Health Insurance Plan
We offer you and your eligible family members several health insurance options:
- Tufts HMO Value Plan
- Tufts Advantage HMO Plan
- Tufts Advantage HMO Saver Plan
- Carelink PPO (for out-of-state employees)
We also offer dental and vision plans. Each option includes comprehensive benefits to protect you against the medical expenses from illness or injury. We've included tools and resources that our employees will need to make informed decisions about their medical care needs and to choose an appropriate health plan.
Here's an overview of Lesley's health insurance options. If there is a discrepancy between the descriptions here and official plan documents and policies, the plan documents and policies govern. Lesley reserves the right to change its benefit plans at any time.
Health and Dental Plan Eligibility and Participation
All eligible Lesley University employees can participate in our health and welfare benefit programs. Employees (except students) are considered eligible if they are regularly scheduled to work at least 17.5 hours per week (Adjunct Faculty hours per week are based on hours worked during the look back period).
Additionally, a temporary employee who works at least 17.5 hours per week and is scheduled to work 3 months or longer is considered an eligible employee. Eligible employees may participate in health and welfare benefits as of the first day of the month following date of hire, if they have completed the appropriate enrollment form(s). Coverage ends on the last day of the month following the date of termination.
An eligible employee may enroll eligible family members in the health or dental insurance programs. Eligible family members include:
- Spousal equivalent (with proper documentation).
- Former spouse until the former spouse remarries or until such time as may be specified in the divorce judgment.
- Dependents are covered through the day before the dependent’s 26th birthday, or two years after the dependent loses federal tax dependent status under the IRS Code, whichever occurs first.
- Dependents age 26 or older who:
- Are incapable of self-sustaining employment by reason of a physical or mental handicap (disability); and
- Was covered by the health and welfare benefits you have selected or any of its affiliates before turning 26 (or has had continuous group health insurance coverage from the onset of the disability to the date of enrollment); or
- Dependent child under the age of 26 for whom you or your spouse is the court-appointed legal guardian. Proof of guardianship must be submitted prior to enrollment; or
- The child of an eligible dependent as defined, until such time as your eligible dependent no longer qualifies.
Refer to information regarding COBRA, as it may apply to eligible dependents upon loss of group-sponsored health insurance coverage.
Enrolling in the Health Plan
An eligible employee can enroll in a health plan within 30 days after date of hire by completing a Tufts Health Plan Enrollment form (Dynamic Form).
Lesley University offers 3 types of health coverage levels.
- Individual (employee)
- Individual + One (employee and one other eligible family member)
- Family (employee and more than one eligible family members)
Employees can make changes to their health or dental plan elections during open enrollment. Open enrollment usually occurs in the fall, and all changes are effective January 1 of the following year.
Changes during the course of a year are allowed only if a qualifying event occurs.
Part-Time Employees Pro-Rated Subsidy
Lesley University offers benefits to part-time employees who are regularly scheduled to work at least 17.5 hours a week in a department where a full-time person is regularly scheduled to work 35 hours/ week; or to part-time employees who are regularly scheduled to work at least 20 hours/week in a department where a full-time person is regularly scheduled to work 40 hours/ week. The University shares the cost of benefit premiums with part-time employees on a prorated basis.
For actual costs, please contact Human Resources at 617.349.8787.
Health Plan Qualifying Events
Throughout the course of a plan year, certain qualifying events may occur which allow employees to add, change, or terminate health or dental plan elections. To make any changes, notify your human resources representative within 30 days of the qualifying event date for these changes to be effective.
These qualifying events must result in you, your spouse, same-sex spousal equivalent, or your qualified dependent gaining or losing eligibility for health insurance coverage. Proper documentation surrounding any of these events is required.
If you do not notify Human Resources within 30 days of the qualifying event date, employees will need to wait until the open enrollment period to make changes to health plan elections.
- Change in legal marital status, including marriage, death of spouse, divorce, legal separation, or annulment.
- Change in number of dependents, including a change due to birth or adoption.
- Change in employment status of employee, spouse, or dependent including a beginning or termination of employment, beginning or termination of an unpaid leave of absence, or a change in employment status (e.g. exempt to non-exempt).
- If a dependent satisfies or ceases to satisfy the requirements for coverage due to reaching a certain age or student status.
- If employee, spouse, spousal equivalent, or eligible dependent changes his or her place of residence, but only if such change affects the persons eligibility for coverage.
Contact your Human Resources representative for information about qualifying events, as this list is not inclusive of all qualified change in status events.
Compare Health Plans
Tufts Health Plan Comparisons
The Health Maintenance Organization (HMO) Value option allows members to choose a Primary Care Physician (PCP) from an extensive network of doctors which provide or authorize all of your care (except in an emergency or in certain cases of self-referral).
Your PCP will be the primary liaison between you and any specialists you might see within the network. Tufts requires that you call your PCP first when seeking medical services, unless it is an emergency. There are no deductibles for medical services; however, there is a deductible for prescription drug benefits.
The HMO Advantage plan requires members to pay an upfront annual deductible prior to coverage for any diagnostic, inpatient, or outpatient procedure. There is a separate deductible for prescription drugs. After deductible is met, the member is covered in full with no co-payment for most services.
Advantage HMO Saver Plan
The HMO Advantage Saver plan is similar to HMO Advantage. It requires members to pay an upfront annual deductible prior to coverage for any diagnostic, inpatient, or outpatient procedure. However, the deductibles and out-of-pocket limits are significantly higher than with the HMO Advantage.
Everything except preventive care is subject to the deductible on this plan. After deductible is met, the member pays a 35 percent co-insurance amount for most covered services.
Carelink PPO allows members to visit any healthcare provider within the Tufts network and the national CIGNA Open Access Plus network with no prior authorization from their primary care physician. Members have the added benefit of coverage outside of the network.
For visits with a non-covered healthcare provider, the member must pay an annual out-of-pocket deductible. A separate deductible for prescription drug benefits must be met before benefits become payable. Once the deductible is met, the member is covered at 80 percent of the Tufts equivalent rate for out-of-network services. Out-of-pocket maximums for the Carelink PPO plan are $2,500/member or $5,000/family.
Your health and dental insurance coverage ends the last day of the month in which you terminate employment from the University. For example, if your last day of work is March 1, your group health insurance coverage will end at midnight on March 31.
The deductions owed for the month will be taken out of your last paycheck. You have the option of electing COBRA insurance for you and your dependents for a period of 18 to 36 months. WageWorks, our administrator for COBRA insurance, will send you information on how to elect COBRA coverage, associated costs, and payment information.
Any questions associated with COBRA should be directed to your human resources representative or WageWorks at 888-678-4881
Glossary of Terms
Refer to the benefits summary for the plan(s) you have chosen for specific information about the costs, services associated with each of these general terms as described.
The percentage of covered expenses paid by you each year after you have met applicable deductibles. Services that require deductibles and co-insurance are indicated in your benefits summary.
A dollar amount that you need to pay each time you see your PCP or specialist within the network.
Expenses that are covered (paid for) either partially or fully by your plan.
An annual amount that you need to pay out of pocket to receive specific services under the plan that you have chosen. Once applicable deductibles have been paid, your plan will cover services you receive either on a partial or full basis.
Care received for medical emergencies (heart attack, stroke, loss of consciousness, broken bones, etc.). Emergency care typically is given in an emergency room and treats the acute condition. Any follow up care needed (including admission to the hospital) is typically not considered emergency care.
Care received within the approved network as described by the health plan option covering you.
Lifetime Maximum Benefit
The amount the plan will pay in benefits for each covered person in a lifetime.
Medically Necessary Services
Services that are deemed as necessary to treat a condition, illness, etc. by the generally accepted standards of medical practice. These services are usually determined as medically necessary by your Primary Care Physician.
Care received outside of the approved network, as described by the health plan option covering you. Generally, when receiving care out of the network, additional costs must be paid by the member receiving services (such as deductibles and co-insurance). If you have selected the HMO option, you will need a referral to see a health care provider other than your PCP for services in or out of the network.
Your out-of-pocket maximum is designed to protect you against high medical expenses, and includes any deductibles and/or co-insurance that you have paid during the year. Once your out-of-pocket limit has been reached, you are not responsible for paying additional amounts for services received. Out-of-pocket limits only pertain to covered services and amounts within the usual and customary limits.
Primary Care Physician (PCP)
Your primary care physician (PCP) is a health care professional that you choose to coordinate all of your health services, visits, etc. Each plan has a network of physicians that you can select by looking on the web page of the plan that you choose, or in hard copy directories available in the Human Resources Department. Your PCP is considered your primary doctor and, as such, will be the first point of contact in understanding your health care needs and history. Your PCP will make arrangements for you to see specialists outside of his/her specialty if necessary. Typically, your PCP will refer you to a provider within the same hospital group in which they are affiliated. Note that you must choose a PCP if you are a member of either the POS or HMO plan.
Reasonable and Customary
Reasonable and customary fees represent the range of usual fees for comparable services charged by the medical or dental professionals in a geographic area. If your provider charges more than the reasonable and customary fee, you will be responsible for paying the difference. Usual and customary fees do not apply to the HMO.
Retiree Health Plans
To be eligible to participate in a Lesley-sponsored retiree health plan, you have to be classified as a retiree of Lesley and be age 65 or older. (If you retire before age 65, you may enroll in one of the available health plans upon reaching age 65.)
Coverage is also available to the eligible spouse of a Lesley retiree.
The University offers 2 types of retiree health plans, as described:
- Tufts HMO Prime RX Plus Plan
This plan works like a traditional HMO (Health Maintenance Organization) and acts as a replacement for Medicare Parts A, B and D. In addition to providing coverage for doctors’ office visits, hospitalization, and prescription drugs, this plan covers annual check-ups, routine eye exams with up to $150 toward the cost of eyewear, hearing exams with fixed or discounted pricing on hearing aids, and other benefits not available when enrolled in traditional Medical.
- Tufts Medicare Preferred Supplement/PDP Plus Plan
This plan is also referred to as a “Medigap” plan because it covers “gaps” in original Medicare coverage such as deductibles and coinsurance. You must be enrolled in Medicare Parts A, B & D. However, with the Medicare Preferred Supplement plan, Medicare Part A deductible for hospitalization, Medicare Part B deductible for medical and hospital out-patient expenses and 20% coinsurance are covered. In addition, this plan includes a Prescription Drug Plan that is more comprehensive than what’s available with traditional Medical.
Health Plan Rates for 2020
Tufts HMO Prime Rx Plus Plan: $338/per month
Tufts Medicare Preferred Supplement/PDP Plus Plan: $388
If you have any questions about your eligibility or about the plans, contact the Tufts New Member Sales Queue at 1.800.246.2400.
- Tufts HMO Prime RX Plus Plan