Navigator by Tufts Health Plan
Navigator™ by Tufts Health Plan is a point of service (POS) plan that covers preventive and medically necessary health care services and supplies. These are services and supplies you need to help you stay healthy or to help you get healthy when you’re sick.
To receive the highest level of benefits:
- You have to choose a primary care provider (PCP).
- You need to obtain PCP referrals to see specialists.
- You receive care from providers in the Tufts Health Plan network.
How this plan works
- Your copayments for office visits will be lower when you see certain specialists in our network who have an excellent or good quality and/or cost-efficiency rating.
- You can get covered health care services from any health care provider in or out of our network; your costs are lower in-network.
- Your copayments for care you get in the hospital will be lower when you go to hospitals in our network that have an excellent quality and costefficiency rating.
Office visit copays are not the same for all doctors who participate in our network. The amount of the copayment depends on the kind of network provider you see.
- PCPs, PCPs who are also specialists, and pediatricians— Preventive services are covered in full.
- Massachusetts specialists in these 13 specialties have been rated based on quality and/or cost-efficiency standards and are grouped in three tiers with these copays: cardiology, dermatology, endocrinology, gastroenterology, neurology, obstetrics/gynecology, orthopedics, ophthalmology, otolaryngology, pulmonology, rheumatology, general surgery, and urology
- Tier 1 (Excellent)—Lowest cost per office visit
- Tier 2 (Good)—Mid-level cost per office visit
- Tier 3 (Standard)—Higher cost per office visit
- All other specialists*—Covered at mid-level cost per visit
*Specialists who are not tiered include those in the 13 specialties who didn’t have enough information to be grouped in tiers, doctors in specialties that were not tiered, and specialists who practice outside of Massachusetts.
Copayments for care you get at network hospitals depend on the hospital you choose. Care you get at hospitals in our network is covered at three levels for inpatient hospital care:
- Tier 1: Hospitals with an excellent quality and cost-efficiency rating—lower copayment for each hospital admission
- Tier 2: Hospitals with a good quality and cost-efficiency rating—mid-level copayment for each hospital admission
- Tier 3: Hospitals with a good quality and lower cost-efficiency rating than Tier 1 and Tier 2 —higher copayment for each hospital admission
Authorized Level of Benefits
Using your “Authorized” level of benefits means that you have selected a PCP, you obtain care from your PCP, you obtain referrals to see specialists when needed, and you stay within the Navigator by Tufts Health Plan network to receive your care.
Unauthorized Level of Benefits
If you choose to use your “Unauthorized” level of benefits, this means you have not selected a PCP, you are not obtaining PCP referrals to see specialists, or you are obtaining care outside of the Navigator by Tufts Health Plan network.
About This Plan’s Deductibles
- Authorized annual deductible: Plan members must pay the authorized deductible for applicable covered services they get from health care providers in our network. The authorized deductible does not apply to mental health and substance abuse services received from network providers under Beacon Health Options.
- Unauthorized annual deductible: If you do not select a PCP, if you do not receive a referral from your PCP to a specialist, or if you receive care from a provider outside of the network, you will pay your plan’s unauthorized deductible. Once you have paid the deductible, we will pay 80% and you will pay 20% of the “reasonable charges” ** until you reach the out-of-pocket maximum. Then you are covered in full up to the reasonable charges for services you receive for the rest of the calendar year. The unauthorized deductible also applies to mental health and substance abuse services received from out-of-network providers under Beacon Health Options.
**Reasonable charges are the customary rate at which providers in a geographical area are paid for a specific service.