Your Choice HMO - A Tiered-Network Option ... - Tufts Health Plan

Your Choice HMO - A Tiered-Network Option
Option 1 Summary of Benefits
With Tufts Health Plan’s Your Choice HMO (health
maintenance organization), a tiered network plan,
you enjoy quality coverage for your health care needs.
Preventive and medically needed health care services and
supplies are, for the most part, covered when they are
given or referred by your network primary care provider
(PCP). The plan also covers emergency medical care you
may need, even when the care is not given or referred by
your PCP.
As a Your Choice HMO member:
• You must choose a PCP from the Tufts Health Plan Your
Choice Tiered Network. Your plan groups PCPs into
three benefit tiers based on cost and quality measures.
PCPs grouped in Tier 1 always have the lowest cost
share for members.
• In most cases, your network PCP must give or refer
your care. Your PCP will direct your care to other Tufts
Health Plan Your Choice Tiered Network providers
within the same independent practice association (IPA)
and hospital that the PCP is affiliated with, most often
on the same tier.
• You pay a copay at the time you receive covered
services.
• You pay coinsurance for durable medical equipment.
Coinsurance is the percentage of cost you must pay for
some covered services.
This plan offers flexibility to choose between three costsharing
levels, based on the tier of your PCP, hospital, or
specialist. Other services are tiered into levels as well.
These include certain services received in a hospital
setting, including:
• Inpatient services and admissions.
• High-tech imaging.
• Day surgery.
• Low-tech imaging/X-rays.
• Diagnostic lab services.
• Diagnostic testing.
As a Your Choice HMO member, you will always have
the option to have the above outpatient services in a
nonhospital, or freestanding, medical facility. You will
pay, for the most part, a higher cost share if you have day
surgery, high-tech imaging, or diagnostic lab services in a
hospital setting.
You can find the tier of a PCP, hospital, or specialist by
going to our website, tuftshealthplan.com, and clicking
on Find a Doctor, and searching the Your Choice Network.
Please remember: There are many ways to measure the
performance of a physician. We have created the provider
tiers for Your Choice at the physician group level, not
on an individual provider basis. A physician’s tier does
not guarantee the quality of care that you might receive
from a specific physician or practice group, nor does it
guarantee a certain health outcome. You should always
speak with your physician when making decisions about
where to get care.
This plan includes the Tiered Provider Network called Your Choice. In this plan you may pay different levels
of copayments, coinsurance, and/or deductibles depending on your plan design and the tier of the provider
delivering a covered service or supply. This plan may make changes to a provider’s benefit tier annually on
January 1, beginning in 2013. Please consult the Your Choice provider directory or visit the provider search tool
at tuftshealthplan.com and click on doctor search to determine the tier of providers in the Your Choice Tiered
Provider Network. If you need a paper copy of the provider directory, please contact member services.

Deductible (per plan year) Tier 1 Tier 2 Tier 3
Deductible N/A N/A N/A
Out-of-Pocket Maximum (per plan year)
Out-of-Pocket Maximum (Includes deductible, coinsurance, and copayments
over $100.)
$5,000 Individual
$10,000 Family
Preventive Services
Routine Physical Exams (including preventive immunizations, preventive Pap
smears and mammograms, well-child care visits, annual gynecological exams, and
Covered in full
most preventive screenings)
Screening for Colon or Colorectal Cancer in the Absence of
Symptoms
Covered in full
Outpatient Medical Care (No PCP referral is necessary for OB/GYN
visits, spinal manipulation, routine eye exams, or mammograms)
Tier 1 Tier 2 Tier 3
Non-routine Primary Care Physician Office Visits and Urgent Care $20 per visit $35 per visit $50 per visit
Non-routine Specialist Office Visits and Urgent Care $35 per visit $45 per visit $60 per visit
Outpatient Maternity Care (This office visit copayment will apply per visit
up to 10 visits per pregnancy. After 10 visits, these services are covered in full for $20 per visit $35 per visit $50 per visit
the remainder of your pregnancy.)
Routine Eye Exams—With an EyeMed Vision Care
provider—(one visit every 24 months)
$20 per visit
Allergy Injections
$5 per visit
Nutritional Counseling (when medically necessary)
$35 per visit
Speech Therapy (when medically necessary)
$35 per visit
Short-Term Physical and Occupational Therapy
(up to 30 visits for each type of service per plan year)
$35 per visit
Spinal Manipulation (up to 12 visits per plan year)
$35 per visit
Colonoscopy Generally Associated with Symptoms (Including
Family History of Cancer)—without surgical intervention
Covered in full
Colonoscopy Generally Associated with Symptoms (Including
Family History of Cancer)—with surgical intervention:
at a freestanding outpatient surgery center
$200 per admission
Colonoscopy Generally Associated with Symptoms (Including
Family History of Cancer)—with surgical intervention:
at a hospital surgery center
Diagnostic Lab Tests and Diagnostic Imaging
(such as X-rays, ultrasounds, diagnostic pap smears and mammograms):
with any nonhospital provider
Diagnostic Lab Tests and Diagnostic Imaging
(such as X-rays, ultrasounds, diagnostic pap smears and mammograms):
with any hospital provider
Diagnostic Imaging—High-Tech Imaging
(such as MRIs, CT/CAT scans, PET scans, and nuclear cardiology):
at a freestanding imaging center
Diagnostic Imaging—High-Tech Imaging
(such as MRIs, CT/CAT scans, PET scans, and nuclear cardiology):
at a hospital-affiliated imaging center
Day Surgery: at a freestanding outpatient surgery center
$250
per admission
Day Surgery: at a hospital surgery center $250
per admission
$750
per admission
Covered in full
Covered in full
$50 per visit
$1,500
per admission
$50 per visit $250 per visit $450 per visit
$200 per admission
$750
per admission
$1,500
per admission

Inpatient Hospital Care and Surgery (semiprivate room, unless
private room is medically necessary)
Tier 1 Tier 2 Tier 3
All Hospital Services — Acute Care and Maternity Care $250 per admission $750 per admission $1,500 per admission
Skilled Nursing in Skilled Nursing Facility
(up to 100 days per plan year)
Covered in full
Emergency Care
In Emergency Room (copay waived if admitted)
$150 per visit
Mental Health and Substance Abuse
Outpatient Care
$20 per visit
Inpatient Care (services provided at a designated facility)
$250 per admission
Other Health Services
Durable Medical Equipment Plan covers 70%
Ambulance Service
Covered in full
Hospice Care
Covered in full
Home Health Care
Covered in full
Pharmacy Coverage
For up to a 30-day supply at a
participating retail pharmacy
For up to a 90-day
supply through our
mail-order service
Tier 1 Copayment $15 $30
Tier 2 Copayment $30 $60
Tier 3 Copayment $50 $100
There are some services that the plan does not cover. These include, but are not limited to: A service or supply not described as a covered service in your Tufts Health
Plan member benefit document • Exams required by a third party, such as your employer, an insurance company, a school, or court • Cosmetic surgery or any other cosmetic
procedure, except certain reconstructive procedures described in your Tufts Health Plan member benefit document • Experimental or investigational drugs, services, and
procedures • Eyeglasses or contact lenses, except as described in your Tufts Health Plan member benefit document • Blood, blood donor fees, blood storage fees, blood
substitutes, blood banking, cord blood banking, or blood products, except as described in your Tufts Health Plan member benefit document • Drugs for use outside of a hospital,
except as described in your Tufts Health Plan member benefit document • Personal comfort items • Custodial care • A service furnished to someone other than the member •
Routine foot care, except as described in your Tufts Health Plan member benefit document • Charges incurred for stays in a covered facility beyond the discharge hour • Care
for conditions that state or local law requires be treated in a public facility • Medical or surgical procedures for sexual reassignment and reversal of voluntary sterilization •
Foot orthotics, except therapeutic or molded shoes for an individual with severe diabetic foot disease • Spinal manipulation services for members age 12 and under • Privateduty
nursing (block or nonintermittent nursing) • Hearing aids • Except for Emergency care and urgent care while traveling, a service, supply or medication that is obtained
outside of the 50 United States.
This is only a summary. Please refer to the member benefit document for a detailed explanation of your coverage. If there is a
difference between the information in this benefit summary and your member benefit document, the terms of your member benefit
document will govern. If you have additional questions, please call a member specialist at 800-462-0224.
Offered by Tufts Associated Health Maintenance Organization, Inc.
This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance.
Massachusetts Requirement to Purchase Health Insurance: As of January 1, 2009, the Massachusetts Health Care Reform Law requires that Massachusetts residents,
eighteen (18) years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards set by the Commonwealth Health
Insurance Connector, unless waived from the health insurance requirement based on affordability or individual hardship. For more information call the Connector at
1-877-MA-ENROLL or visit the Connector Web site (www.mahealthconnector.org). This health plan meets Minimum Creditable Coverage standards that are effective
January 1, 2009 as part of the Massachusetts Health Care Reform Law. If you purchase this plan, you will satisfy the statutory requirement that you have health
insurance meeting these standards. This disclosure is for minimum creditable coverage standards that are effective January 1, 2009. Because these standards may
change, review your health plan material each year to determine whether your plan meets the latest standards. If you have questions about this notice, you may
contact the Division of Insurance by calling (617) 521-7794 or visiting its Web site at www.mass.gov/doi.

Your Choice Hospital Tiers
Massachusetts
REGION HOSPITAL TIER
East Anna Jaques Hospital Tier 1
Beth Israel Deaconess Hospital - Needham Tier 1
Beth Israel Deaconess Medical Center Tier 1
Boston Medical Center Tier 1
Brigham and Women’s Hospital Tier 3
Brockton Hospital Tier 1
Cambridge Hospital (part of Cambridge Health Alliance) Tier 1
Cape Cod Hospital Tier 3
Carney Hospital Tier 1
Children’s Hospital Tier 3
Charlton Memorial Hospital Tier 1
Dana-Farber Cancer Institute Tier 1
Emerson Hospital Tier 3
Falmouth Hospital Tier 3
Faulkner Hospital Tier 3
Good Samaritan Medical Center Tier 1
Hallmark Health Systems Tier 3
(Lawrence Memorial or Melrose Wakefield Hospitals)
Holy Family Hospital Tier 1
Jordan Hospital Tier 1
Lahey Clinic Hospital Tier 1
Lawrence General Hospital Tier 1
Lowell General Hospital Tier 1
Martha’s Vineyard Hospital Tier 3
Massachusetts Eye and Ear Infirmary Tier 1
Massachusetts General Hospital Tier 3
Merrimack Valley Hospital Tier 1
Metrowest Medical Center (Framingham or Leonard Morse) Tier 1
Milton Hospital Tier 1
Morton Hospital and Medical Center Tier 1
Mount Auburn Hospital Tier 2
Nantucket Cottage Hospital Tier 3
New England Baptist Hospital Tier 1
Newton-Wellesley Hospital Tier 3
North Shore Medical Center (Salem or Union campuses) Tier 3
Northeast Hospital Corp. Tier 2
(Addison Gilbert or Beverly Hospitals)
Norwood Hospital Tier 1
Quincy Medical Center Tier 1
Saints Memorial Medical Center Tier 1
South Shore Hospital Tier 1
St. Anne’s Hospital Tier 1
St. Elizabeth’s Medical Center Tier 1
St. Luke’s Hospital Tier 1
Sturdy Memorial Hospital Tier 1
Tobey Hospital Tier 1
Tufts Medical Center Tier 1
Winchester Hospital Tier 1
REGION HOSPITAL TIER
Central Athol Memorial Hospital Tier 1
Clinton Hospital Tier 3
Harrington Hospital Tier 3
HealthAlliance Hospital Tier 1
Henry Heywood Hospital Tier 1
Marlborough Hospital Tier 3
Milford Regional Medical Center Tier 1
Nashoba Valley Medical Center Tier 1
St. Vincent Hospital Tier 1
UMass Memorial Medical Center Tier 3
West Baystate Medical Center Tier 1
Berkshire Medical Center Tier 3
Cooley Dickinson Hospital Tier 3
Fairview Hospital Tier 3
Franklin Medical Center Tier 1
Holyoke Hospital Tier 1
Mary Lane Hospital Tier 1
Mercy Medical Center Tier 1
Noble Hospital Tier 1
North Adams Regional Hospital Tier 3
Wing Memorial Hospital Tier 3
New Hampshire
Catholic Medical Center Tier 1
Elliot Hospital Tier 1
Exeter Hospital Tier 1
Mary Hitchcock Memorial Hospital Tier 1
Parkland Medical Center Tier 1
Portsmouth Regional Hospital Tier 1
Southern N.H. Regional Medical Center Tier 1
St. Joseph Hospital Tier 1
Rhode Island
Kent County Hospital Tier 1
Landmark Medical Center Tier 1
Memorial Hospital of RI Tier 1
Miriam Hospital Tier 1
Newport Hospital Tier 1
Rhode Island Hospital - Tier 1
Including Hasbro Children’s Hospital
Roger Williams Medical Center Tier 1
South County Hospital Tier 1
St. Joseph’s Hospital Tier 1
The Westerly Hospital Tier 1
Women and Infants Hospital Tier 1
Vermont
Southwestern Vermont Medical Center Tier 1
Please note that the status and tiers of our network hospitals are effective as of July 1, 2011.
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