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Medical - PHCS

How Your Medical Plan Works

The PHCS Network Plan covers a wide range of medical services and procedures, including:

  • inpatient hospital care;
  • doctor’s office visits;
  • outpatient care;
  • maternity care;
  • prescription drugs; and
  • other services and procedures.

As a PHCS Network Plan participant, you also have the option of using in-network or out-of-network providers. Using an in-network provider can save you money each time you use the plan.

See the Covered Medical Expenses section for a more complete description of:

  • covered medical services and procedures; and
  • your costs for in-network and out-of-network care.

The PHCS Network Plan meets Massachusetts Minimum Creditable Coverage standards and will satisfy the Massachusetts individual mandate to have health insurance. Please see page (i) of your PHCS Network Plan’s Description of Benefits booklet for additional information.

 

COST TO YOU
You pay the cost of your medical plan coverage through before-tax payroll deduction contributions. The payroll deduction cost to you will depend on the plan, level of coverage you choose, and your annual salary (contact the Human Resources Department for more details).

PRE-EXISTING CONDITION
The PHCS Network Plan does not have a “pre-existing condition” exclusion.

WOMEN'S HEALTH AND CANCER RIGHTS
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

  • all stages of reconstruction of the breast on which the mastectomy was performed;
  • surgery and reconstruction of the other breast, to produce a symmetrical appearance;
  • prosthesis; and
  • treatment of physical complications of all stages of mastectomy, including lymphedema.

Prior authorization is NOT required for these services, unlike other reconstructive services.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the medical plan(s).

DESCRIPTION OF BENEFITS
A more extensive description of the PHCS Network Plan’s covered medical expenses and associated plan payments can be found in the PHCS Network Plan’s Description of Benefits and Summary of Benefits documents. You should carefully read these documents and keep them for future reference.

You can obtain the above documents by contacting a Member Specialist at 1-800-462-0224, ext. 3585 or the Human Resources Department, ext. 2222. TDD: If you have access to a TDD phone, call 1-800-868-5850 to reach the Tufts Health Plan Member Services Department.

OVERVIEW OF PLAN OPERATION
The PHCS Network Plan is a Preferred Provider Organization (PPO). The key features of this plan include:

  • your choice of in-network and out-of-network care;
  • no Primary Care Physician or referral requirement; and
  • emergency care coverage at the in-network level.

You can choose any doctor you want when you use the PHCS Network Plan. However, it will be to your advantage to use network providers whenever possible.

See the Covered Medical Expenses section for a more complete description of:

  • covered medical services and procedures; and
  • your costs for in-network and out-of-network care.

 

NETWORK CARE
As a PHCS Network Plan participant, you have access to Tufts Health Plan’s extensive network of participating health care providers. Using network providers can save you time and money each time you use the plan, because:

  • network providers charge discounted fees for their services, so your out-of-pocket costs are generally lower (compared to out-of-network care);
  • benefits for many network services are paid in full after you pay the deductible or a copayment;
  • there are no claim forms to fill out; and
  • the plan pays participating providers directly, so you do not have to pay the provider’s fee and then wait for a reimbursement check.

You can obtain a list of participating PHCS Network Plan providers at www.tuftshealthplan.com or by contacting Member Services at 1-800-423-8080, ext. 3585. TDD: If you have access to a TDD phone, call 1-800-868-5850 to reach the Tufts Health Plan Member Services Department.

OUT-OF-NETWORK CARE
Your out-of-pocket costs will generally be higher if you use an out-of-network provider (i.e., a provider that does not participate in the PHCS Plan’s provider network). If you use an out-of-network provider:

  • you must pay the provider’s fee directly;
  • benefits for most covered out-of-network services provided within the 50 United States are paid at 80% of covered expenses after the annual deductible (except for emergency room services, which are covered at the in-network level); 
  • outside of the 50 United States, you are only covered for emergency care, or for urgent care while traveling (for these services, Members are covered at the In-Network Level);
  • you must complete a claim form and submit your claim to the Claim Administrator (see Filing Your Claim); and
  • you will only be reimbursed for the amount covered by the plan. You pay any difference between what the PHCS Plan paid and what the provider charged for the services.

Maximum Out-of-Network Benefit
The maximum benefit that the plan will pay for an out-of-network provider service is the "Reasonable Charge" for that service. You are responsible for paying any expenses in excess of the "Reasonable Charge."

A “Reasonable Charge” is the lesser of:

  • the amount charged by the Non-Network Provider; or
  • the amount that the Tufts Health Plan determines to be reasonable, based upon nationally accepted means and amounts of claims payment. Nationally accepted means and amounts of claims payment include, but are not limited to: Medicare fee schedules and allowed amounts, CMS medical coding policies, AMA CPT coding guidelines, and nationally recognized academy and society coding and clinical guidelines.

You can call a Member Specialist at 1-800-423-8080, ext. 3585 if you have any questions or need assistance concerning the plan provisions for out-of-network care. TDD: If you have access to a TDD phone, call 1-800-868-5850 to reach the Tufts Health Plan Member Services Department.


ANNUAL OUT-OF-NETWORK DEDUCTIBLE
Under the PHCS Network Plan, the annual deductible is the amount you pay for covered out-of-network expenses before the plan starts to pay for these expenses.

The out-of-network annual deductible applies only once during the calendar year. The amount of the PHCS Network Plan’s out-of-network annual deductible is $250 per person, with a family maximum of $500 per year.

Note: Any amount paid by you for a covered service received during the last 3 months of a calendar year will be credited toward the next calendar year’s deductible.

Family Out-of-Network Deductible
All amounts that covered family members pay towards their individual deductibles in a given calendar year will count towards the $500 family deductible. For example, assume that you have the following covered out-of-network expenses in a calendar year:

  • you: $200
  • your spouse: $175
  • your child: $125

In the above example, the $500 family deductible would be satisfied, and the PHCS Network Plan will start paying benefits for covered out-of-network services for the rest of the calendar year.

Deductible Exclusions
The following charges do not count towards the out-of-network annual deductible:

  • emergency care copayments;
  • any amount paid for prescription drugs
  • preregistration penalties;
  • any amount paid for covered services received at the in-network level of benefits; and
  • any amount paid for services, supplies, or medications that are not covered by the plan.

You can contact a Member Specialist at 1-800-462-0224, ext. 3585 for additional information concerning the application of the individual and family out-of-network deductibles for the PHCS Network Plan. TDD: If you have access to a TDD phone, call 1-800-868-5850 to reach the Tufts Health Plan Member Services Department.

ANNUAL OUT-OF-POCKET MAXIMUM
The PHCS Network Plan places an annual limit on your out-of-pocket expenses for services received at the out-of-network level. This is called your out-of-pocket maximum. Once you reach this limit in a given calendar year, the plan will pay 100% of your covered out-of-network expenses for the rest of that year.

The PHCS Network Plan’s annual out-of-pocket maximum is $500 per person, with a family maximum of $1,000 each calendar year.

Exceptions: Certain expenses do not count towards the annual out-of-pocket maximum. These expenses include:

  • expenses that exceed the Reasonable Charge for an out-of-network service; and
  • other expenses that are listed in the Out-of-Pocket Maximum Exclusions section (see below).

Family Out-of-Pocket Maximum
All amounts that covered family members pay towards their individual out-of-pocket maximums in a given calendar year will count towards the $1,000 family out-of-pocket maximum. For example, assume that your out-of-pocket expenses for covered out-of-network services are the following in a calendar year:

  • you: $450
  • your spouse: $400
  • your child: $150

In the above example, the $1,000 family out-of-pocket maximum would be satisfied.

Note: Once you have met your Out-of-Pocket Maximum in a calendar year, you continue to pay for any costs in excess of the Reasonable Charge for Out-of-Network services.

Out-of-Pocket Maximum Exclusions
The following charges do not count towards the annual out-of-pocket maximum:

  • emergency care copayments;
  • any amount paid for prescription drugs
  • preregistration penalties;
  • costs above the Reasonable Charge;
  • any amount paid for covered services received at the in-network level of benefits; and
  • any amount paid for services, supplies, or medications that are not covered by the plan.

You can contact a Member Specialist at 1-800-462-0224, ext. 3585 for additional information concerning the application of the individual and family out-of-pocket maximums for the PHCS Network Plan. TDD: If you have access to a TDD phone, call 1-800-868-5850 to reach the Tufts Health Plan Member Services Department.

CLAIM FILING
You must file a claim form to receive reimbursement for an out-of-network claim. The plan’s claim filing procedures are described under Filing Your Claim.