Navigator - Tufts Health Plan

Navigator
Controlling Costs by Empowering Members
Affordability | Quality | Services | Tools

Affordability
A Long-term Solution to the Rising Cost of Health Care
Tufts Health Plan has been a leader in health care innovation for more than 30 years.
When our largest customer, the Commonwealth of Massachusetts’ Group Insurance
Commission (GIC), was looking for a long-term solution to the rising cost of health care,
they wanted a plan that would:
1
Introduce more accountability to their employees
regarding the true cost of health care
2
Introduce more competition among the provider
community
3
Slow the growth of health care costs
Controlling
costs by
empowering
members

Navigator by Tufts Health Plan creates more engaged consumers and more incentives
to the provider community to maintain high-quality standards while controlling costs.
Navigator is a unique PPO plan design that offers members:
Freedom to seek care from any licensed provider they choose
A network of hospitals grouped into copayment levels based on a quality and costefficiency
rating
Decision-support tools that allow members to compare hospitals for specific
conditions and procedures, and provide a wealth of health information
And as with our other PPO plans, Navigator members choosing to see providers outside
of our network are covered subject to deductible and coinsurance.
With health care costs rising in the double digits each year, something must change.
Health insurers, employers, providers, and consumers must work together to create
solutions that control costs; encourage providers to offer high-quality, cost-effective
services; and educate and reward consumers for taking an active role in their health
care.
Navigator is a step in the right direction. It’s a plan that effectively controls costs and
offers more choice and better value to employers and members. Navigator is easy to
understand, appeals to consumers, and is part of a strategy for slowing the growth of
health care costs. Take a look inside and see what Navigator can do for you.

Quality
Navigator Delivers Choice, Quality, and Value
It’s no secret that providing health insurance has become one of the most costly line
items for employers today. To hire and retain the best employees, companies must offer
a competitive benefits package. However, with health care premiums increasing 10 to 14
percent each year, employers are faced with a tremendous challenge.
Double-digit increases in health care costs continue nationwide—a situation that is
clearly unsustainable.
Many employers use a variety of cost-saving strategies in an effort to slow the growth
of health care costs, including:
Increasing employee cost sharing
Implementing disease management programs targeting specific conditions
Providing employees with more health care data to educate and engage them in their
own health care
While each of these may be an effective short-term tactic, Navigator by Tufts Health
Plan combines these with a tiered hospital network that encourages members to select
quality, cost-efficient providers. The result is a plan that delivers more choice, better
quality, informed consumers, and a long-term strategy to control costs.
Navigator promotes value-based
purchasing, with equal weight given
to quality and cost measures.

The Navigator Difference
Navigator’s unique and flexible plan design, which offers employers a variety
of options, is as easy to understand as it is to administer. As a PPO, it allows
members the freedom to choose any provider—whether the provider is in or
out of our network.
What’s different with Navigator is that we’ve created a tiered hospital network
that groups network hospitals into two or three copayment levels. We score
hospitals based on a number of qualitative and quantitative measures focused
on the quality and cost-efficiency of service delivery.
As with our other PPO plan designs, hospitals outside our network are subject
to a deductible and coinsurance.
Inpatient Services
In-Network Services
• Members choose a hospital from the Navigator Inpatient Hospital List.
• Hospitals are ranked in Copayment Level 1, Level 2, or Level 3. Our tiering methodology is based
on a number of qualitative and quantitative measures focused on the quality and cost-efficiency of
care delivery, detailed in our Quality-Cost Value Index.
Out-of-Network Services
• Members have the freedom to choose any licensed hospital.
• All benefits are payable subject to a deductible and coinsurance. Once the deductible and
coinsurance are satisfied, benefits are paid at 100% for covered services.
Worldwide Emergency Coverage
As with all Tufts Health Plan products, the Navigator plan provides 24-hour worldwide
emergency coverage.

Services
Variable Copayments Let Members Decide
We’ve grouped network hospitals in Massachusetts into copayment levels in three
different categories of care: pediatric, obstetric, and adult medical/surgical care.
Copayments vary depending on the hospital’s copayment level for the category of care.
Plans can include either two or three copayment levels, based on the employer’s needs.
Copayment Level 1: Network hospitals with a best quality and cost-efficiency rating
have the lowest copayment.
Copayment Level 2: Network hospitals with a better quality and cost-efficiency
rating have a higher copayment.
Copayment Level 3: Network hospitals with a good quality and cost-efficiency rating
have the highest copayment.
Please note that although network hospitals may be listed at different copayment levels
on our Navigator Copayments for Inpatient Hospital Admissions List, all meet rigorous
credentialing standards. In addition, some Tufts Health Plan-participating hospitals are
not grouped in a copayment level. Please see the Navigator Copayments for Inpatient
Hospital Admissions List and the Quality-Cost Value Index for details.
Outpatient Services
For outpatient services, members choosing network physicians and specialists pay
a copayment for office visits. Out-of-network physicians and specialists are covered
subject to deductible and coinsurance. No referrals are required, and members do not
have to choose a primary care provider.

Covered Inpatient Services
Inpatient Hospital Services
In-Network
Out-of-Network
COPAYMENT LEVEL 1
Best Quality-Cost Score
COPAYMENT LEVEL 2
Better Quality-Cost Score
COPAYMENT LEVEL 3
Good Quality-Cost Score
After $150 individual/
$300 family deductible
Adult Medical/
Surgical
Admissions*
Obstetric
Admissions*
$150 copayment $300 copayment $500 copayment Plan pays 80%
$150 copayment $300 copayment $500 copayment Plan pays 80%
Pediatric
Admissions*
COPAYMENT LEVEL 1
Best Quality-Cost Score
COPAYMENT LEVEL 2
Better Quality-Cost Score
$200 copayment $400 copayment
Plan pays 80%
In-Network Inpatient Copayment Maximum: Each member only pays up to a maximum of four inpatient copayments per calendar year, no
matter how many times each member is admitted to an in-network hospital.
Out-of-Network Inpatient Maximum: When you receive care out of network, you pay your deductible and coinsurance up to $3,000
annually per member for all out-of-network services combined.
* Covered charges include anesthesia, medications, nursing care, X-ray and lab services, intensive/coronary care, radiation therapy, and
physicians’ services while hospitalized.
Other Covered Inpatient Services
In-Network
Out-of-Network
After $150 individual/
$300 family deductible
Chronic Care Hospital Services Covered in full Plan pays 80%
Acute Rehabilitation Hospital Services Covered in full Plan pays 80%
Transplants* $150 per admission Plan pays 80%
Skilled Nursing in a Skilled Nursing Facility
Up to 45 days per member per calendar year, combined in- and
out-of-network
Plan pays 80% Plan pays 80%
Mental Health and Substance Abuse
$25 per visit outpatient
$250 per admission inpatient
Plan pays 80%
Out-of-Network Inpatient Maximum: When you receive care out of network, you pay your deductible and coinsurance up to $3,000
annually per member for all out-of-network services combined. There is no out-of-pocket maximum for skilled nursing in a skilled nursing
facility out-of-network. Deductible and coinsurance apply.
* Approval of an authorized reviewer is required.
Please note that all copayments listed in these charts are examples only.
Employers can choose copayment structures to meet their needs.

Tools
Decision-support Tools to Create Informed Consumers
An important component of the Navigator plan is helping members become more
engaged in their health care decisions. That’s why the plan includes support tools to give
members the information they need to make informed choices, including:
The Navigator Copayments for Inpatient Hospital Admissions List groups hospitals
in our Massachusetts network in two or three copayment levels, based on the quality
and cost-efficiency of services they deliver. The Quality-Cost Value Index provides
additional, more specific information used by Tufts Health Plan in determining a
hospital’s copayment level.
WebMD Hospital Advisor SM compares hospital quality and cost information, and
helps users make informed decisions about where to receive care.
Treatment cost estimator by Optimum Health SM helps users calculate average
cost information for hundreds of treatments, procedures, and conditions so they can
evaluate their options for obtaining cost-effective health care.
Healthwise® Knowledgebase, an online health encyclopedia, gives members access
to information about a wide range of health topics, medical tests and medications, a
symptom checker, and much more.
Informed health decision videos help users make key decisions about health care and
treatment options.
A Personal Health Assessment will provide members with a personalized report
that will help them identify any personal risk factors they may have and guide them
toward healthier lifestyle choices.
Health trackers help members gather their most important health measurements
online—such as blood pressure, cholesterol, weight, and blood sugar levels—and
follow their progress, using simple but powerful charting tools.

Everything You Expect From Tufts Health Plan
With Navigator, you not only get a PPO plan design with incentives that encourage
employees to select high-quality, cost-efficient hospitals, you also get a plan with all the
great benefits of being a Tufts Health Plan customer, including:
A full spectrum of health management programs that allow us to help improve
our members’ quality of life while keeping coverage affordable. Our integrated suite
of disease management programs, pharmacy management programs, behavioral
health management, and wellness programs helps members maintain or improve their
quality of life, while managing health care costs.
Customized work site wellness programs through our new Destination Wellness
initiative to help you improve the health of your employees and take control of costs.
Online administration tools to make enrollment and billing tasks easier.
Valuable discounts on fitness centers, nutrition information and counseling,
acupuncture, massage therapy, and other products and services that promote a
healthier lifestyle for your employees.
Superior account management and member services teams committed to providing
you and your employees with the best possible service.
Tools and
information help
members make
better choices.

10 Reasons
to Choose Navigator TM
by Tufts Health Plan
1
The same great quality and value you expect
from Tufts Health Plan.
2
Extensive provider network. Members can
choose from our network of 25,000 providers
and more than 90 hospitals. Or, they can
go outside the network and still receive
comprehensive coverage nationwide.
3
No hassles. With Navigator, there are no claim
forms to fill out for in-network services.
4
No referrals required. With Navigator, there’s
no need to choose a primary care provider, and
specialist referrals are not required.
5
Plan design flexibility. Employers can choose the
copayment levels that are right for their employees.

6
Ability to control costs. Members can choose
hospitals rated higher in quality and cost-efficiency,
and pay lower out-of-pocket costs.
7
Worldwide emergency coverage 24 hours a day,
7 days a week.
8
Superior customer service delivered by highly
trained and committed member specialists.
9
Decision-support tools.
10
Easy administration with our suite of online
enrollment and billing tools.
With Navigator, you have the
confidence that you’re taking the
first step in creating a long-term
strategy for slowing the growth
of health care costs.

Contact
tuftshealthplan.com
705 Mount Auburn Street | Watertown, MA 02472 | Phone: 1-800-208-8013 | Fax: 1-617-923-5880
102 Shore Drive, Suite 402 | Worcester, MA 01605 | Phone: 1-800-208-9545 | Fax: 1-508-757-8311
1441 Main Street, Suite 925 | Springfield, MA 01103 | Phone: 1-800-337-4447 | Fax: 1-413-746-8300
One West Exchange Place | Providence, RI 02903 | Phone: 1-800-455-2012 | Fax: 1-401-272-1233