imaging | Covered |
How this plan works
HMO: You pick a primary care doctor in the network, and most specialists need a referral from them. Care outside the network is not covered, except emergencies.
- Referral for specialists
- Required
- Coinsurance
- None after the deductible
- Works with an HSA
- No
- Network
- Harvard Pilgrim Health Care Full Network - HMO (MAN001)
- Sold in
- Every Massachusetts county
Insurer's note on referrals: A Referral is Needed for all Specialist except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.
Other Harvard Pilgrim Health Care plans on the same network
The same doctors and hospitals, with different costs.
| Plan | Metal | Deductible | Out-of-pocket max |
|---|---|---|---|
| Standard Silver II HMO | Silver | $2,000 | $10,150 |
Questions about Standard High Gold
What kind of plan is Standard High Gold?
It is an HMO plan: you pick a primary care doctor in the network, and most specialists need a referral from them. Care outside the network is not covered, except emergencies. It is a Gold plan.
How much is a doctor visit with Standard High Gold?
A primary care visit costs Covered. A specialist visit costs Covered. These are in-network costs for one person. "After deductible" means you pay the full cost until you reach the $1,000 deductible.
Where is Standard High Gold sold?
It is sold to people who live in every Massachusetts county, through Massachusetts Health Connector.
Why is there no monthly premium on this page?
Premiums depend on your age, county, household size and income, and most people get a subsidy, so a single price would mislead. Massachusetts Health Connector shows the price for your household.
About this data
NPI Profile is not an insurance company, agent or broker, and it does not sell insurance or enroll anyone in a plan. It is a free reference tool built on public files that CMS and insurers publish, to help you compare Marketplace plans and check whether your current or future doctor is in a plan's network. It is not affiliated with CMS, HealthCare.gov, any state exchange or any insurer. Confirm costs and networks with the insurer and the doctor's office, and enroll on Massachusetts Health Connector.
| Source | What it provides here | Source date |
|---|---|---|
| CMS public use files for Massachusetts Health Connector | This plan's costs, covered services, coverage examples and the counties where it is sold | Plan year 2026 |
| Harvard Pilgrim Health Care's provider directory | The doctors and facilities listed in this plan's network. Only providers with an address in Massachusetts are counted. | As of November 8, 2026 |
| NPPES NPI registry | Provider names, practice addresses and primary specialties | Matched November 8, 2026 |
- Costs are for the standard version of the plan, for one person, in network. People who qualify for cost-sharing reductions pay less. CMS does not publish copays for plans sold on Massachusetts Health Connector, so this page shows what is covered, without per-visit costs.
- Monthly premiums are not shown: they depend on age, county, household and income. Massachusetts Health Connector lists them for your household.
- Confirm costs in the plan documents and with the insurer, and confirm with the doctor's office that they take this plan.
