MA BENEFIT COMPARISON PLAN OPTIONS FOR MA-SMGP-COMP-1216
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1 MA BENEFIT COMPARISON PLAN OPTIONS FOR -MA-SMGP-COMP-1216
2 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Copay Plans HMO Value Platinum - $0/$0 0/ $ CIF 0 $200 $40 $70 HMO Basic Platinum - $0/$0 / CIF 0 0 $200 $20 $40 $60 $125 HMO uctible Plans 500 Gold - 0/ 5 5 $65 $ Gold - / $6800/ $ $60 $ Gold - 0/ 0 $6500/ $60 $ Gold - 00/ $ Silver - 0/ 00 $35 $60 $60 $ Silver - 0/ $35 $65 $65 $35 0 $35 1 All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room * Max is the maximum amount of coinsurance a member would pay per fill for drugs.
3 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO urance / Low Option Plans 2000 (8) Silver - $35 $65 $65 $ (65%) Silver - $35 $65 $65 $35 $ Low Option Silver - 1 / $ Low Option Silver - 1 0/ 0 : / 0 / $12000 $35 $60 $60 $ $ Low Option Silver - 1 $6500/ $35 $65 $65 $ HMO HSA-Compliant Plans Saver 1500 Gold - 0/ 0 00/ 0 0 $60 $80 Saver 2000 Silver - $6550/ $20 $40 $40 $20 $10 Saver 2500 Silver - 0/ 00 $6550/ Saver 3000 Silver - ** 0/ $6550/ 1 All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room * Max is the maximum amount of coinsurance a member would pay per fill for drugs. ** Plan features embedded family deductible.
4 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Tiered Plans Your Choice HMO 2-Tier Option 8 Gold / 0 / $200 $ $20 $80 Your Choice HMO 2-Tier Option 9 Gold / 5 / $12000 / 5 5 $450 $20 $80 Your Choice HMO 3-Tier Option 9 Gold / 0 5 $ / $35 $ CIF $20 $60 $90 Your Choice HMO 3-Tier Option 10 Gold 0/ 5 $200 0 / $35 $ CIF $20 5 $80 All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room * Max is the maximum amount of coinsurance a member would pay per fill for drugs.
5 Massachusetts Small Group Plan Design Comparison uctible Medical// / Health Connector Plans Premier Platinum - $0/$0 0/ $40 $40 $40 CIF CIF 0 0 CIF $15 Premier Gold / 00/ 0 $45 $45 $45 $20 $20 $200 0 $20 Premier Silver $700 $20 $60 $90 Premier Bronze Saver $3300/ $6600 $6550/ $40 $65 $65 $65 $35 All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room * Max is the maximum amount of coinsurance a member would pay per fill for drugs.
6 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Select Plans HMO 500 Gold - HMO 1000 Gold - HMO 1500 Gold - HMO 2000 Gold - HMO 2000 (8) Silver - (NEW) HMO 2500 Silver - (NEW) HMO Steward Plans Steward Community Choice 1000 Gold - Steward Community Choice 1500 Gold - Steward Community Choice 2000 Gold - 0/ / 0/ 0 0/ 00 / 0/ 0 $6800/ $13600 $6500/ 00/ 0 $6800/ $13600 $6500/ 00/ $35 $65 $65 $35 $35 $60 $60 $ $65 $90 $60 $80 $60 $80 5 $80 1 $60 $80 $60 $80 5 $80 All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room Select Network plans have a limited provider network and limited service area that excludes Berkshire, Dukes and Nantucket counties. Steward Community Choice plans utilize a limited provider network. * Max is the maximum amount of coinsurance a member would pay per fill for drugs.
7 Massachusetts Small Group Plan Design Comparison uctible Medical// / PPO Copay Plans IN-NETWORK PPO Value Platinum - $0/$0 0/ $7000 CIF 0 $200 $40 $70 PPO Basic Platinum - $0/$0 / / $16000 CIF 0 0 $200 $20 $40 $60 $125 PPO uctible Plans IN-NETWORK 500 Gold - 0/ / $28000 $35 $35 $35 $35 $65 $ Gold Gold Gold Silver Silver - / 0/ 0 0/ / 0/ 00 00/ 0 0/ / $12000 $6800/ $13600 $13600/ $27200 $6500/ / $ / 0 0/ 0 / $28600 / $28600 $35 $35 $35 $35 $35 $35 $35 $35 Please see a Summary of Benefits and Coverage for more information or refer to your Benefit Document for complete information. All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room * Max is the maximum amount of coinsurance a member would pay per fill for drugs. $35 $35 $35 $35 $45 $45 $45 $ $60 $80 $60 $80 $80 1 $35 1
8 Massachusetts Small Group Plan Design Comparison uctible Medical// / PPO urance Plans IN-NETWORK 2000 (8) Silver - 4 / / $7000 / / $28000 $35 $35 $35 $ (65%) Silver - 5 / / $28000 $45 $45 $45 $45 $35 PPO HSA-Compliant Plans IN-NETWORK Saver 1500 Gold - 0/ 0 0/ 00/ 0 0/ 0 0 $60 $80 Saver 2000 Silver - / $6550/ / $26200 $10 Saver 2500 Silver - 0/ 00 00/ 0 $6550/ / $26200 Saver 3000 Silver - ** 0/ / $12000 $6550/ / $ Saver 4500 Bronze - ** 45% $4500/ $9000 $9000/ $18000 $6550/ / $ $35 $110 All plans meet Minimum Credible Coverage (MCC) standards. CIF = Covered In Full, = Primary Physician, = Emergency Room * Max is the maximum amount of coinsurance a member would pay per fill for drugs. ** Plan features embedded family deductible.
9 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 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 Mount Auburn St. Watertown, MA Phone: ext , [TTY number or 711] Fax: OCRCoordinator@tufts-health.com You can file a grievance in person or by mail, fax, or . 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 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 , (TDD) Complaint forms are available at ocr/office/file/index.html. -MA-SMGP-COMP Mt Auburn Street - Watertown, MA tuftshealthplan.com
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Any missing information may cause a delay in processing your request.
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