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.

With your plan, you must select a primary care provider (PCP) that is in-network. Your relationship with your PCP is an especially important one because, in most cases, your care must be provided by or authorized by your PCP and received in-network.

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.

WIth your plan, you do not have out-of-network coverage, which means Tufts Health Plan will not cover the cost of care or services you receive outside our network--except for in cases of emergency. In most cases, you will likely be responsible for the full cost of care you receive out-of-network.

If you have a life-threatening emergency medical condition, seek care immediately at the nearest medical facility or call 9-1-1 for emergency medical assistance. Don’t worry about whether the facility is in-network or out-of-network or getting approval from your PCP.

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 9-1-1 for emergency medical assistance, if needed.

If you receive care in an emergency room and:

  • Are not admitted as an inpatient, you or someone acting on your behalf should notify your PCP within 48 hours after you receive care.
  • Are admitted as an inpatient, you or someone acting on your behalf, must call your PCP or Tufts Health Plan within 48 hours after you receive care in order to be covered at the authorized level of benefits.

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 When Traveling

Tufts Health Plan covers any emergency medical care you may need, whether or not you receive the care from a provider in our network. If you’re traveling outside Massachusetts, Rhode Island or New Hampshire, it’s important to note that the Cigna PPO Network is available to HMO members 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*

*PLEASE 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.