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Point-of-Service (POS) Option Overview

Tufts Health Plan’s Point-of-Service Option (POS) plan covers preventive and medically necessary health care services and supplies.

As a POS member, you can choose between two levels of coverage:

  • Coverage at the authorized level of benefits, a higher level of coverage, when care is provided or authorized by your primary care provider (PCP) in the Tufts Health Plan network. You pay a copayment at the time you receive covered health care services.
  • Coverage at the unauthorized level of benefits, when covered health care services are not provided or authorized by your Tufts Health Plan PCP. You pay a deductible and coinsurance when you obtain care at the unauthorized level of benefits.
    • A deductible is the amount you must pay out of pocket before any coverage is available at the unauthorized level of benefits.
    • Once you have paid the deductible, you pay coinsurance—a percentage of the covered medical costs you are responsible for paying at the unauthorized level of benefits—until you reach the out-of-pocket maximum.
    • Once you reach the out-of-pocket maximum, you are covered in full up to the reasonable charge for most out-of-network covered services for the remainder of the plan year.
    • To be reimbursed for covered services at the unauthorized level of benefits, you may need to submit a claim form. You may be responsible for paying any difference between what the plan covers and what the out-of-network provider charges for a service.

Emergency care is covered at the authorized level of benefits, regardless of whether you see an in-network or out-of-network provider.

Imaging

Sometimes when you are receiving care, your doctor may order diagnostic imaging. There are two main types: low-tech imaging and high-tech imaging.

Low-Tech Imaging—includes services such as x-rays, bone density tests, mammography, and ultrasounds. Low-tech imaging is sometimes performed in your doctor’s office or during an emergency room visit. It is covered as part of your visit and does not require a separate copayment. If your plan has a deductible, low-tech imaging services will apply toward the deductible.

High-Tech Imaging—includes CT/CTA, MRI/MRA, PET Scans, and Nuclear Cardiology. These procedures require prior authorization. This means your doctor needs to submit a request for approval before they will be covered. Many members are on a plan that has a high-tech imaging copayment. If this applies to you, this means you are responsible to pay a copayment for the procedure that is separate from your office visit or hospital copayment. Important Note: Members are exempt from paying the high-tech imaging copayment when the imaging is required as part of an active treatment plan for a cancer diagnosis. If you aren’t sure whether your plan has a high-tech imaging copayment, please check your Benefit Document or contact a Member Services Representative.

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