Tufts Health Plan Spirit is an exclusive provider organization (EPO) 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. This plan is offered to give you a more affordable health plan choice.
Tufts Health Plan Spirit offers the same benefits and copayments as the Navigator plan, with several important differences:
- A lower premium than Navigator—your monthly premium cost will be 20% lower.
- The provider network is different—there are fewer participating providers and hospitals.
- Except as described below under How this plan works, there are NO out-of-network benefits. Members of this plan must select participating providers from the Tufts Health Plan Spirit provider network to receive covered health care services.
How this plan works
- You don’t need referrals.
- You can’t seek covered health care services outside of the Tufts Health Plan Spirit network unless there is a medical emergency, or urgent care is needed while traveling outside of the Spirit service area. Otherwise, only health care services obtained within the Tufts Health Plan Spirit network are covered.
- Your copayments for office visits will be lower when you see specialists in the Spirit network who have an excellent or good quality and/or cost-efficiency rating.
- Your copayments for care you get in the hospital will be lower when you go to hospitals in the network that have an excellent quality and costefficiency rating.
- You will not need to satisfy a new deductible if you change plans from Navigator to Tufts Health Plan Spirit.
- Primary Care Providers (PCPs), PCPs who are also specialists, and pediatricians—Covered at $20 per office visit
- 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 office visit
Preventive care services are covered in full.
Copayments for care you get at network hospitals depend on the hospital you choose. Care you get at network hospitals is covered at two levels for inpatient hospital care:
- Tier 1: Hospitals with an excellent quality and cost-efficiency rating—Lowest copayment for each hospital admission
- Tier 2: Hospitals with a good quality and cost-efficiency rating—Higher copayment for each hospital admission
To see the copayments that apply at each network hospital, check the Copayments for Inpatient Hospital Admissions list in this brochure.
About This Plan’s Deductible
Plan members are responsible for a deductible for some covered services they get from providers in the Tufts Health Plan Spirit network.
*Specialists in the 13 specialties who didn’t have enough information to be grouped in tiers, and doctors in specialties that were not tiered.