Snapshot of Your Plan
 
 

Your Advantage PPO Saver Plan, at a Glance

Deductible Yes. Your plan has a deductible.
Copay **Please see details below**
Coinsurance **Please see details below**
Out-of-Pocket Max Yes.
Health Savings Account (HSA) **Please see details below**
Primary Care Physician (PCP) No. You are not required to select an in-network PCP.
Referrals No. Referrals are not required to see a specialist. 
Out-of-Network Coverage Yes.
Routine Vision Care Yes.

Important note: You will see the term “Benefit Document” throughout this Welcome Kit. Your Benefit Document is a legally binding document provided by us that explains your medical coverage, including covered benefits, exclusions, termination, continuation of coverage, and appeals. It is sometimes referred to as an Evidence of Coverage (EOC) document or a Certificate of Insurance (COI). If there is a difference between the information in this Welcome Kit and your Benefit Document, please rely on your Benefit Document.

You can find your Benefit Document in the My Coverage section of mytuftshealthplan.com.

Cost Sharing

Deductible

The amount you have to pay for covered health care services before Tufts Health Plan starts to pay.After you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and Tufts Health Plan pays the rest. Please check your benefit document (located in the My Coverage section of mytuftshealthplan.com) for details. The benefit document is also called an Evidence of Coverage (EOC) or Certificate of Insurance (COI).

To confirm the deductible amount that applies to your plan, check your benefit document. If you are enrolled in family coverage, your plan will have an individual deductible and a family deductible. The individual deductible will work in one of two ways:

  • Each family member has to meet the individual deductible before insurance kicks in. This is known as a “capped” deductible.
  • Each family member has to meet the full family deductible before insurance kicks in. This is known as an “aggregate” deductible.

If you’re unsure which type of individual deductible your plan has, check your benefit document or ask your employer.

How does a deductible work when it is capped?

Let’s say your plan has a $1,000 family deductible and a $500 individual deductible. You’re working in the yard, you have an accident, and you have to make a trip to the emergency room. Your maximum responsibility as an individual would be $500, not the entire $1000. Now let’s say you have another accident in the same plan year. Your individual deductible of $500 has already been met, so you’re not responsible for any deductible amount.

Now let’s say your spouse needs surgery. Your family is now responsible for the remaining $500 deductible, since it’s a different individual. But now your total amount paid toward your $1000 deductible has been met. The next time anyone in your family needs medical services that are subject to the deductible, you don’t have to worry about the deductible. The deductible for the plan year has been met.

How does an aggregate deductible work?

Let’s say your plan has a $1000 family deductible and a $500 individual deductible. You’re working in the yard, you have an accident, and you have to make a trip to the emergency room. Your maximum responsibility as an individual would be the entire $1,000 of the family deductible. Now let’s say you or another family member has another accident in the same plan year. Because your family deductible of $1,000 has already been met, you will not be responsible for any additional deductible amount.


The cost of covered prescription drugs also applies to your plan deductible. Once you meet the deductible, you are responsible for a copayment.

Log in to your secure portal, and click on “claims” > “deductible” to view your specific deductible information.

 

Copayments

There are some services that may require a copayment with your plan. A copayment is the cost-share that you pay for certain covered pharmacy or medical services. Depending on your plan, you might have a copayment for a doctor’s office visit or for a prescription drug.

You can find your copayment amounts in 3 places:

  1. On the front of your ID card
  2. In the My Coverage section of mytuftshealthplan.com
  3. In your Benefit Document
Coinsurance

There are some services that may require coinsurance with your plan. Coinsurance is the percentage of costs you pay for certain covered services. As an example, if your plan has 20% coinsurance, Tufts Health Plan will pay 80% of the cost, and you’ll be responsible for paying 20% of the cost. It mainly applies to durable medical equipment (things like wheelchairs, crutches and hearing aids).

You can find out which services require coinsurance in 2 places:

  1. In the My Coverage section of mytuftshealthplan.com
  2. In your Benefit Document 

Login to mytuftshealthplan.com. Under My Coverage (1) you will find a complete list of your plan benefits. Select a benefit category to see your cost sharing responsibility (2) including copayments and coinsurance, if applicable.

Out-of-Pocket Max

The Out-of-Pocket maximum is the most you can pay during your plan year for your share of covered medical, pharmacy, vision and mental health services. After you spend this amount on deductibles, copayments, and coinsurance, Tufts Health Plan will pay 100% of remaining costs for covered services. However, your monthly premium does not count toward this total.

You can find the Out-of-Pocket Max for your plan in several places:

  1. In your Benefit Document
  2. In the Claims section of mytuftshealthplan.com, select the Out-of-Pocket Maximum tab

Login to mytuftshealthplan.com. Under Claims (1) select the Out-of-Pocket Maximum tab (2) to view how your costs have applied to your Individual and Family limits.

Health Savings Account (HSA)

Your plan is a high-deductible health plan (HDHP) as defined by the Internal Revenue Service. This means you may be eligible for a Health Savings Account (HSA) which can help you save and plan for expected or unexpected costs.

Think of an HSA as a medical bank account. You can use HSA funds toward your plan’s deductible, coinsurance, or co-payments. You can also use HSA funds for qualified medical expenses, such as dental or vision services, prescription drugs, and certain medical equipment. 

You also get these tax advantages:

  • You can claim a tax deduction for contributions that you, or someone other than your employer, make to your HSA - even if you don’t itemize your deductions on Form 1040.
  • Any contributions that your employer makes to your HSA may be excluded from your gross income.
  • Contributions remain in your account until you use them - unused funds roll over from one year to the next.

More tax information can be found in this IRS publication.

This information has been provided for informational purposes only. While we aim to ensure that content is current, accurate and complete, Tufts Health Plan makes no representations or warranties regarding its accuracy or completeness, and the information provided should not be construed as legal or tax advice or as a recommendation of any kind. Please consult your own tax advisor or legal counsel with respect to your individual circumstances and needs.

Getting Care

Visiting the Doctor

Your plan gives you the freedom to visit any health care provider you want. You may visit a Primary Care Provider (PCP), or you can visit a specialist. No referral is required.

When you choose a doctor, you should consider whether that doctor is in our network or not. Choosing an in-network doctor will result in the lowest out-of-pocket costs possible.

Check your Benefits Document in your member portal for more details on in-network and out-of-network costs. 

View your in-network provider directory.

Vision

You have access to EyeMed Vision Care, one of the nation’s leading vision care organizations. You can receive routine eye exams and other vision care services provided through EyeMed’s extensive network of providers, which includes many independent practices, as well as retail stores like LensCrafters, Sears Optical, Target Optical, JCPenney Optical and Pearle Vision (most locations).

Search for an EyeMed provider here.