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Advantage HMO

How Your Plan Pays for Covered Services

The better you understand your Advantage HMO plan, the easier it will be to navigate your health care. That’s why we want you to learn a few tips about how this plan will pay for covered services.

You can also visit, our secure members-only site, to learn the details of the specific plan your employer has chosen for you. And be sure to read your Benefit Document, available at, to see a complete list of your specific plan’s covered and non-covered benefits.

What You Need To Know Before You See a Doctor

First, you must meet your plan’s deductible.

This is a specific dollar amount that you must spend each year before your insurance will begin to cover the cost of certain services. This means you’ll have to pay for certain medical bills you receive until the deductible is satisfied. For some other services, such as doctor visits or lab work, your plan may only require you to pay a co-payment to be covered.

Once you meet your deductible for certain services, you’ll typically pay only a copayment or coinsurance—and Tufts Health Plan will pay the rest.

We cover routine preventive care 100%—no deductible or other out-of-pocket costs at all. That’s because regular checkups, screenings, and immunizations are essential to your good health.

Know Your Plan Basics

Along with understanding your plan’s deductible, you also need to know a few plan basics to have the best member experience:

  • You must select a primary care provider (PCP) from our network.
  • You must get a referral from your PCP before you can see a specialist or other provider in our network.
  • Know your out-of-pocket costs and plan ahead.

Cost Sharing

The overall idea behind the Advantage HMO plan is to enable employers to offer high-quality health care to their valuable employees (you). 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

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.

The Copay

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


Coinsurance 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

The Out-of-Pocket Maximum

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 Tools

We’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 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. Be sure to have your member ID number handy, and sign up today.

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