RCAB Health Plan Information - Boston Catholic Benefits Connection

On behalf of all of us here at Tufts Health Plan, we’d like to say
thank you. Thank you for caring enough about your health to
want to learn more.
That desire to learn more is especially valuable in this rapidly
changing healthcare environment. The people who make the
effort to learn more and to take an active role in their healthcare
are the ones who will benefit the most. They won’t be surprised
by unexpected out-of-pocket costs, and they will know exactly
how to be able to use the doctor and hospital they want to use.
At Tufts Health Plan, we’re doing our part, too, by working to
create health plan options that employers can afford to offer
their employees. Plans just like the one you’ll read about
momentarily. Remember, as you work to understand your plan’s
benefits and options, you’re not alone. We’ll be here to answer
any questions you might have, and to help you get the health
care that’s right for you.
Tom Croswell,
President and CEO, Tufts Health Plan
TUFTS
Health Plan
TUFTS HEALTH PLAN
MEMBER DISCOUNTS
Member Discounts Help You Save on Products and Services That Promote Good Health
Tufts Health Plan will help you reach your wellness goals with discounts on nutrition, mind and body,
fitness, and other services related to good health through the following providers and vendors.*
HEALTHY EATING
WEIGHT MANAGEMENT
Counseling
Jenny Craig®
You can receive 25% off the cost of visits with a registered
dietitian or licensed nutritionist participating in our network
when you do not have a medical doctor’s referral. To find
a dietitian or nutritionist, visit tuftshealthplan.com and click
Find a Doctor, choose your plan and submit, then search
under Other Services. With a medical doctor’s referral,
nutritional counseling is a covered benefit with zero co-pay
with participating providers.
When you’re ready to lose weight, Jenny Craig makes it
simple. With Jenny Craig, you don’t have to count, track or
worry over every meal. Jenny Craig gives you everything
you need to succeed. A day on Jenny Craig includes highly
personal one-on-one support plus breakfast, lunch, dinner,
snacks and desserts.
Supplements
Save up to 40% on a wide variety of vitamins,
supplements, and popular energy and protein bars through
ChooseHealthy.com. Standard shipping is also free for
members.
MIND AND BODY
Acupuncture and Massage
Save 25% on acupuncture treatments and massage therapy.
To find a participating provider, go to tuftshealthplan.com
and click Find a Doctor, choose your plan and submit, then
search under Other Services.
Natural Therapies
Save up to 40% on aromatherapy, homeopathic remedies,
and other natural remedies. To learn more, go to
ChooseHealthy.com.
Brain Fitness
Members can receive 17% off the price of a subscription
to BrainHQ™, an online cognitive training program. This
program offers brain exercises that can help people
improve memory, attention, social connection, and more.
The Original Healing Threads™
You and your plan dependents are eligible to receive 20%
off The Original Healing Threads collection of tops and
breakaway pants made of soft machine wash and dry
polyester micro-fiber, treated to allow liquids to just roll
off the fabric. Shop online for The Original Healing Threads
designer wear at healingthreads.com and choose from a
variety of colors and sizes ranging from XS to 3X.
To receive your 20% member discount, enter “Tufts” in the
“Enter Promotional Code” box located in the Shopping Bag
section during check-out.
tuftshealthplan.com | 800.462.0224
}5
0% off Jenny Craig All Access enrollment, plus 5% off All
Jenny Craig Food*
} Visit jennycraig.com/orgcode=THP to receive online
discounts.
*50% discount on $99 Enrollment fee. Enrollment and monthly fees of $19 required. Plus the
cost of food. Plus the cost of shipping if applicable. Member is responsible for all payments for
the Jenny Craig Program. Active program enrollment and program eligibility status required.
Upon request, must provide proof of eligibility for participation in organization’s wellness
program that is registered with Jenny Craig. Food Discount not applicable to shipping cost
and only valid for personal consumption. Non-transferable. No cash value. Not valid with any
other offer or discounts. Only available at participating locations and Jenny Craig Anywhere.
Not valid at jennycraig.com. Restrictions apply. Offer expires 12/31/2016. Jenny Craig® is a
registered trademark. Used under license.
Nutrisystem®
Tufts Health Plan members receive the following discounts/
benefits from Nutrisystem:
} 12% off every 28-Day Nutrisystem My Way® program
order. My Way is a metabolism and lifestyle based weight
loss program.
} A free Fast 5™ kit.* Fast 5 is designed to help you
lose 5 pounds in your first week—or your money back
guaranteed.** It offers:
— A
bonus week of specially selected breakfasts, lunches,
and dinners
—
7 EnergiZING™ shakes to promote metabolism
—
7 Craving Crusher™ shakes to curb cravings
— A 7-day meal plan to promote weight loss
To get started, call Nutrisystem at 888.377.1441 and identify
yourself as a Tufts Health Plan member, or nutrisystem.
com/tuftshealthplan.
* Free Fast 5 kit available with new 28-Day Auto Delivery program purchase only. Not valid
with Nutrisystem D program. Included with first order only. With Auto-Delivery you receive a
discount off the Full Retail Value and free shipping to Continental US only. With Auto-Delivery,
you are automatically charged and shipped your 28-Day program once every 4 weeks unless
you cancel. You can cancel Auto-Delivery at any time by calling 877.338.8446. The Nutrisystem
Select program is available to Continental US residents only and cannot be shipped to PO
Boxes, APO Boxes or military addresses. Cannot be combined with any prior or current
discount or offer. Limit one offer per customer.
** Results vary depending on starting weight, adherence to the program and other factors. If
you’re not 100% satisfied, call to cancel within 14 days and return the remaining non-frozen
food to us for a full refund. Nutrisystem will cover return shipping. Guarantee good on new
28-Day plans, first order only. Limit one Guarantee per customer.
MORE WAYS TO SAVE
MEMBER-DISCOUNTS-01/16
iDiet®
Home Instead Senior Care®
This easy-to-follow program helps retrain your brain to
crave healthy foods that support weight loss while keeping
you full and satisfied.
Receive a $100 one-time credit toward home care support
services when you show your Tufts Health Plan ID card.
These include help preparing meals, light housekeeping, and
other nonmedical home care services. A free home-safety
inspection is also provided once you contract for home
care services. This includes a review of the home entrance,
kitchen, bathrooms, and more. This benefit is available to
eligible family members of Tufts Health Plan members.
Save 15% on the iDiet program ($45 savings) for enrolling
in the Engage (entry level) or Advance (experienced dieter)
programs.
Visit myidiet.com/hi/tuftshealth/ to learn more.
FITNESS CENTERS
}S
ave 20% on annual memberships and pay no fee for
joining at Tufts Health Plan network fitness centers in
Massachusetts, New Hampshire, and Rhode Island. The
network includes almost 80 health and fitness centers.
} Save 50% off the joining fee when you join a participating
New England Curves® club.
} Save 10% on a personal training package at Fitness
Together and receive a free fitness evaluation.
} Save 20% on an Appalachian Mountain Club membership
and receive discounts on lodging, subscriptions, and
programs.
} Members 18 years old and younger pay no fee to join
network Boys & Girls Clubs in Massachusetts and Rhode
Island. Members also receive a 20% discount on the cost
of most programs.
If you’re not ready to join a fitness center, you and your
family can go to a fitness center in the Tufts Health Plan
network and pay a small copayment of $6-$10 for each visit,
up to five times a month.
For a full list of fitness centers in the Tufts Health Plan
network, go to tuftshealthplan.com and click Find a Doctor,
choose your plan and submit, then search under Other
Services.
Mindfulness and Stress Management
Experience how training in mindfulness and meditation
can help you achieve greater energy and enthusiasm
for life. Attend the 8 week Mindfulness-Based Stress
Reduction program at the UMass Medical School’s Center
for Mindfulness in Shrewsbury, MA and receive 15% off the
cost of tuition. Participants have found an increased ability
to relax, reductions in pain levels and an enhanced ability to
cope with pain that may not go away, enhanced ability to
cope with stressful situations, and improved self-confidence.
For more information, call the Center at 508-856-2656 or
visit umassmed.edu/cfm/stress-reduction/tufts-healthplan/.
CVS Caremark ExtraCare® Health Card
You and your family can save when you use the CVS/
caremark ExtraCare Health Card. With the CVS/caremark
ExtraCare Health Card, you, your spouse, and your
dependents receive 20 percent* off regular-priced CVS/
pharmacy Brand,** health-related items valued at $1 or
more. The ExtraCare Health Card can be used at CVS/
pharmacy stores nationwide.
*The 20 percent discount is restricted to items purchased for the health care of the cardholder, spouse
or dependents and applies to regularly priced CVS/pharmacy Brand health-related items valued at $1 or
more. Excludes alcohol, lottery, money orders, prescriptions and copays, postage stamps, pre-paid cards,
gift cards, newspapers and magazines, milk, sale/promotional merchandise, bottle deposits, bus passes,
hunting and fishing licenses, and are not valid on other items reimbursed by a governmental program.
Plan restrictions may apply. Check with your plan administrator for more details.
**All CVS/pharmacy Brand products are 100% satisfaction guaranteed or your money back. If you’re
dissatisfied for any reason, you can return the CVS/pharmacy Brand product (opened or unopened)
MORE SAVINGS
along with your receipt or invoice to any CVS/pharmacy store. We’ll refund the full purchase price — no
questions asked! To return the item by mail, call Customer Care at 888.607.4CVS (888.607.4287).
©2015 CVS/caremark. All rights reserved.
Discounts on Glasses and Contacts
With the EyeMed Vision Care program, you can receive
35% off the price of frames, along with discounts on lenses
and lens options, when you buy a pair of eyeglasses from
an EyeMed network provider. EyeMed Vision Care also
offers a replacement contact lens program, 20% off the
price of nonprescription sunglasses, and 5%-15% off the
cost of LASIK and PRK laser vision correction. To find an
eye care provider in the EyeMed Vision Care network, go to
tuftshealthplan.com and click Find a Doctor, choose your
plan and submit, then search under Vision Care.
*This information has been provided by the vendors below and has not been independently confirmed by Tufts Health Plan. Check with your health care provider regarding any health or medical condition before beginning any new treatment, exercise, or nutrition regimen.
EYE CARE BENEFITS
DISCOUNTS ON GLASSES & CONTACTS
Tufts Health Plan offers coverage for routine eye exams and other
vision services through the EyeMed Vision Care network. EyeMed
offers you the freedom to choose your care from a list of more
than 24,000 eye care providers and these well-known retail stores:
most locations
Routine Eye and Vision Care Services
} To receive the highest level of coverage
Eye Care Providers
for routine eye exams and other vision care
services, you must visit an optometrist or
ophthalmologist in the EyeMed network.
} To find an eye care provider in the EyeMed
network or to find out if your eye doctor is in
the network, go to tuftshealthplan.com and
click on Find a Doctor.
} Optometrist (O.D.): a licensed eye care provider
Discounts on Glasses and Contacts
As a Tufts Health Plan member, you will receive
these discounts from eye care providers in the
EyeMed network.
who performs eye exams and other eye care
services, and prescribes glasses, contacts, and
other vision aids.
} Ophthalmologist (M.D.): an eye doctor who
performs eye exams, treats eye disease, conducts
surgery, and prescribes glasses, contacts, and
other vision aids.
} Optician: an eye care provider who reads vision
prescriptions and helps you choose the glasses,
contact lenses, and other eye aids that are right
for you.
} Save 35% on the price of frames and get
discount prices on lenses when you buy a
pair of glasses. Discounts may not apply to
some frames. Prices may vary by retail store.
} Save 20% on the price of nonprescription
sunglasses.
} Save 5%-15% on the price of LASIK and PRK
laser vision correction. For a location near
you and approval for the discount, please call
877-5LASER6.
} To order contact lenses for less than the
retail price and have them shipped to your
home or office, visit eyemedcontacts.com.
The cost of a contact lens evaluation and
fitting is not covered by your eye care
benefit, so members need to pay for these
services themselves.
tuftshealthplan.com | 800.462.0224
LEARN MORE
EYE-CARE-BENEFITS-01/16
Your Eye Care Benefit
Know Your Benefits
Your eye care benefit covers routine eye exams.
Routine eye exams may include some or all of the
following services.
Providers within the EyeMed network are able
to meet your routine eye care and certain
medical optometry needs. If you need to see
an ophthalmologist to treat or monitor an eye
disease or condition, be sure to confirm that the
ophthalmologist is in the Tufts Health Plan network.
If your plan requires a referral for specialty care, you
will need to get one from your PCP.
} A review of the history of your eyes and vision,
along with a general health history and a review of
medicines you are taking
} A discussion of any vision problems you may have
and the reasons for your visit
} An exam of the inside and outside of your eyes
and of the areas around your eyes
} A measure of the pressure in your eyes
} Dilation to make your pupils larger so that your
eye care provider can see and check the entire
inside of your eye
} A measure of how well you see close up and at a
distance
} A test of your vision to see if you need prescription
glasses and whether or not you can use contact
lenses
} A treatment plan, follow-up eye exams, and eye
health advice
To learn more about your eye and vision care
benefit, log in at mytuftshealthplan.com, your secure
online account, or call the EyeMed Vision Care
Network at 866.504.5908.
NURSE ADVICE LINE
Reliable health information is a phone call
away­— just call the toll-free number!
1.866.855.0183
Available
24 hours a day,
7 days a week.
For more information on the
Roman Catholic Archdiocese of
Boston Benefit Trusts, please visit:
www.bostoncatholicbenefits.org
UTILIZATION
MANAGEMENT
To help you receive quality health care in an
appropriate treatment setting, we provide utilization
management (UM).
We use up-to-date medical standards and medical
necessity guidelines for making coverage decisions
about medically needed services through our UM
activities. Standards and guidelines are updated each
year—or more often—as new treatments, new uses
for treatments, and new technologies are adopted as
generally accepted professional practices.
We may check utilization of health care services before
(prospective review), during (concurrent review), or
after members get them (retrospective review).
}
Prospective (Before Treatment): We determine
whether a treatment is medically necessary before
it begins.
}
Concurrent (During Treatment): We review
treatment during the course of care to determine
medical necessity.
Supporting Members With Complex
Medical Conditions
If you suffer from a severe illness or sustain a severe
injury, or if you have an ongoing chronic condition like
diabetes or asthma, you may be able to get valuable
help by working with a nurse in Tufts Health Plan’s
Complex and Chronic Care Management programs.
The goal of our care management is to help you:
} Manage your health interests and goals
} Implement your doctor’s plan of care
If you find you might need complex or chronic care
management, contact us. A Tufts Health Plan nurse
care manager will then get in touch with you to discuss
health interests and goals, as well as any issues that
might prevent you from being as healthy as possible,
and from getting any health care you might need.
During the program, you and the nurse will work
together to help you:
}
Retrospective (After Treatment): We review
treatment for medical necessity after treatment is
complete. You have the right to appeal coverage
decisions.
} Learn about your illness and learn how to best take
For services and prescriptions that require preauthorization, we conduct pre-service reviews. If you
are hospitalized, we review all available information
in order to facilitate the transition from hospital to
home, or hospital to another health care environment.
Reviews are also conducted post-service, to review
prescriptions and other medical needs.
} Arrange care, including any community services that
care of yourself
} Manage symptoms of your illness
} Learn about your medicines
might be needed
Taking part in the program is always up to you. Your
decision to take part or not take part in the program
has no effect on your health care coverage or
health benefits.
For clinical coverage decisions regarding medical
services, denials are made only by board-certified
physicians. For clinical coverage decisions regarding
medications, denials are made only by board-certified
physicians or registered pharmacists.
If you have any questions about what your specific
plan covers, please read your Benefit Document
or access your secure member account at
mytuftshealthplan.com.
FLYER-UM-2/16
tuftshealthplan.com | 800.462.0224
Notice of
Privacy Practices
This notice describes how health
information about you may be used and
disclosed and how you can get access
to this information.
Please review it carefully.
Tufts Health Plan is committed to safeguarding the
privacy of our members’ protected health information
(“PHI”). PHI is information which:
} identifies you (or can reasonably be used to identify
you); and
} relates to your physical or mental health or condition,
the provision of health care to you or the payment
for that care.
We are required by law to maintain the privacy of
your PHI and to provide you with notice of our legal
duties and privacy practices with respect to your
PHI. This Notice of Privacy Practices describes how
we may collect, use and disclose your PHI, and your
rights concerning your PHI. This Notice applies to
all members of Tufts Health Plan’s insured health
benefit plans, (including: HMO plans; Tufts Health Plan
Medicare Preferred plans; and insured POS and PPO
plans. It also applies to all members of health plans
insured by Tufts Insurance Company (a Tufts Health
Plan affiliate)). It does not apply to products offered
by Tufts Health Public Plans. Unless your employer has
notified you otherwise, this Notice of Privacy Practices
also applies to all members of self-insured group
health plans that are administered by a Tufts Health
Plan entity.
How We Obtain PHI
As a managed care plan, we engage in routine
activities that result in our being given PHI from
sources other than you. For example, health care
providers—such as physicians and hospitals—submit
claim forms containing PHI to enable us to pay
them for the covered health care services they have
provided to you.
How We Use and Disclose Your PHI
We use and disclose PHI in a number of ways to carry
out our responsibilities as a managed care plan. The
following describes the types of uses and disclosures
of PHI that federal law permits us to make without
your specific authorization:
} Treatment: We may use and disclose your PHI to
health care providers to help them treat you. For
example, our care managers may disclose PHI to a
home health care agency to make sure you get the
services you need after discharge from a hospital.
} Payment Purposes: We use and disclose your PHI
for payment purposes, such as paying doctors and
hospitals for covered services. Payment purposes
also include activities such as: determining eligibility
for benefits; reviewing services for medical necessity;
performing utilization review; obtaining premiums;
coordinating benefits; subrogation; and collection
activities.
} Health Care Operations: We use and disclose
your PHI for health care operations. For example,
this includes: population-based activities relating
to improving health or reducing health care
costs; coordinating/managing care; assessing
and improving the quality of health care services;
reviewing the qualifications and performance of
providers; reviewing health plan performance;
conducting medical reviews; and resolving
grievances. It also includes business activities
such as: underwriting; rating; placing or replacing
coverage; determining coverage policies; business
planning; obtaining reinsurance; arranging for legal
and auditing services (including fraud and abuse
detection programs); and obtaining accreditations
and licenses. We do not use or disclose PHI that is
genetic information for underwriting purposes.
} Health and Wellness Information: We may use or
disclose your PHI so that you may be contacted with
information about: appointment reminders; treatment
alternatives; therapies; health care providers; settings
of care; or other health-related benefits, services
and products that may be of interest to you. For
example, you may receive information about
smoking cessation programs, or weight management
programs, or we might send a mailing to subscribers
approaching Medicare eligible age with materials
describing our senior products and an application
form.
} Organizations That Assist Us: In connection with
treatment, payment and health care operations,
we may share your PHI with our affiliates and third
party “business associates” that perform activities
for us or on our behalf, for example, our pharmacy
benefit manager. We will obtain assurances from
our business associates that they will appropriately
safeguard your information.
} Plan Sponsors: If you are enrolled in Tufts Health
Plan through your current or former place of work,
you are enrolled in a group health plan. We may
disclose PHI to the group health plan’s plan sponsor—
usually your employer—for plan administration
purposes. A plan sponsor of an insured health
benefit plan must certify that it will protect the PHI in
accordance with law.
} Public Health and Safety; Health Oversight: We
may disclose your PHI: to a public health authority
for public health activities, such as responding to
public health investigations; when authorized by law,
to appropriate authorities, if we reasonably believe
you are a victim of abuse, neglect or domestic
violence; when we believe in good faith that it
is necessary to prevent or lessen a serious and
imminent threat to your or others’ health or safety;
or to health oversight agencies for certain activities
such as: audits; disciplinary actions; and licensure
activity.
} Legal Process; Law Enforcement; Specialized
Government Activities: We may disclose your PHI:
in the course of legal proceedings; in certain cases, in
response to a subpoena, discovery request or other
lawful process; to law enforcement officials for such
purposes as responding to a warrant or subpoena;
or for specialized governmental activities such as
national security.
} Research; Death; Organ Donation: We may
disclose your PHI to researchers, provided that certain
established measures are taken to protect your
privacy. We may disclose PHI, in certain instances, to
coroners, medical examiners and in connection with
organ donation.
} Workers Compensation: We may disclose your PHI
when authorized by workers’ compensation laws.
} Family and Friends: We may disclose PHI to a
family member, relative or friend—or anyone else you
identify—as follows: (i) when you are present prior
to the use or disclosure and you agree; or (ii) when
you are not present (or you are incapacitated or
in an emergency situation) if, in the exercise of our
professional judgment and in our experience with
common practice, we determine that the disclosure
is in your best interests. In these cases we will only
disclose the PHI that is directly relevant to the
person’s involvement in your health care or payment
related to your health care.
} Personal Representatives: Unless prohibited by
law, we may disclose your PHI to your personal
representative, if any. A personal representative is a
person who has legal authority to act on your behalf
regarding your health care or health care benefits.
For example, an individual named in a durable
power of attorney or a parent or guardian of an
unemancipated minor are personal representatives.
} Communications: We will communicate information
containing PHI to the address or telephone
number we have on record for the subscriber
of your health benefits plan. Also, we may mail
information containing your PHI to the subscriber.
For example, communication regarding member
requests for reimbursement may be addressed to
the subscriber. We will not make separate mailings
for enrolled dependents at different addresses,
unless we are requested to do so and agree to the
request. See below “Right to Receive Confidential
Communications” for more information on how to
make such a request.
} Required by Law: We may use or disclose your PHI
when we are required to do so by law. For example,
we must disclose your PHI to the U.S. Department
of Health and Human Services upon request if they
wish to determine whether we are in compliance with
federal privacy laws.
If one of the above reasons does not apply, we will
not use or disclose your PHI without your written
permission (“authorization”). You may give us written
authorization to use or disclose your PHI to anyone
for any purpose. You may later change your mind
and revoke your authorization in writing. However,
your written revocation will not affect actions we’ve
already taken in reliance on your authorization.
Where state or other federal laws offer you greater
privacy protections, we will follow those more
stringent requirements. For example, under certain
circumstances, records that contain information about:
alcohol abuse treatment; drug abuse prevention or
treatment; AIDS-related testing or treatment; or certain
privileged communications, may not be disclosed
without your written authorization. In addition, when
applicable we must have your written authorization
before using or disclosing medical or treatment
information for a member appeal. See below “Who to
Contact for Questions or Complaints” if you would like
more information.
How We Protect PHI Within Our
Organization
Tufts Health Plan protects oral, written and electronic
PHI throughout our organization. We do not sell
PHI to anyone. We have many internal policies and
procedures designed to control and protect the
internal security of your PHI. These policies and
procedures address, for example, use of PHI by our
employees. In addition, we train all employees about
these policies and procedures. Our policies and
procedures are evaluated and updated for compliance
with applicable laws.
Your Individual Rights
The following is a summary of your rights with respect
to your PHI:
} Right of Access to PHI: You have the right to
inspect and get a copy of most PHI Tufts Health
Plan has about you, or a summary explanation of
PHI if agreed to in advance by you. Requests must
be made in writing and reasonably describe the
information you would like to inspect or copy. If your
PHI is maintained electronically, you will also have
the right to request a copy in electronic format. We
have the right to charge a reasonable cost-based fee
for paper or electronic copies as established by state
or federal law. Under certain circumstances, we may
deny your request. If we do so, we will send you a
written notice of denial describing the basis of our
denial. You may request that we send a copy of your
PHI directly to another person that you designate.
Your request must be in writing, signed by you, and
clearly identify the person and the address where the
PHI should be sent.
} Right to Request Restrictions: You have the right
to ask that we restrict uses or disclosures of your
PHI to carry out treatment, payment and health care
operations; and disclosures to family members or
friends. We will consider the request. However, we
are not required to agree to it and, in certain cases,
federal law does not permit a restriction. Requests
may be made verbally or in writing to Tufts Health Plan.
} Right to Receive Confidential Communications:
You have the right to ask us to send communications
of your PHI to you at an address of your choice or
that we communicate with you in a certain way. For
example, you may ask us to mail your information
to an address other than the subscriber’s address.
We will accommodate your request if: you state
that disclosure of your PHI through our usual means
could endanger you; your request is reasonable; it
specifies the alternative means or location; and it
contains information as to how payment, if any, will
be handled. Requests may be made verbally or in
writing to Tufts Health Plan.
} Right to Amend PHI: You have the right to have us
amend most PHI we have about you. We may deny
your request under certain circumstances. If we deny
your request, we will send you a written notice of
denial. This notice will describe the reason for our
denial and your right to submit a written statement
disagreeing with the denial. Requests must be in
writing to Tufts Health Plan and must include a
reason to support the requested amendment.
} Right to Receive an Accounting of Disclosures:
You have the right to a written accounting of the
disclosures of your PHI that we made in the last six
years prior to the date you request the accounting.
However, except as otherwise provided by law, this
right does not apply to: (i) disclosures we made
for treatment, payment or health care operations;
(ii) disclosures made to you or people you have
designated; (iii) disclosures you or your personal
representative have authorized; (iv) disclosures
made before April 14, 2003; and (v) certain other
disclosures, such as disclosures for national security
purposes. If you request an accounting more than
once in a 12-month period, we may charge you a
reasonable fee. All requests for an accounting of
disclosures must be made in writing to Tufts Health Plan.
} Right to authorize other use and disclosure: You
have the right to authorize any use or disclosure
of PHI that is not specified within this notice. For
example, we would need your written authorization
to use or disclose your PHI for marketing, for most
uses or disclosures of psychotherapy notes, or if
we intended to sell your PHI. You may revoke an
authorization, at any time, in writing, except to the
extent that we have taken an action in reliance on
the use or disclosure indicated in the authorization.
} Right to receive a privacy breach notice: You
have the right to receive written notification if
we discover a breach of your unsecured PHI, and
determine through a risk assessment that notification
is required.
tuftshealthplan.com | 1.800.462.0224
18128-8/15
} Right to this Notice: You have a right to receive a
paper copy of this Notice from us upon request.
} How to Exercise Your Rights: To exercise any
of the individual rights described above or for
more information, please call a member services
coordinator at 1-800-462-0224 (TDD: 1-800-8158580) or write to:
Compliance Department
Tufts Health Plan
705 Mount Auburn Street
Watertown, MA 02472-1508
Effective Date of Notice
This Notice takes effect October 1, 2015. We must
follow the privacy practices described in this Notice
while it is in effect. This Notice will remain in effect
until we change it. This Notice replaces any other
information you have previously received from us with
respect to privacy of your medical information.
Changes to this Notice of Privacy Practices
We may change the terms of this Notice at any time in
the future and make the new Notice effective for all PHI
that we maintain—whether created or received before or
after the effective date of the new Notice. Whenever we
make an important change, we will publish the updated
Notice on our Web site at www.tuftshealthplan.com.
In addition, we will use one of our periodic mailings to
inform subscribers about the updated Notice.
Who to Contact For Questions or
Complaints
If you would like more information or a paper copy
of this Notice, please contact a member services
representative at the number listed above. You can
also download a copy from our Web site at www.
tuftshealthplan.com. If you believe your privacy rights
may have been violated, you have a right to complain
to Tufts Health Plan by calling the Privacy Officer at
1-800-208-9549 or writing to:
Privacy Officer
Compliance Department
Tufts Health Plan
705 Mount Auburn Street
Watertown, MA 02472-1508
You also have a right to complain to the Secretary
of Health and Human Services. We will not retaliate
against you for filing a complaint.
Tufts Associated Health Maintenance Organization, Inc., Total
Health Plan, Inc., Tufts Benefit Administrators, Inc. and Tufts
Insurance Company do business as Tufts Health Plan. Tufts
Health Plan is a registered trademark of Tufts Associated Health
Maintenance Organization, Inc.
© 2015 Tufts Associated Health Maintenance Organization, Inc.
All rights reserved.
Contact Us
Need something? We’re here for you. Contact us in the way that’s most convenient for you.
Translation Available: With the help of
LanguageLine Solutions, Tufts Health Plan speaks
over 200 languages. Just ask your member services
coordinator for a translator.
Massachusetts
Please Note: E-mail may not be encrypted and may
be accessed and viewed by other Internet users
without your knowledge while in transit to us.
For that reason, please do not submit confidential
health care or personal information to us via e-mail.
800.462.0224 (TDD/711)
Member Services
[email protected]
Monday – Thursday, 8 a.m. – 7 p.m.
Friday, 8 a.m. – 5 p.m.
Behavioral Health Services
Corporate Offices
705 Mt Auburn Street
Watertown, MA 02472
800.208.9565
Monday – Thursday, 8:30 a.m. – 5 p.m.
Friday, 10 a.m. – 5 p.m.
Rhode Island
Member Services
[email protected]
800.682.8059 (TDD/711)
Monday – Thursday, 8 a.m. – 7 p.m.
Friday, 8 a.m. – 5 p.m.
Behavioral Health Services
800.208.9565
Monday – Thursday, 8:30 a.m. – 5 p.m.
Friday, 10 a.m. – 5 p.m.
TUFTS
Health Plan
Access your secure member account at mytuftshealthplan.com

This health plan meets Minimum Creditable Coverage standards and satisfies 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 1-877MA-ENROLL or visit the Connector Web site (www.mahealthconnector.org). This health plan meets Minimum Creditable Coverage standards that are effective
January 1, 2009 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, 2009. 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 group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As
permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.
Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for
example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain
other consumer protections in the Affordable Care Act, for example, restrictions on annual limits on essential health benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from
grandfathered health plan status can be directed to the plan administrator at 800-462-0224. You may also contact the U.S. Department of Health and Human
Services at www.healthreform.gov.
: RCAB Health Benefit Trust
Coverage Period: 10/1/2016 - 9/30/2017
Coverage for: Individual/Family | Plan Type: POS
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
:RCAB Health Benef
Coverage Period: 10/1/201
:RCAB
Health
Benefit
Trust
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
www.tuftshealthplan.com or by calling 800-462-0224.
Important Questions
What is the overall
deductible?
Answers
$500 person/$1,500 family unauthorized medical
deductible
If you participate in your employer’s HRA, the HRA
will pay for or reimburse you for certain out-ofpocket, qualified medical expenses, including copays
or amounts under the deductible, if applicable, up to
the balance available in your HRA.
Are there other deductibles
for specific services?
No
Is there an out-of-pocket
limit on my expenses?
Yes, $3,000 person/$9,000 family unauthorized outof-pocket maximum
Premiums, balance-billed charges and health care
What is not included in
this plan doesn't cover.
the out-of-pocket limit?
Is there an overall annual
No
limit on what the plan pays?
Does this plan use a
network of providers?
Yes. For a list of authorized providers, see
www.tuftshealthplan.com “find a doctor” - select
“HMO, POS, PPO, and EPO Basic, Value, and
Premium Plans” from the select a plan dropdown
list, or call 800-462-0224.
Do I need a referral to see
a specialist?
Yes
Are there services this plan
doesn’t cover?
Yes
Why this Matters:
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy
or plan document to see when the deductible starts over (usually, but
not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
You don’t have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered
services. This limit helps you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the
out–of–pocket limit.
The chart starting on page 2 describes any limits on what the plan
will pay for specific covered services, such as office visits.
If you use an authorized doctor or other health care providers, this
plan will pay some or all of the costs for covered services. Be aware,
your authorized doctor or hospital may use a non-authorized
provider for some services. Plans use the term in-network, preferred,
or participating for providers in their network. See the chart starting
on page 2 for how this plan pays for different types of providers.
This plan will pay some or all of the costs to see a specialist for
covered services but only if you have the plan’s permission before
you see the specialist.
Some of the services this plan doesn’t cover are listed later in this
summary. See your policy or plan document for additional
information about excluded services.
Questions: Call 800-462-0224 or visit us at www.tuftshealthplan.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.tuftshealthplan.com or call 800-462-0224 to request a copy.
971023123752-10000-POS-POS Value-2017-1
1 of 11




Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an unauthorized provider charges more than the
allowed amount, you may have to pay the difference. For example, if an unauthorized hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use authorized providers by charging you lower deductibles, copayments and coinsurance amounts.
Your cost if you use an
Common
Medical Event
Services You May Need
If you visit a
health care
provider’s office or
clinic
Primary care visit to treat an injury
30% coinsurance
$20 copay/visit $25 copay/visit
or illness
after deductible
———— none ————
If you have a test
Steward
Health Care
Provider
Tufts Health
Plan Provider
Unauthorized
Provider
Limitations & Exceptions
Specialist visit
$30 copay/visit $40 copay/visit
30% coinsurance
after deductible
———— none ————
Other practitioner office visit
$25 copay/visit for chiropractor
30% coinsurance
after deductible
Spinal manipulations limited to 18
visits per year. Not covered for
children under age 12.
Preventive
care/screening/immunization
No charge
No charge
30% coinsurance
after deductible
———— none ————
Diagnostic test (x-ray, blood work) No charge
No charge
30% coinsurance
after deductible
———— none ————
Imaging (CT/PET scans, MRIs)
No charge
30% coinsurance
after deductible
———— none ————
No charge
2 of 11
Your cost if you use an
Common
Medical Event
Services You May Need
If you need drugs to
treat your illness or
condition
More Information
Tier 1 - Generic drugs
about prescription
drug coverage is
available at
www.caremark.com
Tier 2 - Preferred brand
Tier 3 - Non-preferred brand
drugs
Steward
Health Care
Provider
Tufts Health
Plan Provider
Unauthorized
Provider
$10 copay/prescription (retail);
$20 copay/prescription (CVS
Caremark mail order or at a
CVS/Pharmacy)
$30 copay/prescription (retail);
$60 copay/prescription (CVS
Caremark mail order or at a
CVS/Pharmacy)
$45 copay/prescription (retail);
$90 copay/prescription (CVS
Caremark mail order or at a
CVS/Pharmacy )
Not covered
Limitations & Exceptions
Retail copay is for up to a 30-day
supply; mail order copay is for up
to a 90-day supply. After one
initial fill plus two refills for longterm medications, must switch to
mail/90-day supply at CVS or two
retail copays apply for each 30day supply at retail. Some drugs
require prior authorization to be
covered. Some drugs have
quantity limitations. Contraceptive
coverage is generally excluded
under the Archdiocese of
Boston's prescription drug
plan with the exception of oral
contraceptives for compendia uses
such as amenorrhea treatment,
hypermenorrhea treatment,
dysmenorrhea, dysfunctional
uterine bleeding, endometriosis
prophylaxis or treatment, ovarian
hyperandogenism treatment, and
polycystic ovary syndrome
treatment, which require a prior
authorization from your prescriber
to ensure clinical appropriateness.
3 of 11
Your cost if you use an
Common
Medical Event
If you have
outpatient surgery
If you need
immediate
medical attention
Services You May Need
Steward
Health Care
Provider
Tufts Health
Plan Provider
Unauthorized
Provider
Limitations & Exceptions
Not covered
Limited to a 30-day supply when
provided by a designated specialty
pharmacy. Some drugs require
prior authorization to be covered.
Some drugs have quantity
limitations. Some specialty drugs
may also be covered under your
medical benefit.
$150
copay/visit
30% coinsurance
after deductible
Some surgeries require prior
authorization in order to be
covered.
No charge
30% coinsurance
after deductible
Specialty drugs
Limited to a 30-day supply with
appropriate tier copay (see
above) when purchased at a
designated specialty pharmacy
Facility fee (e.g., ambulatory
surgery center)
$75 copay/visit
Physician/surgeon fees
No charge
Emergency room services
$100 copay/visit
Copay waived if admitted.
Emergency medical transportation
No charge
Some emergency transportation
requires prior authorization to be
covered.
Urgent care
$20 copay/visit
for PCP
$25 copay/visit for PCP
$30 copay/visit $40 copay/visit for specialist
for specialist
Services with unauthorized
providers inside the service area
are covered subject to deductible
and coinsurance.
4 of 11
Your cost if you use an
Common
Medical Event
If you have a
hospital stay
Services You May Need
Tufts Health
Plan Provider
Unauthorized
Provider
Facility fee (e.g., hospital room)
$100
copay/visit
$250
copay/visit
30% coinsurance
after deductible
Physician/surgeon fee
No charge
No charge
30% coinsurance
after deductible
If you have mental Mental/Behavioral health
outpatient services
health, behavioral
health, or substance
Mental/Behavioral health inpatient
abuse needs
services
If you are pregnant
Steward
Health Care
Provider
Limitations & Exceptions
Maximum of two copays per
member per calendar year. Prior
authorization may be required.
$20 copay/visit $25 copay/visit
30% coinsurance
after deductible
Prior authorization may be
required.
$100
copay/visit
30% coinsurance
after deductible
Maximum of two copays per
member per calendar year. Prior
authorization may be required.
$250
copay/visit
Substance use disorder outpatient
services
$20 copay/visit $25 copay/visit
30% coinsurance
after deductible
Prior authorization may be
required.
Substance use disorder inpatient
services
$100
copay/visit
$250
copay/visit
30% coinsurance
after deductible
Maximum of two copays per
member per calendar year. Prior
authorization may be required.
Prenatal and postnatal care
No charge
No charge
30% coinsurance
after deductible
———— none ————
Delivery and all inpatient services
$100
copay/visit
$250
copay/visit
30% coinsurance
after deductible
Maximum of two copays per
member per calendar year.
5 of 11
Your cost if you use an
Common
Medical Event
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Services You May Need
Steward
Health Care
Provider
Tufts Health
Plan Provider
No charge
Unauthorized
Provider
Limitations & Exceptions
30% coinsurance
after deductible
Prior authorization is required.
30% coinsurance
after deductible
Prior authorization may be
required.
30% coinsurance
after deductible
30% coinsurance
after deductible
30% coinsurance
after deductible
30% coinsurance
after deductible
Prior authorization may be
required.
Home health care
No charge
Rehabilitation services
$20 copay/visit $25 copay/visit
Habilitation services
$20 copay/visit $25 copay/visit
Skilled nursing care
No charge
No charge
Durable medical equipment
No charge
No charge
Hospice service
No charge
No charge
Eye exam
$20 copay/visit $25 copay/visit
30% coinsurance
after deductible
Limited to one visit every 12
months with an EyeMed vision
care provider.
Glasses
Not covered
Not covered
Discounts may apply through
EyeMed Vision Care.
Dental check-up
Not covered
Not covered
———— none ————
Limited to 100 days per year.
Prior authorization may be
required.
Prior authorization is required.
6 of 11
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)




Acupuncture
Long-term care
Private-duty nursing
Weight loss programs



Cosmetic surgery
Non-emergency care when traveling outside
the U.S.
Routine foot care



Dental care (Adult)
Pregnancy terminations
Services that are not in keeping with
teachings of the Catholic church
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.) Please note: Certain coverage limits may apply.


Bariatric surgery
Routine eye care (Adult)


Chiropractic care (spinal manipulation)

Infertility treatment (coverage for diagnosis
and some treatment per guidelines and in
keeping with teaching of the Catholic church)
Hearing aids (age 21 or younger)
7 of 11
Continuation of Coverage:
The medical plan of the Roman Catholic Archdiocese of Boston Health Benefit Trust is a church plan and as such is exempt from COBRA
(Consolidated Omnibus Budget Reconciliation Act of 1985). If you lose coverage under the plan, then, depending upon the circumstances, The Roman
Catholic Archdiocese of Boston Health Benefit Trust may provide protections that allow you to keep health coverage. Health coverage may be limited
in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other
limitations to continue coverage may also apply.
For more information on Continuation of Coverage, please see the detailed Description of Benefits or contact Tufts Health Plan at 800-462-0224.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact Tufts Health Plan Member Services at 800-462-0224. 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.
You may also contact the Plan Administrator at Roman Catholic Archdiocese of Boston Health Benefit Trust/Plan Administrator, 66 Brooks Drive,
Braintree, MA 02184
Consumer Assistance Resource
If you need help, the consumer assistance programs in Massachusetts or Rhode Island can help you file your appeal.
Massachusetts
Rhode Island
Contact: Health Care for All
Contact: Rhode Island Department of Business Regulation
30 Winter Street, Suite 1004
1511 Pontiac Avenue, Bldg. 69-2
Boston, MA 02108
Cranston, RI 02920
(800) 272-4232
(401) 462-9520
http://www.hcfama.org/helpline
www.dbr.state.ri.us and www.ohic.ri.gov
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
8 of 11
Language Access Services:
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––
9 of 11
About these Coverage
Examples:
These examples show how this plan might
cover medical care in given situations. Use
these examples to see, in general, how much
financial protection a sample patient might get
if they are covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
Managing type 2 diabetes
Having a baby
(routine maintenance of
a well-controlled condition)
(normal delivery)
Amount owed to providers: $7,540
Amount owed to providers: $5,400
Plan pays $7,240
Plan pays $4,420
Patient pays $300
Patient pays $980
Sample care costs:
Sample care costs:
Hospital charges (mother)
$2,700
Prescriptions
$2,900
Routine obstetric care
$2,100
Medical Equipment and Supplies
$1,300
Hospital charges (baby)
$900
Office Visits and Procedures
$700
Anesthesia
$900
Education
$300
Laboratory tests
$500
Laboratory tests
$100
Prescriptions
$200
Vaccines, other preventive
$100
Radiology
$200
Total
Vaccines, other preventive
Total
$5,400
$40
$7,540
Patient pays:
Deductibles
See the next page for
important information
about these examples.
Copays
Patient pays:
Deductibles
Copays
$0
$300
$0
$900
Coinsurance
Limits or exclusions
$0
$80
Coinsurance
$0
Total
Limits or exclusions
$0
If you participate in your employer’s
HRA, the HRA will pay for or reimburse
you for certain out-of-pocket, qualified
medical expenses, including copays or
amounts under the deductible, if
applicable, up to the balance available in
your HRA.
Total
$300
$980
10 of 11
Questions and answers about the Coverage Examples:
What are some of the assumptions
behind the Coverage Examples?
What does a Coverage Example
show?
Can I use Coverage Examples to
compare plans?


For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up.
It also helps you see what expenses might be
left up to you to pay because the service or
treatment isn’t covered or payment is
limited.
Yes. When you look at the Summary of





Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health
plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the
example.
The patient received all care from
authorized providers. If the patient had
received care from unauthorized
providers, costs would have been
higher.
Does the Coverage Example
predict my own care needs?

examples. The care you would receive
No. Treatments shown are just
for this condition could be different
based on your doctor’s advice, your
age, how serious your condition is, and
many other factors.
Does the Coverage Example predict
my future expenses?
No. Coverage Examples are not cost

estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on the
care you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Benefits and Coverage for other plans,
you’ll find the same Coverage
Examples. When you compare plans,
check the “Patient Pays” box in each
example. The smaller that number, the
more coverage the plan provides.
Are there other costs I should
consider when comparing plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement
accounts (HRAs) that help you pay outof-pocket expenses.
Questions: Call 800-462-0224 or visit us at www.tuftshealthplan.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.tuftshealthplan.com or call 800-462-0224 to request a copy.
11 of 11
WELLNESS PROGRAM
October 1, 2016 – September 30, 2017
The RCAB Health Plan is once again partnering with Tufts Health Plan
to promote wellness and reward healthy activities with the Momentum+
wellness program.
Employees and spouses enrolled in the RCAB Health Plan can each earn up to $500 into a Health
Reimbursement Account (HRA) by participating and tracking wellness related activities! This year
we have added several new activities and have provided even more wellness-related opportunities
to reach the maximum. You can choose the activities that best fit your goals and lifestyle.
Get Started
} Go to www.mytuftshealthplan.com
} Log in or register as a new member if you do not have an account (you will need your ID# located
on your Tufts Health Plan member ID card)
} Click “Use your Health Tools” located in the bottom left of the screen
} This will take you to your personalized home page where you can track and complete your activities
For assistance logging in, please call Tufts Health Plan Member Services at 800.462.0224.
For assistance with the wellness portal, please call 866.201.7919 - Option 7.
Health Reimbursement Accounts (HRA)
Credits will be provided in a HRA incentive, so there are no tax implications for you! An HRA can be
used to pay for medical copays, prescription copays and more. Funds roll over year to year as long
as you remain a member of the RCAB Health Plan. HRAs are administered by Choice Strategies. You
may contact Choice Strategies Member Services directly at 888.278.2555 to check your account
balance or request a new card.
For additional information regarding the above, please visit www.bostoncatholicbenefits.org/health
or contact the RCAB Benefits Office at 617.746.5640 or [email protected].
Important Note:
Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to
all similarly situated employees, regardless of health status. If you think you might be unable to meet a health contingent standard (i.e,
a program that requires an individual to satisfy a standard related to a health factor to obtain a reward or that requires an individual to
undertake more than a similarly situated individual to obtain the same reward) under this wellness program, you might qualify for an
opportunity to earn the same reward by different means. Furthermore, if you are disabled, we will work with you to provide a reasonable
accommodation to help you meet any standards (whether health contingent or not) under this wellness program. Contact Carol
Gustavson at 617.746.5830, and we will work with you (and if you wish, your doctor) to find a wellness program with the same reward
that is right for you in light of your health status.
tuftshealthplan.com | 800.462.0224
RCAB-Momentum-08/16
This year $1,000 in credits for activities is available! The maximum credit each member and spouse
can earn is $500 for the Plan Year. Choose the activities that work best for you and get started today!
Activity
Max
HRA $ Per
Activity
Total HRA
$ Available
Personal Health
Assessment (PHA)
The PHA is a great way to learn whether you’re making smart
choices, how your choices are affecting your health, and
what you can do to feel even better and live a long, healthy
life. This online questionnaire is confidential and only takes 15
minutes to complete.
1
$75
$75
Know Your Numbers
(Biometric Health Values)
To get the best results from your PHA, have your most recent
biometric health values in hand. You will get $5.00 HRA
dollars for each of the following: height and weight for BMI,
blood pressure, cholesterol, HDL, and glucose.
5
$5
$25
Individual Wellness
Challenges
Complete set, month-long wellness challenges to help you
live healthier and feel better. Look out for these upcoming
challenges for the chance to develop healthier habits while
having fun!
12
$20
$240
Employer Worksite
or Family Activity
Complete a wellness activity with co-workers or family
members. Examples include participating in a walking group,
creating a cookbook, or meeting with the Benefits Office
Staff Worksite Wellness Nurse.
4
$20
$80
Online Seminars
Want to learn more about a health topic in 15 minutes? Try
out a seminar right here online. New seminars are released
each month and available 24/7.
12
$15
$180
Condition Management (DM)*
or Health Coaching**
Completion of the Tufts Health Plan Condition Management
or Health Management Program. Call 866.201.7919 to begin.
1
$100
$100
Wellness Champion
Promote wellness and serve as an information resource at
your worksite regarding wellness and the RCAB Health Plan.
1
$100
$100
Virtual Health Coaching
New! Invest some time in your health by taking 1 personalized
interactive tutorial. (six sessions)
1
$50
$50
Quarterly Step Challenge
New! Track at least 7,500 steps each day for at least one
month per quarter to complete this activity.
4
$25
$100
Dental Cleaning
New! Receive at least 1 dental cleaning during the year.
1
$25
$25
Immunization or
Preventive Screening
New! Receive at least 1 immunization or preventive screening
during the year.
1
$25
$25
Activity
Details
*Condition Management – Complete 3 sessions with a Nurse Condition Manager including the Initial Assessment and 2 Follow up sessions. Qualifying conditions include:
Heart Failure, Coronary Artery Disease, Diabetes, and Chronic Obstructive Pulmonary Disease.**Health Coaching - Complete at least 4 monthly check-in calls with a Health
Coach within 4 months of enrollment and complete one short assessment on the program.
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.
Por servicio de traducción gratuito en español, llame al número de su tarjeta de miembro.
若需免費的中文版本，請撥打ID卡上的電話號碼。
tuftshealthplan.com | 800.462.0224
RCAB-Momentum-08/16
Welcome To Your New Momentum+ Home Page!
Ready to get started?
Sign in or register for
mytuftshealthplan.com!
Make the most of your health care
coverage and get instant access
to your secure online account. All
you’ll need is a few minutes, your
Tufts Health Plan member ID card
and your personal email address to
create an account.
1
Go to mytuftshealthplan.com
2
To register for a new account, click ‘Register here’
3
Enter your Tufts Health Plan Member ID number and Date of
Birth and click Continue
4
Verify your identity and create your account
5
Once you have created your account, log in to access your
secure member portal
6
Click ‘Start Living a Healthier Lifestyle’ under Explore Health
and Wellness Resources. This will take you to your new
Momentum+ home page!
Just a few of the new features include:
- Displays that show your progress toward existing and upcoming goals
- Deadline reminders so you won’t miss out on credits and rewards
- Highlights of programs or challenges you are currently enrolled in
Progress trackers to keep you on top of your healthy habits!
Join a challenge and
develop healthier
habits! Keep track of
and enter your points
to earn credits.
You now have more tools than ever to track your progress,
achieve your goals, and earn your credits and rewards.
Go to mytuftshealthplan.com today to start learning about your
new and improved Momentum+ site!
NEW! WELLNESS REWARDS
Effective January 1, 2016
Reward yourself with up to $150 in HRA Dollars!
To encourage you to stay healthy, the RCAB Health Plan offers a number of ways for you to
save on certain wellness costs, both in and outside of our network.
Receive a Wellness Reward of up to
$150 per family (expenses incurred
by enrolled employee or spouse) per
Plan year!
Tufts Health Plan members can save
even more with these great
discounts:

Eligible expenses include:






Fitness club membership
Fitbit or other fitness tracker purchase
Weight management membership
(Weight Watchers, Jenny Craig, etc.)
Group fitness class (Aerobics,
kickboxing, etc.)
Stress management or other
non-physical wellness class
Sports team membership
Reimbursement will be provided in a Health
Reimbursement Account (HRA) incentive, so
there are no tax implications for you!
An HRA can be used to pay for medical copays,
prescription copays and more. Funds roll over
year to year as long as you remain a member of
the RCAB Health Plan. As with the Momentum+
wellness program, HRA accounts are
administered by Choice Strategies.
You may submit multiple requests (minimum of
$25), or one request if your expense is $150 or
more, for expenses incurred during the Plan
year (between January 1 and September 30,
2016). Complete the enclosed Wellness
Reward Claim Form with the required
documentation to receive your credit!




Save 20% on one-year memberships and
pay no joining fee at any of the THP
network fitness centers in MA, NH and RI.
There are almost 80 to choose from.
Save 50% when you join a participating
New England Curves® club.
Save 10% on a personal training packet at
Fitness Together and receive a free fitness
evaluation.
Save 20% on Appalachian Mountain Club
membership rates and receive discounts on
accommodations, subscriptions and
programs.
Members 18 years old and younger pay no
fee to join a network Boys & Girls Clubs in
MA and RI. Members also receive a 20%
discount on the cost of most programs.
If you’re not ready to join a fitness center, you
and your family can go to a center in the THP
network and pay a small copayment of $6-$10
for each visit, up to five visits per month.
For a full list of fitness centers in the Tufts
Health Plan network, go to
www.tuftshealthplan.com and click on Find a
Doctor, then search under Other Medical
Services.
WELLNESS REWARD CLAIM FORM
Please print clearly. Retain a copy of all receipts and documents for your records. Please be
sure to sign the form.
To qualify for the wellness rebate as a credit to your Health Reimbursement Account (HRA),
you or your spouse must be covered under the RCAB Health Plan at the time the expense was
incurred, which must be on or after January 1, 2016. The rebate applies for expenses incurred
by an enrolled employee and/or spouse one time per family, one time per Plan year. Rebates
are typically processed within 4 weeks of receipt.
HRA accounts are administered by Choice Strategies. If you already have an HRA account
from completing Momentum+ activities, the same account will be used for this reimbursement.
If you do not currently have an HRA account with Choice Strategies, one will be opened for
you. You should receive Choice Strategies cards (MasterCard) and information in the mail
within 6 weeks of submission of this claim form. Funds will rollover from year to year. However,
you must be enrolled in the RCAB Health Plan for your HRA account to be active and funds
available. Choice Strategies can be reached at 888-278-2555 with account questions.
Accounts will be opened in the employee’s name. All dependents on the RCAB Health Plan
can utilize the funds.
Employee Information
Full Name:
Employer Location:
E-Mail Address:
Date of Birth:
Spouse Information (if claim being submitted is for spouse)
Full Name:
Date of Birth:
REBATE INFORMATION
Which wellness activity are you requesting reimbursement for?







Fitness club membership
Fitbit or other fitness tracker purchase
Weight management membership (Weight Watchers, Jenny Craig, etc.)
Group fitness class (Aerobics, kickboxing, etc.)
Stress management or other non-physical wellness class
Sports team membership
Other (please describe):
Requested Amount
$
($150 maximum)
Please enclose one of the following for proof of payment and enrollment/purchase:

An itemized receipt or statement on letterhead with an authorized signature from the
fitness club, non-physical wellness class (i.e., stress management), sports team
membership and/or group exercise class showing the dates of membership and the
amount paid.

Receipt showing enrollment in a weight management membership with dates of
membership and amount paid.

Receipt showing purchase of fitness tracking device with store name, date of purchase
and item purchased.
I attest that the above information is true and accurate and that the services were received and
paid for in the amount requested as indicated above. I acknowledge that if any information on
this form is misleading or fraudulent, my coverage may be canceled and I may be subject to
criminal and/or civil penalty for false health care claims. I also understand that the RCAB
Health Plan may request any additional information it deems necessary to verify that services
were received and payment was made.
Employee Signature:
Please submit this form and documentation to:
RCAB Lay Benefits Office
66 Brooks Drive
Braintree, MA 02184
Phone: 617-746-5641
Fax: 617-779-4567
E-Mail: [email protected]
Date: