Cost Sharing

Some of the Tufts Health Direct plans have a cost-sharing structure, meaning as a member, your employees may pay for a portion of their health care costs not covered by Tufts Health Plan. The amount or percentage your employees pay will depend on their Tufts Health Direct plan level.

Here are some key terms and definitions to help your employee's health plan shopping experience:

Annual medical deductible
Your employee's annual medical deductible is an amount they may need to pay each benefit year before we will pay for covered services. Your employee may need to pay part or all of their medical bill(s) until they reach their total annual medical deductible.

If your employee has a family plan, their family annual medical deductible is the combined amount individuals within their family must pay before we will pay for covered services. Your employee needs to reach their total family annual medical deductible before we will pay for covered services for all members enrolled under their family plan.

Annual medical out-of-pocket maximum
Your employee's annual medical out-of-pocket maximum is a limit on the amount they need to pay for covered medical services within a benefit year. All Tufts Health Direct members have an annual out-of-pocket maximum. Your employee's annual deductibles (if applicable), medical co-insurance, and medical co-payments all contribute to this maximum amount.

Once your employee reaches their full annual medical out-of-pocket maximum, we will pay for covered services for the remainder of the benefit year and they no longer need to pay co-payments or co-insurance for covered medical services. Keep in mind, once your employee reaches their full annual medical out-of-pocket maximum, they are still responsible for their monthly premiums.

If your employee has a family plan, and a medical out-of-pocket maximum, their family out-of-pocket maximum combines the annual deductibles, medical co-insurance, and medical co-payments paid by covered family members. For all members enrolled under a family plan, once the family reaches the full annual medical family out-of-pocket maximum no one in their family plan will need to pay for covered medical services for the rest of the benefit year. Keep in mind, once your employee reaches their full family annual medical out-of-pocket maximum, they are still responsible for their monthly premium.

Annual pharmacy out-of-pocket maximum
Your employee's annual pharmacy out-of-pocket maximum is a limit on the amount they need to pay for covered prescription drugs within a benefit year. All Tufts Health Direct members have an annual pharmacy out-of-pocket maximum. Your employee's annual pharmacy deductibles (if applicable), pharmacy co-insurance, and pharmacy co-payments all contribute to this maximum amount. Your employee's monthly premium, medical co-payments, and medical co-insurance do not apply toward this maximum amount.

Once your employee reaches their annual pharmacy out-of-pocket maximum, they no longer need to pay pharmacy co-payments or pharmacy co-insurance for covered pharmacy services. We will pay for covered pharmacy services for the remainder of the benefit year. However, they will still need to pay their monthly premiums.

If your employee has a family plan, their family annual pharmacy out-of-pocket maximum combines the annual deductibles, pharmacy co-insurance, and pharmacy co-payments paid for pharmacy services by covered family members. For all members enrolled under a family plan, once their family reaches their total family annual pharmacy out-of-pocket maximum no one in their family plan will need to pay for covered pharmacy services for the rest of the benefit year.

Benefit year
A benefit year is the consecutive 12-month period during which your employee's health plan benefits are purchased and administered.

Note: In some cases, their first benefit year will not be a full 12 months.

Co-insurance
Co-insurance is a percentage of the cost of a service, which your employee may pay for covered services or prescriptions. For example, if your employee has 20% co-insurance for a $100 covered medical service, they will owe $20 at the time of the service.

Co-payment
A co-payment is a fixed amount your employee may pay for covered services or prescriptions. All plan levels have co-payments.

What is a medical co-payment?

A medical co-payment is a fixed amount your employee may have to pay for a covered service other than pharmacy. Your employee may need to pay a co-payment for covered services, like doctors' visits and nonemergency hospital care.

What is a pharmacy co-payment?

A pharmacy co-payment is a fixed amount your employee may have to pay for a covered prescription drugs.

Integrated annual deductible
A deductible is the amount that your employee must pay toward covered health care services before we will begin paying. An integrated annual deductible is when their payments for either medical or pharmacy services both apply toward their deductible.

For example, if your employee has a $500 integrated annual deductible, and spends $400 on medical costs and $100 on pharmacy costs, they have met their $500 integrated annual deductible. Once they've met their integrated annual deductible, they only have to pay pharmacy or medical co-insurance or pharmacy or medical co-payments until they reach their total integrated out-of-pocket maximum.

If your employee has a family plan, their family integrated annual deductible combines their annual medical and pharmacy deductibles by covered family members. For all members enrolled under a family plan, once their family reaches their total family integrated annual deductible members of their family will only have to pay pharmacy or medical co-insurance or pharmacy or medical co-payments until they reach their total integrated out-of-pocket maximum.

Note: Your employee's monthly premiums do not contribute toward their integrated deductible.

Integrated annual out-of-pocket maximum
An integrated annual out-of-pocket maximum is the maximum amount your employee may pay in a benefit year for both medical and pharmacy covered services.

Once they reach their annual out-of-pocket maximum, they no longer need to pay medical co-payments or medical co-insurance for covered medical services. We will pay for covered medical services for the remainder of the benefit year. However, they will still need to pay their monthly premiums. Your employee's monthly premiums do not contribute toward this maximum amount. If your employee's plan level does not have an integrated annual out-of-pocket maximum, then their plan may have an annual medical out-of-pocket maximum and a separate pharmacy annual out-of-pocket maximum.

If your employee has a family plan, their family integrated annual out-of-pocket maximum combines any annual medical and pharmacy deductibles, co-insurance, and co-payments paid for services by covered family members. For all members enrolled under a family plan, once their family reaches their total family integrated annual out-of-pocket maximum no one in their family plan will need to pay for covered services for the rest of the benefit year.

Premium
Your employee's premium is their monthly contribution to pay for their health plan coverage.

If your employee is not part of a group:

  • Your employee's premium is determined based on their age, residence, plan level, and type of coverage. Your employee can check their monthly invoice to see what their premium is.
  • Your employee should receive a monthly invoice in the mail, unless they set up electronic billing at the time of their enrollment

If your employee is part of a group:

  • Your employee's premium is determined based on their employer's selected plan level, their type of coverage, and additional factors.
  • Your employee's employer may pay part or all of their premium.
  • Your employee's group may ask them to pay a portion of their monthly premium to them, in which case their group will pay the full premium to Tufts Health Plan.

Find more information and definitions in the Tufts Health Direct Member Handbook (PDF). Or call us at 888-257-1985. We're happy to help.

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