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HomeMy Public PortalAboutNavigator 2018-2019 I] TUFTS Health Plan This is a Massachusetts Large Group Plan 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, 2010 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, 2010. 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. This plan includes the Tiered Provider Network called Navigator by Tufts Health Plan, or Navigator. In this plan members may pay different levels of copayments, coinsurance, and/or deductibles depending on their 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 July 1. Please consult the Navigator provider directory by visiting the provider search tool at tuftshealth plan.com and click on Find a Doctor to determine the tier of providers in the Navigator Tiered Provider Network. If you need a paper copy of the provider directory, please contact Member Services. CommonwealthofMassachusetts Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: 7/112018—6/30/2019 =;Group Insurance Commission GIC Navigator POS Coverage for: Individual/Family Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health Ilan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium)will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see nttgs://www.tuftshealthr)lan.cori, or call 800-870-9488 (TDD: 711). For general definitions of common terms, such as allowed amount, balance billina., coinsurance, copavment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at httos://www.healthcare.ciov/sbc-cilossarv/or call 800-870-9488 to request a copy. ImportantI $500 individual/$1,000 family Generally, you must pay all of the costs from providers up to the deductible amount before this Ilan What is the overall begins to pay. If you have other family members on the Ilan, each family member must meet their own deductible? authorized; individual ed 0uctible. individual deductible until the total amount of deductible expenses paid by all family members meets the family unauthorized medicall deductible. overall family deductible. Are there services covered Yes.Authorized preventive care, This Ilan covers some items and services even if you haven't yet met the deductible amount. But a before you meet your primary care, and specialist care are cor)avment or coinsurance may apply. For example, this Ilan covers certain preventive services without deductible? covered before you meet your cost-sharina and before you meet your deductible. See a list of covered preventive services at deductible. httgs://www.healthcare.00v/coveraae/preventive-care-benefits/. Are there other deductibles Yes. $100 individual/$200 family for You must pay all of the costs for these services up to the specific deductible amount before this Ilan for specific services? prescription drua coveraae. begins to pay for these services. $5,000 individual/$10,000 family for The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family What is the out-of-Docket authorized medical and pharmacy members in this Ilan, they have to meet their own out-of-pocket limits until the overall family limit for this plan?. expenses; $5,000 individual/$10,000 out-of-pocket limit has been met. family unauthorized medical expenses. What is not included in the Premiums, balance-billed charges, and Even though you a these expenses, the don't count toward the out-of-pocket limit. out-of-pocket limit? health care this Ilan doesn't cover. g y pay p y Yes. See tuftshealthpan.com/gic, "Find This Ilan uses a provider network.You will pay less if you use a provider in the Ip an's network.You will Will you pay less if you use a doctor, hospital..."or call pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the a network provider? 800-870-9488 (TDD: 711)for a list of difference between the provider's charge and what your Ilan pays (balance billina). Be aware, your network providers. network provider might use an out-of-network provider for some services(such as lab work). Check with your provider before you get services. Do you need a referral to Yes. This Ilan will pay some or all of the costs to see a specialist for covered services but only if you have a see a specialist? referral before you see the specialist. 030117063837-13355-POS-Navigator-2017-0 1 of 7 All copavment and coinsurance costs shown in this chart apply both before and after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Services You May Authorized Provider Unauthorized Provider Limitations, Exceptions, &Other Important Informationj Event Need- (You will pay the least) (You will pay the most) If you visit a health Tier 1 -$10 copav/visit care provider's office Primary care visit to treat Tier 2-$20 copav/visit 20%coinsurance None or clinic an injury or illness Tier 3-$40 copav/visit; deductible does not apply Tier 1 -$30 copav/visit Specialist visit Tier 2-$60 copav/visit 20%coinsurance Prior authorization may be required. Tier 3-$75 copav/visit; deductible does not apply Preventive care/ No charge; deductible does not o You may have to pay for services that aren't preventive.Ask screenina/immunization apply 20%coinsurance your provider if the services you need are preventive. Then check what your Ilan will pay for. If you have a test Diagnostic test(x-ray, No charge 20%coinsurance Prior authorization may be required. blood work) Imaging (CT/PET scans, Imaging $100 co all/test 20%coinsurance Prior authorization is required. Limit of one copav per day. If you need drugs to Reimbursable at in network treat your illness or Tier 1 -Generic drugs $10 copav/fill retail); $25 level condition copav/fill (maill order) Tier 2- Preferred brand $30 copav/fill (retail); $75 and some generic drugs copav/fill (mail order) Tier 3- Non-preferred $65 copav/fill (retail); $165 brand drugs copav/fill (mail order) More information about prescription drug Limited to a 30-day supply with Limited to a 30-day supply. Must be obtained at a coverage is available by appropriate tier copav(see designated specialty pharmacy.Some drugs require prior calling Express Scripts Specialty drugs above)when purchased at a Not covered authorization to be covered.Some drugs have quantity dedicated GIC phone line designated specialty pharmacy limitations.Some specialty drugs may also be covered at 855-283-7679 under your medical benefit. 2of7 What You Will Pay Common Medical Services You May Authorized Provider Unauthorized Provider Limitations, Exceptions, &Other Important Information Event Need (You will pay the least) (You will pay the most) If you have outpatient Facility fee(e.g., Some surgeries require prior authorization in order to be surgery ambulatory surgery $250 copav/visit 20%coinsurance covered. center) Limit of 4 copays, per member, per Ilan year maximum. Physician/surgeon fees No charge 20%coinsurance If you need immediate Emeraencv room care $100 copav/visit Cost share waived if admitted. medical attention Emeraencv medical No charge Some emeraencv transportation requires prior authorization transportation to be covered Free-standing Uraent Care Center-$20 copav/visit Tier 1 PCP-$10 copav/visit, specialist-$30 copav visit Services with unauthorized providers inside the service area Uraent care Tier 2 PCP-$20 copav/visit, specialist-$60 copav/visit are covered subject to deductible and coinsurance. Tier 3 PCP-$40 copav/visit, specialist-$75 copav visit; deductible does not apply If you have a hospital Tier 1 -$275 copav/admission Some hospitalizations require prior authorization to be stay Facility fee(e.g., hospital Tier 2-$500 copav/admission 20%coinsurance covered. room) Tier 3-$1,500 Maximum of one copav, per member, per quarter. copav/admission Physician/surgeon fees No charge 20%coinsurance If you need mental Prior authorization may be required. Please contact the Ilan health, behavioral $10 copav/visit; deductible o for specifics regarding SUD treatment. health,or substance Outpatient services does not apply 20/o coinsurance abuse services Inpatient services $200 copav/admission; 20%coinsurance deductible does not apply 3of7 What You Will Pay Common Medical Services You May Authorized Provider Unauthorized Provider Limitations, Exceptions, &Other Important Information Event • (You will •.y the least) (You will pay the most) If you are pregnant Tier 1 -$10 copav/visit Cost sharinq does not apply to certain preventive services. Tier 2-$20 copav/visit ° Depending on the type of services, copavment, coinsurance Office Visits 20/°coinsurance or deductible may apply. Maternity care may include tests Tier 3-$40 copav/visit; y pp y. y y deductible does not apply and services described elsewhere in the SBC (i.e. Childbirth/delivery ultrasound). professional services No charge 20%coinsurance Tier 1 -$275 copav/admission Childbirth/delivery facility Tier 2-$500 copav/admission 20%coinsurance services Tier 3-$1,500 copav/admission If you need help recovering or have Home health care No charge 20%coinsurance Prior authorization is required. other special health needs Short-term physical and occupational therapy limited to 30 Rehabilitation services doe copav/visit; deductible 20%coinsurance visits for each type of service per year. No set limit on does not apply speech therapy. Prior authorization may be required. Short-term physical and occupational therapy limited to 30 Habilitation services doe copav/visit; deductible 20%coinsurance visits for each type of service per year. No set limit on does not apply speech therapy. Prior authorization may be required. Skilled nursing care 50%coinsurance 20%coinsurance Limited to 45 days per year. Prior authorization is required. Durable medical No charge No charge Prior authorization may be required. equipment Hospice services No charge 20%coinsurance Prior authorization is required. If your child needs Children's eye exam $20 copav/visit; deductible 20%coinsurance Limited to one visit every 24 months with an EyeMed vision dental or eye care does not apply care provider. Children's glasses Not covered Not covered None Children's dental Not covered Not covered None check-up Excluded Services &Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or Ilan document for more information and a list of any other excluded services.) oo Acupuncture oo Long-term care/custodial care oo Treatment that is experimental or investigational, oo Cosmetic surgery oo Non-emergency care when traveling outside the for educational or developmental purposes, or oc Dental care (Adult) U.S. does not meet Tufts Health Plan Medical oo Routine foot care Necessity Guidelines (with limited exceptions specified in your Ilan document) oo Weight loss programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your Ilan document.) oo Abortion oo Hearing Aids (children and adults) oo Private-duty nursing oo Bariatric surgery oo Infertility treatment oo Routine eye care (Adult) oo Chiropractic care (spinal manipulation) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends.The contact information for those agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272)or https://www.dol.00v/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit https://www.HealthCare.Qov or call 1-800-318-2596. If you are a Massachusetts resident, contact the Massachusetts Health Connector at https://www.mahealthconnector.orQ.. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your Ilan for a denial of a claim. This complaint is called a grievance or aLpeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim.Your Ilan documents also provide complete information to submit a claim, a2pe2l, or a grievance for any reason to your Ilan. For more information about your rights,this notice, or assistance, contact:Tufts Health Plan Member Services at 800-870-9488. Or you may write to us at Tufts Health Plan,Appeals and Grievances Department, 705 Mt.Auburn St., P.O. Box 9193,Watertown, MA 02471-9193 or contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA(3272)or https://www.dol.Qov/ebsa/healthreform .Additionally, a consumer assistance program can help you file your aLpeal. Contact: MA: Health Care for All, One Federal Street, Boston, MA 02110, 1-800-272-4232, https://www.massconsumerassistance.ora.. Does this Ilan provide Minimum Essential Coverage?Yes If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this Ilan meet the Minimum Value Standards?Yes If your Ilan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay fora Ilan through the Marketplace. 5 of 7 Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 800-870-9488. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800-870-9488. Chinese(IP 3r): PHTA5IP�COh9NJ, i0fttTTL"4W�800-870-9488. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800-870-9488. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this Ilan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing.amounts (deductibles, copavments and coinsurance) and excluded services under the Ilan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. - • is Having a : . • . • • Joe's type 2 Diabetes • - Fracture (9 months of in-network pre-natal care and a _W (a year of routine in-network care of a (in-network emergency room visit and follow 'V hospital delivery) well-controlled condition) care) ■ The Ip an's overall deductible $500 ■ The Ip an's overall deductible $500 ■ The Ip an's overall deductible $500 ■ Tier 1 Specialist copavment $30 ■ Tier 1 Specialist copavment $30 a Tier 1 Specialist copavment $30 ■ Tier 1 Hospital (facility) copavment $275 ■ Tier 1 Hospital (facility) copavment $275 ■ Tier 1 Hospital (facility) copavment $275 1 Plan coinsurance 0% ■ Plan coinsurance 0% 1 Plan coinsurance 0% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies) Childbirth/Delivery Professional Services education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $7,300 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $500 Deductibles $300 Deductibles $500 Copayments $200 Copayments $1,500 Copayments $300 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn't covered What isn't covered What isn't covered Limits or exclusions $0 Limits or exclusions $50 Limits or exclusions $0 The total Peg would pay is $800 The total Joe would pay is $1,960 The total Mia would pay is $800 The plan would be responsible for the other costs of these EXAMPLE covered services. 7of7 ADDENDUM DISCRIMINATION IS AGAINST THE LAW Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Tufts Health Plan: • Provides free aids and services to people with disabilities to communicate effectively with us,such as: - Written information in other formats(large print,audio,accessible electronic formats,other formats) • Provides free language services to people whose primary language is not English,such as: Qualified interpreters Information written in other languages If you need these services,contact Tufts Health Plan at 800-870-9488. If you believe that Tufts Health Plan has failed to provide these services or discriminated in another way on the basis of race,color,national origin,age,disability,or sex,you can file a grievance with: Tufts Health Plan,Attention: Civil Rights Coordinator Legal Dept. 705 Mt.Auburn St.Watertown, MA 02472 Phone:888-880-8699 ext.48000,[TTY number—800-439-2370 ext.711] Fax:617-972-9048, Email:OCRCoordinatoran..tufts-health.com You can file a grievance in person or by mail,fax,or email. If you need help filing a grievance,the Tufts Health Plan Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services,Office for Civil Rights,electronically through the Office for Civil Rights Complaint Portal,available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,or by mail or phone at: U.S.Department of Health and Human Services 200 Independence Avenue,SW Room 509F, HHH Building Washington, D.C.20201 800-368-1019,800-537-7697(TDD) Complaint forms are available at httr)://www.hhs.ciov/ocr/office/file/index.html For no cost translation in English, call the number on the top of page 1. Arabic 1J Chinese 17$��u�`7asb , French Pour demander une traduction gratuite en frangais, composez le numero indiqu6 en haut de la page 1. German Um eine kostenlose deutsche Ubersetzung zu erhalten, Men Sie bitte die Telefonnummer oben auf Seite 1 an. Greek FIG 6Wp£CIV P£T6(PpaGn OTa EAAnVIKq, KgAE6T£ TOV apiOp6 Trou Waypq(P£Tal 6TnV KOPU(Dn Tns CYEAftS 1. 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