Health Insurance 101

How Does Health Insurance Work?

how health insurance works for you and your family


We know that health insurance can be hard to understand, so we created this section to make it easier for you to get the answers you need.

Why is it important to use in-network vs. out-of-network Doctors + Specialists for my care?

To answer this question, we will be using our network as an example.

Depending on your plan*, our full network includes up to 29,000 hospitals and doctors across Massachusetts, New Hampshire, Rhode Island, and Connecticut.

Why should I see an “in-network” provider?

An in-network provider has contracted with Tufts Health Plan to provide you with health care services at a contracted, reduced rate. Since Tufts Health Plan has negotiated a contracted rate with the health care provider, you will typically save money—without sacrificing quality or care.

Why does an “out-of-network” provider cost more?

Tufts Health Plan does not have negotiated contracts or rates with out-of-network providers, so the provider decides how much you will pay for receiving health care services. If your plan includes out-of-network benefits and you decide to see an out-of-network provider, you will typically need to pay more out of pocket.

Do I need to worry about in- or out-of-network hospitals or providers in an emergency?

If you have an emergency medical condition, Tufts Health Plan covers treatment and ambulance services. Always seek care in an emergency. The following will help you decide what to do in case of emergency:

  • Seek care immediately at the nearest medical facility. PCP approval is not required before receiving emergency care.
  • Call 911 for emergency medical assistance, if needed. If 911 services are unavailable in the area, call local emergency medical services or the police.

Urgent Medical Care While Traveling

Tufts Health Plan covers urgent care. An urgent condition is one that requires immediate care, but isn't life-threatening. If you seek urgent care while traveling, you or someone acting on your behalf should notify your doctor within 48 hours of the onset of the urgent condition in order to be covered at the in-network level of benefits.

*Some plans may have a limited network, access the Carelink network, or require members to use in-network providers.

Am I eligible for health insurance subsidies and/or tax credits?
If you enroll in a new plan through the Health Connector, you may be eligible for certain state and federal subsidies to help you pay for your health insurance premiums and other costs. The level of help you can get is based on the federal poverty level applicable to you (determined by your income and family size).  
When you apply for and enroll in a new Health Connector plan, you will find out exactly what subsidies you qualify for.
 
  • You may be eligible for an advanced federal premium tax credit, which helps lower the amount of your monthly premium.
  • Or, you may be eligible for a lower-cost Health Connector plan called a ConnectorCare plan, which offers lower monthly premiums, and lower out-of-pocket costs when you receive covered services.

Federal premium tax credits

You may be eligible for a federal premium tax credit if you:
 
  • Are a Massachusetts resident
  • Are a U.S. citizen/national, a qualified immigrant, or a lawfully present immigrant
  • Earn up to 400% of the federal poverty level percentage ($46,680 yearly for an individual)
  • Do not have access to affordable employer-sponsored health insurance that meets minimum value standards
  • Are not incarcerated
  • Are not eligible for other government-sponsored insurance (e.g., MassHealth, Medicare, TRICARE)
Federal premium tax credits are paid directly to your selected Health Connector plan on a monthly basis, to lower your share of your monthly premium. (No payments are made directly to you.) If you apply for a federal premium tax credit, you don’t have to wait until you file your taxes to receive this subsidy; these will begin once you enroll.
 
Your federal premium tax credit amount is calculated using a formula that looks at your tax household’s projected annual income (what you expect to earn in the upcoming year), along with the Health Connector plan premiums available to you and the eligible members of your family (if applicable). Because this formula uses your projected annual income, if your income changes during the benefit year, you may need to reconcile the amount of premium tax credits you receive when you file your next tax return. It is important that you update the Health Connector if there are any changes to your income during the benefit year.
 
If you do apply for a federal premium tax credit, when you file next year’s tax return, you may be eligible for an additional tax credit if your premium tax credit was too low (included in your tax refund), or you may actually owe the government if you received a higher amount of premium tax credit than you were eligible for.
 

ConnectorCare plans

You may be eligible for a lower-cost ConnectorCare plan, such as Tufts Health Direct, if you:
 
  • Are a Massachusetts resident
  • Are a U.S. citizen/national, a qualified immigrant, or a lawfully present immigrant
  • Earn up to 300% of the federal poverty level ($35,016 yearly for an individual)
  • Do not have access to affordable employer-sponsored health insurance that meets minimum value standards
  • Are not incarcerated
  • Are not eligible for other government-sponsored insurance (e.g., MassHealth, Medicare, TRICARE)
When you apply for/enroll in a new Health Connector plan, such as Tufts Health Direct, you will learn more about your exact costs, what kind of subsidy or subsidies you qualify for (if any), and what options are available to help lower your health insurance costs.
How much of my treatment will my health insurance cover?

Below you will find some key definitions and explanations to help you understand your health plan costs, along with a few tips that can save you some out-of-pocket costs.

Annual Deductible

Your annual deductible is an amount you may need to pay each benefit year before your health plan pays for covered services. You may need to pay part or all of your medical bill(s) until you reach your total annual deductible.

Co-insurance

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

Co-payment

A co-payment is a fixed amount you may pay for covered services or prescriptions, such as doctors' visits and prescription drugs.

Out-of-pocket Maximum

Your out-of-pocket maximum is a limit on the amount you need to pay for covered medical services within a benefit year. Your annual deductibles (if applicable), co-insurance, and co-payments all contribute to this maximum amount.

Once you reach your full out-of-pocket maximum, your health plan will pay for covered services for the remainder of the benefit year, and you no longer need to pay co-payments or co-insurance for covered services. Keep in mind that once you reach your full annual out-of-pocket maximum, you are still responsible for your monthly premiums.

Premium

Your premium is your monthly contribution to pay for your health plan coverage.

If you receive health insurance through your employer, your premium is determined based on your employer's selected plan level, your type of coverage, and additional factors.

Save on some out-of-pocket costs

The following tips can help you save on some out-of-pocket costs:

  • choose urgent care centers or retail clinics when the emergency room isn’t necessary
  • take advantage of your health insurance plan's member discounts
  • get a prescription for a generic drug when possible
  • talk to your doctor about less expensive alternatives to your medications
How do I sign up for Tufts Health Direct or Tufts Health Together?

Applying for Tufts Health Direct

During Open Enrollment, you can apply for Tufts Health Direct—our individual and small-group plan—online, by mail, by fax, or by phone. Once your enrollment form is approved and processed, your coverage will begin on the first day of the month of your requested effective date.

You may also apply for Tufts Health Direct outside of Open Enrollment, if one or more qualifying events apply.

Learn more about applying for Tufts Health Direct.

Applying for Tufts Health Together

To join Tufts Health Together, you first need to be approved for MassHealth. Once approved, you can enroll in Tufts Health Together at any time—there is no need to wait for an open enrollment period.

Learn more about applying for Tufts Health Together.

What is the Affordable Care Act (ACA)?

The Patient Protection and Affordable Care Act (or ACA) was enacted by Congress in 2010. The main goal of the act was to increase the number of Americans covered by health insurance by improving access, affordability, and quality in health care.

Individual Mandate

One key requirement of the ACA is the individual mandate, which requires most Americans to have “minimum essential”—or a minimum required amount—of health insurance coverage, or pay a fee or penalty. The way to meet the requirement (if you are not exempt, or do not receive health insurance through an employer or government program) is to buy insurance from a private company.

Shared Responsibility Payment

In 2014, the Federal Government began collecting a “shared responsibility payment” from individuals who do not meet the minimum coverage requirement. This payment is made to the Internal Revenue Service (IRS) with an individual’s taxes, and is assessed and collected like other tax penalties.

Medicaid Expansion

Another key part of the ACA is the expansion of Medicaid. The Medicaid program provides health care coverage for some low-income individuals, families and children, pregnant women, the elderly, and people with disabilities. The ACA was designed to expand Medicaid eligibility to more low–income individuals.



Explore our Health Insurance Glossary to better understand what some of the health insurance terms mentioned above actually mean.

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