Tufts University 2016 Health Plan Options Frequently Asked Questions Miscellaneous Questions What does coinsurance mean? Coinsurance is a percentage of the total bill. For example, if you use out‐of‐network services, you will be responsible for 20% of the total bill (the university will pay the remaining 80%) once the deductible is met. The 20% is based off of the Reasonable and Customary charges billed by a non‐contracting provider. For example, if you are enrolled in the Traditional Plan and you decide to see an out‐of‐network specialist in New York. In this example, assume the total cost of the visit is $700. If your deductible is $500, you will first be responsible for paying the deductible. After the $500 deductible is met, you will then be responsible for 20% of the remaining $200 left on the bill, which is $40. The university will pay $160. Therefore, your total cost for the specialist visit will be $540. What does “Out of Pocket Maximum” mean? The Out of Pocket Maximum is the maximum amount you will pay for your share of the cost of covered services during a calendar year, which includes medical and pharmacy copayments, deductible, and coinsurance. However, the out of pocket maximum does not include the payroll deductions (“premiums”) you pay. What is an Urgent Care Center? An urgent care center is a convenient cost‐effective option when someone's regular physician is on vacation or unable to offer a timely appointment. Or, when illness strikes outside of regular office hours, urgent care offers an alternative to waiting for hours in a hospital Emergency Room.. Urgent Care Centers are growing in numbers and are staffed by qualified doctors to treat conditions such as head colds, sore throats, stomach pain, fever, stomach pain, and ear infections. Urgent Care Centers are not appropriate for medical situations that are emergencies or that need to be treated in a hospital setting. Are Routine Eye Exams covered on my plan? Yes. All three plans provide coverage for one routine eye exam per calendar year with a contracting provider. To find out if your vision provider is contracting with Tufts Health Plan, please view the provider search on www.tuftshealthplan.com/tuftsuniversity. Do any of the plan options require referrals? No. None of the three plans require referrals. You are able to self‐refer to any in‐network provider to be covered at the in‐network level of benefits. Your plan will also cover you to see an out‐of‐network provider without a referral; however a higher member cost share will apply. Do copayments accrue towards the deductible? No. Copayments do not count towards the deductible. How long can my dependent child remain on my plan? Dependents can remain on your plan until they turn age 26 (unless your dependent is disabled). What does “Out of Network” mean? Out‐of‐Network refers to providers that are not contracting with Tufts Health Plan. For example, if you would like to see a specialist in New York, this would be considered out‐of‐network. There is a deductible and 20% coinsurance applied to out‐of‐network services. Please keep in mind that if you are traveling and in need of emergency care, you will be subject to your applicable Emergency Roomcopayment. Emergency services are not subject to the out‐of‐network deductible and coinsurance. What happens if I am traveling outside of Massachusetts and have a medical emergency? If you enroll in a Tufts University Health Plan, you have emergency coverage wherever you are, which is always processed with an in‐network copayment. Our intention is that you seek the closest care to you in the event of an emergency, so which provider you use should not be a deciding factor. Please note that you have emergency only health coverage if you are out of the United States for up to 90 days. If I live outside of Massachusetts, can I still enroll on one of the health plan options? Yes. If you live outside of the Tufts Health Plan service area (which includes all of Massachusetts, all of Rhode Island, and parts of Southern New Hampshire) you still can enroll on the new health plan options. If your providers are mostly in MA and RI, you have the option to enroll in all three plan options. If your providers are mostly outside of MA and RI, the Traditional or Value plan would be the best options for you. Please contact the Tufts University Human Resources Benefits Office for more information. Quality Tiered Plan Can I use providers on both Tier 1 and Tier 2? Yes. You may primarily use Tier 1 providers, but decide to see a Tier 2 specialist. You are covered to see any provider on Tier 1 or Tier 2 throughout the year, but you will pay a higher member cost share if you utilized Tier 2 providers. How often does Tufts Health Plan re‐tier providers? Tufts Health Plan will re‐tier providers once a year in January. The tiers are set for calendar year 2016 and are not subject to change until January 1, 2017. Am I responsible to pay towards the deductible for an office visit on Tier 2? No. The deductible only applies on Tier 2 for outpatient surgery, inpatient services, and high tech imaging. Will I pay a deductible if I use a Tier 1 provider? No. There is no deductible on Tier 1. What if my physician is on a different Tier than my hospital? The Quality Tiered Plan groups hospitals and physicians (PCPs, Specialists) at an organizational level. Your providers will fall under the same Tier as your hospital. Why are Massachusetts General Hospital and Brigham and Women’s Hospital on Tier 2? All of our providers in the network must meet the Tufts Health Plan minimum quality standards to even be in our network. For the Quality Tiered Plan, we then apply an additional quality threshold to all of our providers, using National Published Standard metrics, for example, from the Joint Commission, Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS)s, Health Effectiveness Data and Information Set measures (HEDIS), and the Massachusetts Health Quality Partners Patient Experience Survey (MHQP). Once a provider system is rated on quality, if it meets the quality threshold, the tier placement is then based on relative price and total medical expense. If the provider does not meet the cost threshold, then they are placed into Tier 2. Therefore, Mass General and Brigham and Women’s are on Tier 2 due to higher costs. Why can’t I find Tier 2 hospitals on the Quality Tiered Plan Hospital flyer? All Massachusetts and Rhode Island hospitals are included in the Tufts Health Plan network. If your hospital does not appear on the Quality Tiered Plan TU Preferred Hospital list, but it is in MA, this means that your hospital is on Tier 2. Pharmacy Can you find out the tier of a prescription drug in advance of going to the pharmacy? Yes. You can check to see how your prescription drug is covered at tuftshealthplan.com/tuftsuniversity, or by calling the Tufts University dedicated Member Services Queue at # 844‐516‐5790. What if my doctor writes a 90 day supply and I want to pick it up at the pharmacy (not through the mail order)? Is this allowed on my plan? Yes, you can fill a 90 day supply at a local pharmacy. You will be responsible for a 3 times the monthly copayment. Why doesn’t the Traditional Plan include the Value Based Pharmacy Program? The Traditional plan offers traditional benefits, and includes the standard pharmacy benefit. The Value Based Program is an innovative program designed for non‐standard plan designs, such as the Quality Tiered Plan and the Value Plan. Are insulin pumps covered through the Value Based Pharmacy benefit? No, insulin pumps are covered under the Medical benefits, not the Pharmacy benefit. Please contact the Tufts University dedicated Member Services Queue at # 844‐516‐5790 for more information. Why does my prescription drug require prior authorization? All health plans standardly use clinical edits for your safety. Tufts Health Plan uses a variety of approaches to manage the pharmacy benefit. Our goal is to balance quality, safety, and affordability so that you and your provider can make decisions for your care that are right for you.