Understanding them is the first step toward getting the most out of your coverage.
Premium
Your monthly contribution to pay for your health plan coverage. A plan with a lower premium will often have higher out-of-pocket costs (copayment, deductible and coinsurance) when you receive covered services.
Copayment
There are some services that may require a copayment with your plan. A copayment is the cost-share that you pay for certain covered pharmacy or medical services. Depending on your plan, you might have a copayment for a doctor’s office visit or for a prescription drug.
The amount you have to pay for covered health care services before Tufts Health Plan starts to pay. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and Tufts Health Plan pays the rest. Please check your benefit document (located in the My Coverage section of mytuftshealthplan.com) for details. The benefit document is also called an Evidence of Coverage (EOC) or Certificate of Insurance (COI).
Coinsurance
The percentage of costs you pay for certain covered services. As an example, if your plan has 20% coinsurance, Tufts Health Plan will pay 80% of the cost, and you’ll be responsible for paying 20% of the cost.
Out-of-pocket maximum
The most you can pay during your plan year for your share of covered medical, pharmacy, vision and mental health services. After you spend this amount on deductibles, copayments, and coinsurance, Tufts Health Plan will pay 100% of remaining costs for covered services. However, your monthly premium does not count toward this total.
In-network
A network is a group of 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.
Make sure that your doctor or other health care providers are in the network for your plan prior to receiving care by using our provider search at any time or by logging into mytuftshealthplan.com once you’re effective.
Out-of-network
“Out-of-network” refers to any physician, hospital or other care provider that is not in the group of 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. Because of this, receiving care from an out-of-network provider can be a lot more expensive for you.