Steward Employee Choice DPO/POS FAQs

What is the Steward Employee Choice Health Plan?

The Steward Employee Choice Health Plan is the health plan offered by Steward Health Care to its employees and their families. There are two plan options—an Exclusive Provider Option (EPO) and a Designated Provider Option (DPO). Both options are administered by Tufts Health Plan, the second largest health insurer in the state of Massachusetts.

What’s the difference between the EPO and the DPO?

There are a number of differences between the two plan options, which we will explain in this document, however, the basic difference is that with the EPO, you have a Primary Care Provider (PCP) directing and referring your health care within the Steward Employee Choice network. With the DPO, you still have to have a PCP directing your care, but you can see any Tufts Health Plan provider—in the Steward Employee Choice provider network, or outside of it. But seeing providers outside the Steward Health Care network may cost you significantly more money than seeing Steward providers.

What is the Steward Employee Choice network?

The Steward Health Care Employee Choice provider network includes providers from Steward Health Care, which is a fully integrated community care organization comprised of 10 hospitals, more than 2,000 physicians, and a full service network of ancillary providers including hospice and a home care agency.

What is a PCP?

A PCP is a doctor or a nurse practitioner who is your primary point of contact when you need health care services. Your PCP will either provide care to you, or will refer you to specialists within the Steward Employee Choice network, or the Tufts Health Plan network, as needed. Your PCP must refer you in order for services to be covered by your health plan.

Choosing a PCP
• You and your dependents must choose a PCP
• Choose your PCP from the Steward Employee Choice network or the Tufts Health Plan    Standard network

How does the DPO plan work?

The DPO plan allows you to choose between four levels of coverage:

The Tier 1 level of benefits is care that is authorized by your PCP, and rendered by Steward Health Care providers. Most services are covered in full, or covered with a copayment.

The Tier 2 level of benefits is care that is authorized by your PCP, and rendered by either Steward Health Care Preferred Tufts Health Plan facilities or any Tufts Health Plan provider. You will either pay a copay or these services will track towards a deductible and/or coinsurance.

The Tier 3 level of benefits is care that is authorized by your PCP, and rendered by Steward Health Care Non-Preferred Tufts Health Plan facilities. These services will take a copay, as well as track towards a deductible and/or coinsurance. The Tier 3 level of benefits only applies to services rendered in hospital settings. All care from physicians in the Tufts Health Plan network is covered at the Tier 2 level of benefits.

The Tier 4 level of benefits is care that is not authorized by your PCP, and rendered outside of the Tufts Health Plan network. You will pay a deductible and coinsurance at this level of benefits.

I am on the DPO. Do I have to see Steward Employee Choice providers for all my care?

To be covered at the Tier 1 level of benefits, you must see Steward Employee Choice providers.  Services from all other Tufts Health Plan providers are covered at the Tier 2 level of benefits.

In the event of an emergency, you are covered for emergency services wherever you seek care.

How do I find a PCP in the network for myself and my family?

Choosing a PCP
• You and your dependents must choose a PCP
• Choose your PCP from the Steward Employee Choice network or the Tufts Health Plan    Standard network

You can also call Tufts Health Plan Member Services Monday – Thursday from 8:00a.m. to 7:00p.m., and Friday from 10:00a.m. to 5:00p.m. at 877-658-3640 (TDD: 800-868-5850). A Member Specialist can assist you in choosing a PCP.

You do not have to choose a Steward PCP on this plan, but will need to choose a Tufts Health Plan PCP.

Do I need to tell Tufts Health Plan which PCP(s) I’ve chosen?

Yes. When you have chosen a PCP for yourself and any covered dependents, call Tufts Health Plan Member Services at 877-658-3640 (TDD: 800-868-5850) prior to your first visit to let them know which PCP you’ve chosen. That way, our records will be up-to-date and your benefits will be processed correctly. 

Can I change my PCP during the plan year?

Yes, you may change your PCP during the plan year but you must notify Tufts Health Plan before your first visit so that your records will be up-to-date.

When do I need a referral from my PCP?

You need a referral from your PCP for most services. If you do not obtain a PCP referral prior to your visit, your claims will process at the unauthorized level of benefits and you will have the highest out-of-pocket expense.  Referrals to all specialists are required, except for certain services such as:
• Emergency care received in an emergency room
• Maternity care
• Routine gynecological exams and medically necessary follow-up care
• Evaluations and related services for acute or emergency gynecological conditions
• Breast cancer screenings
• Routine eye exams
• Spinal manipulation
• Mental Health (Please note: You do not need a referral to obtain mental health services, but
   you do need pre-approval from Tufts Health Plan. Please call 800-208-9565.)
• Out-of-network services (Please note: You do not need a referral to obtain out-of-network
   services, but deductible and coinsurance apply.)

If my PCP refers me to a non-Steward provider, how will benefits be paid?

If your PCP refers you outside of the Steward Employee Choice network to a:
• Tier 2 Steward Health Care Preferred Tufts Health Plan facility and/or Tufts Health Plan
   provider, you will be responsible for a $500 per individual deductible, and 20% coinsurance
   up to $2000 per individual.
• Tier 3 Steward Health Care non-preferred Tufts Health Plan facility, you will be responsible for
   a $750 per individual deductible, and coinsuranc of 35% up to $2000 per individual.

If I receive care out-of-network, how will benefits be paid?

You will be responsible for an $800 deductible and 40% coinsurance up to $6,000.

My child is away at college outside of the service area. What do I need to do?

Under the DPO Plan, your child will be covered worldwide for emergency and urgent care obtained in an emergency room. You will be responsible for the $100 ER copay.

Where can I get more information?

For more information, please call:
• Tufts Health Plan Member Services: 877-658-3640 (TDD: 800-868-5850)
   Monday – Thursday from 8:00am to 7:00pm, and Friday from 10:00am to 5:00pm
• Steward Care Coordination Team: 855-295-4441