Advantage HMO Plan
How Advantage HMO Plans Work
Not all health plans work the same way so it's important you understand the differences between plans when you're evaluating the options your employer has provided you.
This section provides a general overview of how the Advantage HMO plan works. Once you're a member, you'll have access to mytuftshealthplan.com, our secure members-only site, where you'll find the details of the specific Advantage HMO plan your employer has chosen for you. This includes your Benefit Document so you can see a complete list of your specific plan’s covered and non-covered benefits.
The overall idea behind the Advantage HMO plan is to enable employers to offer high-quality health care to their employees. The Advantage HMO plan helps accomplish this by incorporating a fee structure that requires some cost-sharing on your part.
This cost-sharing is primarily in the form of two components: the deductible and the copay.
The deductible is the amount you must pay before your insurance kicks in. We’re speaking here only of the services that are subject to a deductible. Not everything you go to the doctor for is subject to the deductible. In other words, there are some things you can go to the doctor for that are covered right away, without your having to meet your deductible. These are generally preventive services, but they’re spelled out in greater detail in the second section of this Member Kit.
The deductible for your specific plan can vary. The amount is chosen by your employer, based on how much the entire plan costs them. We work closely with your employer to provide the best possible plan at the best possible cost for both employer and employee.
Here’s an example of how the deductible works. 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 $500, not the entire $1000. 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.
Regardless of the status of your deductible, there are some services that may also require a copay. A copay is a fee that you pay as partial payment for certain services. For instance, a visit to the doctor’s office requires a copay. That means you pay, for example, $20 out-of-pocket as your copay. Whether or not your deductible has been met, if a copay is required for the type of medical service you want, you are responsible for the copay. Again, the best way to control out-of-pocket costs is to read this Member Kit so you understand what you are and what you are not responsible for. And you can always find out exactly what your specific plan covers by reading your Benefit Document or accessing your secure member account at mytuftshealthplan.com
There’s one more component of the Advantage HMO plan’s fee structure that bears mentioning. It’s called coinsurance, and it applies primarily to durable medical equipment (such as a wheelchair or crutches), hearing aids, low-protein foods and prosthetics. If you require any of those items, you would share a percentage of the cost. In some cases, coinsurance may also apply to other items. You can find the specifics of your plan, including the exact amount of your coinsurance, by reading your Benefit Document or by visiting mytuftshealthplan.com.
You’ll be glad to know there’s a limit on what you may possibly pay during a calendar year. It’s called an Out-of-Pocket maximum. The Out-of-Pocket maximum is the most you can pay during your coverage period (typically one year) for your share of the cost of covered services.
Online ToolsWe’ve made managing your health plan easier.
When you sign up for a plan through Tufts Health Plan, we give you an easy way to manage it. It’s our members-only site called mytuftshealthplan.com. As a member, you’ll be able to check to see what your plan covers, see what your benefits are, search for doctors in your network, request prescription refills, check on claim updates and much more.