Compare 2021 Medicare Health Plans
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Medicare Plans
Massachusetts
Suffolk County
Medicare Plans
Massachusetts
Suffolk County
Saturday, September 18, 2021
Tufts Medicare Preferred HMO Prime (HMO)
(H2256-016)
by Tufts Health Plan Medicare Preferred - Suffolk County, MA
Contact Information
Tufts Associated Hmo Inc.
705 Mt Auburn Street
Watertown, MA 02472
Phone: 1-800-701-9000
Toll free: 1-800-701-9000
Website
http://tuftsmedicarepreferred.org
Pharmacy
http://tuftsmedicarepreferred.org/druglist.php
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Plan details
| Plan Rating | 4.5 out of 5 stars |
| Premium and Other Important Information | $102.00 monthly plan premium in addition to your monthly Medicare Part B premium. |
| $112.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |
| $126.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |
| $54.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |
| $82.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |
| Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |
| $3 400 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |
| Doctor and Hospital Choice | You must go to network doctors specialists and hospitals. |
| Referral required for network specialists (for certain benefits). | |
| Inpatient Hospital Care | No limit to the number of days covered by the plan each hospital stay. |
| $300 annual deductible | |
| $0 copay | |
| $300 out-of-pocket limit every year. | |
| Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |
| Inpatient Mental Health Care | $0 copay |
| You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |
| Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |
| Skilled Nursing Facility (SNF) | Authorization rules may apply. |
| Plan covers up to 100 days each benefit period | |
| No prior hospital stay is required. | |
| $0 copay for SNF services | |
| Home Health Care | Authorization rules may apply. |
| $0 copay for Medicare-covered home health visits | |
| Hospice | You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
| Doctor Office Visits | $10 copay for each primary care doctor visit for Medicare-covered benefits. |
| $10 to $15 copay for each in-area network urgent care Medicare-covered visit | |
| $15 copay for each specialist visit for Medicare-covered benefits. | |
| Chiropractic Services | $15 copay for each Medicare-covered visit |
| Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |
| Podiatry Services | $15 copay for each Medicare-covered visit |
| Medicare-covered podiatry benefits are for medically-necessary foot care. | |
| Outpatient Mental Health Care | Authorization rules may apply. |
| $15 copay for each Medicare-covered individual therapy visit | |
| $15 copay for each Medicare-covered group therapy visit | |
| $15 copay for each Medicare-covered individual therapy visit with a psychiatrist | |
| $15 copay for each Medicare-covered group therapy visit with a psychiatrist | |
| $0 copay for Medicare-covered partial hospitalization program services | |
| Outpatient Substance Abuse Care | $15 copay for Medicare-covered individual visits |
| $15 copay for Medicare-covered group visits | |
| Outpatient Services/Surgery | Authorization rules may apply. |
| $50 copay for each Medicare-covered ambulatory surgical center visit | |
| $50 copay for each Medicare-covered outpatient hospital facility visit | |
| Ambulance Services | $50 copay for Medicare-covered ambulance benefits. |
| Emergency Care | $65 copay for Medicare-covered emergency room visits |
| Worldwide coverage. | |
| If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. | |
| Urgently Needed Care | $10 to $15 copay for Medicare-covered urgently-needed-care visits |
| Outpatient Rehabilitation Services | $15 copay for Medicare-covered Occupational Therapy visits |
| $15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits | |
| Durable Medical Equipment | Authorization rules may apply. |
| $0 copay for Medicare-covered items | |
| Prosthetic Devices | Authorization rules may apply. |
| $0 copay for Medicare-covered items | |
| Diabetes Programs and Supplies | Authorization rules may apply. |
| $0 copay for Diabetes self-management training | |
| $0 copay for: | |
| If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $10 to $15 may apply | |
| Diagnostic Tests X-Rays Lab Services and Radiology Services | Authorization rules may apply. |
| $0 copay for Medicare-covered: | |
| Cardiac and Pulmonary Rehabilitation Services | Authorization rules may apply. |
| $0 copay for: | |
| Preventive Services and Wellness/Education Programs | $0 copay for all preventive services covered under Original Medicare at zero cost sharing: |
| HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. | |
| The plan covers the following supplemental education/wellness programs: | |
| Kidney Disease and Conditions | $0 copay for renal dialysis |
| $0 copay for kidney disease education services | |
| Outpatient Prescription Drugs | Most drugs not covered. |
| $0 copay for Part B-covered drugs. | |
| This plan does not offer prescription drug coverage. | |
| Dental Services | In general preventive dental benefits (such as cleaning) not covered. |
| $15 copay for Medicare-covered dental benefits | |
| Hearing Services | Hearing aids not covered. |
| Vision Services | $0 copay for |
| $150 plan coverage limit for eye wear every year. | |
| Over-the-Counter Items | The plan does not cover Over-the-Counter items. |
| Transportation | This plan does not cover supplemental routine transportation. |
| Acupuncture | This plan does not cover Acupuncture. |
| Premium and Other Important Information | In 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140. |
| If a doctor or supplier does not accept assignment their costs are often higher which means you pay more. | |
| Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |
| Doctor and Hospital Choice | You may go to any doctor specialist or hospital that accepts Medicare. |
| Inpatient Hospital Care | In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day |
| Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. | |
| Lifetime reserve days can only be used once. | |
| "A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have." | |
| Inpatient Mental Health Care | In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day |
| You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |
| Skilled Nursing Facility (SNF) | In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $144.50 per day |
| 100 days for each benefit period. | |
| "A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have." | |
| Home Health Care | $0 copay. |
| Hospice | You pay part of the cost for outpatient drugs and inpatient respite care. |
| You must get care from a Medicare-certified hospice. | |
| Doctor Office Visits | 20% coinsurance |
| Chiropractic Services | Supplemental routine care not covered |
| 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |
| Podiatry Services | Supplemental routine care not covered. |
| 20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs. | |
| Outpatient Mental Health Care | 40% coinsurance for most outpatient mental health services |
| Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. | |
| """Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization." | |
| Outpatient Substance Abuse Care | 20% coinsurance |
| Outpatient Services/Surgery | 20% coinsurance for the doctor's services |
| Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible. | |
| 20% coinsurance for ambulatory surgical center facility services | |
| Ambulance Services | 20% coinsurance |
| Emergency Care | 20% coinsurance for the doctor's services |
| Specified copayment for outpatient hospital facility emergency services. | |
| Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. | |
| You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. | |
| Not covered outside the U.S. except under limited circumstances. | |
| Urgently Needed Care | 20% coinsurance or a set copay |
| NOT covered outside the U.S. except under limited circumstances. | |
| Outpatient Rehabilitation Services | 20% coinsurance |
| Durable Medical Equipment | 20% coinsurance |
| Prosthetic Devices | 20% coinsurance |
| Diabetes Programs and Supplies | 20% coinsurance for diabetes self-management training |
| 20% coinsurance for diabetes supplies | |
| 20% coinsurance for diabetic therapeutic shoes or inserts | |
| Diagnostic Tests X-Rays Lab Services and Radiology Services | 20% coinsurance for diagnostic tests and x-rays |
| $0 copay for Medicare-covered lab services | |
| Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol. | |
| Cardiac and Pulmonary Rehabilitation Services | 20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services |
| This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments. | |
| Preventive Services and Wellness/Education Programs | No coinsurance copayment or deductible for the following: |
| Kidney Disease and Conditions | 20% coinsurance for renal dialysis |
| 20% coinsurance for kidney disease education services | |
| Outpatient Prescription Drugs | Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. |
| Dental Services | Preventive dental services (such as cleaning) not covered. |
| Hearing Services | Supplemental routine hearing exams and hearing aids not covered. |
| 20% coinsurance for diagnostic hearing exams. | |
| Vision Services | 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. |
| Supplemental routine eye exams and glasses not covered. | |
| Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. | |
| Annual glaucoma screenings covered for people at risk. | |
| Over-the-Counter Items | Not covered. |
| Transportation | Not covered. |
| Acupuncture | Not covered. |
| Point of Service | You may go to any doctor specialist or hospital that accepts Medicare. |
Medicare Terms
- • Co-payment
- An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.
- • Cost Plans
- A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan's network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).
- • Deductible
- The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
- • HMO - Health Maintenance Organization
- Local HMOs are plans with defined networks of providers, which beneficiaries must use in order to receive coverage, serving specific geographic areas consisting of aggregations of counties.
- • HMO SNP - Special Needs Plan
- Medicare Special Needs Plans are a type of Medicare Advantage Plan (Part C) for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions). Medicare SNPs provide their members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D). Medicare SNPs were created to give certain groups of people better access to Medicare with plans designed to meet their unique needs.
- • HMO with POS Option
- An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.
- • LPPO - Local Preferred Provider Organization
- Local PPOs are network based plans that serve specific geographic areas consisting of aggregations of counties, like HMOs, but with more flexibility in provider choice within the network. Beneficiaries may use providers outside the network but will pay more out of pocket cost.
Related Links
- Medicare.gov
The official U.S. Government site for Medicare - AARP
American Association of Retired Persons - HHS.gov
United States Department of Health & Human Services - CMS.gov
Centers for Medicare & Medicaid Services - Social Security Administration
The official website of the U.S. Social Security Administration
Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or prescription drug coverage costs. For more information, visit socialsecurity.gov, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.
If you have questions about Medicare, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
