Understanding Our Network
 
 

What does it mean to be In-Network or Out-of-Network?

In-Network

A network is a list of approved doctors, hospitals and other care providers associated with your plan that have contracts with Tufts Health Plan to provide services at pre-negotiated rates. These providers are considered “in-network”, and every one of our network providers meets rigorous standards for quality care. 

Physicians, hospitals, and other providers who contract with Tufts Health Plan may change during the year. This can happen for many reasons, including a provider’s retirement, relocation out of the area, or failure to continue to meet our credentialing standards. In addition, because providers are independent contractors who do not work for Tufts Health Plan, this can also happen if Tufts Health Plan and the provider are unable to reach agreement on a contract. 

You receive coverage from Tufts Health Plan at the in-network level of benefits when you receive care from an in-network provider. You pay the applicable copayment for certain covered services. Some PPO members may have additional member costs, and some of their health care services may be subject to deductibles or coinsurance. Please review your member benefit document for the specifics on your plan. 

Always remember to check and see that your doctor, specialist, or other health care provider is in the network for your plan prior to receiving care.

You can determine if a doctor is in-network by searching for them in our provider directory based on your specific network.

Out-of-Network

“Out-of-network” refers to any physician, hospital or care provider that is not on the list of approved in-network doctors described above. Out-of-network providers do not have contracts with Tufts Health Plan as part of your plan, and thus, can determine the rate they charge you. Because of this, receiving care from an out-of-network provider can be a lot more expensive.

When you receive benefits from an out-of-network provider, you pay a deductible and coinsurance, and you submit a reimbursement form for each covered service you receive. Please check your member benefit document for more information about member costs for medical services.

Emergency Care

If you have a life-threatening emergency medical condition, seek care immediately at the nearest medical facility. Don’t worry about whether the facility is in-network or out-of-network or getting approval from your PCP. We’ll cover your treatment and ambulance services in an emergency situation. Call 911 for emergency medical assistance, if needed.

As a PPO member, If you receive emergency services at any hospital in or out of the Tufts Health Plan network but are not admitted as an inpatient, you are covered at the in-network level of benefits, and you pay a copayment.

If you are admitted as an inpatient, you or someone acting on your behalf (this could be the attending emergency physician) must notify Tufts Health Plan within 48 hours of seeking care to be covered at the in-network level of benefits. You must pre-register your admission if you are admitted to a facility that is out-of-network.

Urgent Care

Your plan also covers urgent care centers for a medical condition that requires immediate care but isn't life-threatening.  Consider an urgent care center when you can’t get to your PCP. Examples of non life-threatening injuries include:

  • Cuts or burns that don’t respond to basic first aid
  • Back muscle strains
  • Sprains
  • Broken bones

Learn more about immediate care.

Out-of-Network Savings Program While Traveling

If you’re traveling outside Massachusetts, Rhode Island or New Hampshire, it’s important to note that the Cigna PPO Network is available for both emergency and urgent care. Be sure, however, that you or someone acting on your behalf notifies your doctor within 48 hours of the onset of your condition in order to be covered at the in-network level of benefits.

Only medical providers located OUTSIDE of Massachusetts, Rhode Island, and New Hampshire participate and offer savings through this Out-of-Network Savings program.

Find a Provider Outside of Massachusetts, Rhode Island and New Hampshire in the CIGNA PPO Network

IMPORTANT NOTE: This provider search will return some provider types that are not part of our Out-of-Network Savings Program. Please disregard the following provider types: Dentists in any state and Medical Providers located in Massachusetts, Rhode Island, and New Hampshire.