Tufts Health Forward Member Handbook · Don’t risk losing your health benefits because we can’t find you. If you move, you must call the Commonwealth Health Insurance ... Management

This health plan meets Minimum Creditable Coverage

standards and will satisfy the individual mandate that

you have health insurance. Please see page 6 for

additional information.

Effective Date: October 1, 2014

Issue Date: October 1, 2014

Member Handbook

Tufts Health Forward

2014

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Welcome!This handbook is full of information about how your health plan works. If you want to know how to get care when you need it, what services are covered, or who to talk to when you have a question, you’ll find the answers here.

This page includes important information to keep handy.

Contact us:888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays

TTY: 888-391-5535 (for people with partial or total hearing loss)

Web: Network-Health.org

Mail: 101 Station Landing, Fourth Floor, Medford, MA 02155

We have bilingual staff available and we offer translation services in 200 languages. All translation services are free to members.

Call us: • If you move or change your phone number

Don’t risk losing your health benefits because we can’t find you. If you move, you must call the Commonwealth Health Insurance Connector Authority (Health Connector) and us to tell us your new address and phone number. You should also put the last names of all Tufts Health Forward members of your household on your mailbox. The post office may not deliver mail from the Health Connector or us to someone whose name is not listed on the mailbox.

If you move, call the Health Connector’s customer service center at 877-623-6765 (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m., and Tufts Health Plan – Network Health at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays, to update your contact information.

Also, tell the Health Connector about any changes in your income, family size, employment status, or disability status; if you become pregnant; or if you have additional health insurance.

• To find out if other household members are eligible for Commonwealth Care

If other people in your home may be eligible for Commonwealth Care, we can help! Call us at 888-257-1985. They can also call the Health Connector’s customer service center at 877-623-6765 (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

• If you want to change your Primary Care Provider (PCP)

You can switch your PCP up to three times a year for any reason by calling us at 888-257-1985 or by visiting us at Network-Health.org.

IN AN EMERGENCY GET CARE RIGHT AWAY: Take immediate action if you believe that you are in a life-threatening emergency situation.

• For medical or Behavioral Health (mental health and/or substance abuse) Emergencies, call 911 or go to the nearest emergency room right away. For Behavioral Health Emergencies, you may also call the local Emergency Services Program (ESP) Provider in your area. Please call us at 888-257-1985 or visit us at Network-Health.org for a complete list of emergency rooms and ESPs in Massachusetts, or call the statewide directory at 877-382-1609 to find the closest ESP to you. You can also find this list in our printed Tufts Health Plan – Network Health Provider Directory. Call us at 888-257-1985 to ask for a copy of the Provider Directory.

• Bring your Tufts Health Forward ID card with you.

• Tell your PCP and, if applicable, your Behavioral Health Provider within 48 hours of an Emergency to get any necessary follow-up care.

You don’t need Prior Authorization for any emergency care, including ambulance transportation and Post-stabilization Care Services.

IN AN URGENT CARE SITUATION, CALL YOUR PCP OR BEHAVIORAL HEALTH (MENTAL HEALTH AND/OR SUBSTANCE ABUSE) PROVIDER:If you need Urgent Care for a problem that is serious but does not put your life in danger or risk permanent damage to your health, call your PCP or Behavioral Health Provider. Your PCP or Behavioral Health Provider can usually address these health problems.

You can contact any of your Providers’ offices 24 hours a day, seven days a week.

Make an appointment if your Provider asks you to come in. If you request an Urgent Care appointment, your Provider must see you within 48 hours.

Member Services Team hours:If you want to talk to a Member Services Team representative who can answer your questions, call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays. We’re also available at 888-257-1985, 24 hours a day, seven days a week, to help with any medical or behavioral health questions or needs.

24/7 NurseLine:888-MY-RN-LINE (888-697-6546), for general health information and support, 24 hours a day, seven days a week

TTY: 800-942-1859

Visit us on the Web!Visit us at Network-Health.org to:

• Find a PCP, Specialist, or health center near you

• Find a Behavioral Health Provider near you

• Sign up for Tufts Health Plan – Network Health Member Connect, and:

m Change your address or phone number

m Choose or change your PCP

m Use the secure messaging center to send us information and questions

m Get answers to your questions

• Download the forms to get your Tufts Health Forward EXTRAS

• Get important information, such as:

m How we make sure you get the best care possible (Quality Management and Improvement Program)

m How we make sure you get the right care in the right place (Utilization Management Program). Please note: We never reward our staff for denying care.

m How we use information your Providers give us to decide what services you need to make you better or keep you healthy (Utilization Review)

m How you can file a Grievance or an Appeal

m How you have the right to request an External Review if we deny an Appeal, as well as your other rights and responsibilities

m How we may collect, use, protect, and release information about you and your health (your Protected Health Information) according to our privacy policy

• Learn much more!

© 2014 Tufts Health Public Plans, Inc. 4819 09214

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Table of contents

The benefits of Tufts Health Plan – Network Health 6 Translation and other formats

Your Tufts Health Forward Evidence of Coverage

Minimum creditable coverage and mandatory health insurance requirement

Getting the care you need 7 In an Emergency, get care right away

For Urgent Care, call your Provider

You are covered for Post-stabilization Care Services

Carry your Tufts Health Forward Member ID Card

Getting information about Tufts Health Forward Providers

Choose your Primary Care Provider (PCP)

When you need Prior Authorization

Seeing Specialists

We support Continuity of Care

You can get a second opinion

Getting hospital services

Getting care away from home

Premiums (for Premium-paying Members) 12

Co-payments 12 Co-payment waivers (Plan Type I and IIa non-premium-paying Members)

Co-payment Caps

Co-payment transfers

Pharmacy Co-payments (Plan Type I, II, and III Members)

Medical Co-payments (Plan Type II and III Members)

Care Management 14 Health and wellness support

Disease management programs

Care coordination

Integrated care management

Covered Services 18 Services we cover

Access to Covered Services

If you get a bill for a Covered Service

Services not covered 23

Quality Management 24

Utilization Management 24 Experimental and/or investigational drugs and procedures

Tufts Health Forward EXTRAS 25

Coverage 28 Renewing your coverage Effective Coverage Date

Protecting your benefits 28

Disenrollment 28 Changing health plans

Your rights and responsibilities 29 Your right to appeal

As a Tufts Health Plan – Network Health Member, you have the right to

Advance Directives

As a Tufts Health Plan – Network Health Member, you have the responsibility to

Additional information available to you

How to resolve concerns with Tufts Health Plan – Network Health 31 Inquiries

Grievances

Appeals

External Review process

Expedited External Reviews

Questions or concerns?

When you have additional insurance 35 Coordination of Benefits

Subrogation

Member cooperation

Motor vehicle accidents and/or work-related injury/illness

Notice of Privacy Policy 36 Our responsibilities

Your rights for privacy practices

Glossary 38

Benefit and Co-payment Summary 43 Plan Type I

Plan Type II

Plan Type III

A great health plan at a great price

Keep this handbook — it has all the information you need to make the most of your Tufts Health Forward membership.

If you have any questions, please call us at 888-257-1985. Members with partial or total hearing loss should call our TTY line at 888-391-5535 for assistance.

Have questions? Please call Tufts Health Plan – Network Health’s Member Services Team at 888-257-1985 (TTY: 888-391-5535), Monday through Friday, from 8 a.m. to 5 p.m., excluding holidays. For help with any medical or behavioral health (mental health and/or substance abuse) questions or needs, you can call anytime, 24 hours a day, seven days a week. You can also visit us at Network-Health.org.

For Commonwealth Care-related questions, please call the Health Connector’s customer service center at 877-623-6765 (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

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The benefits of Tufts Health Plan – Network HealthYou deserve great care. We want you to get the most out of your Tufts Health Forward membership. You get all the benefits of your Commonwealth Care plan, PLUS additional free and discounted Tufts Health Forward EXTRAS.

To bring you the best value in health care, we work with a high-quality Network of doctors, hospitals, and other Providers across Massachusetts. We serve Tufts Health Forward Members in all or parts of the following counties: Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester. For a complete listing of our Providers, or to see a map of our Service Area, please visit Network-Health.org.

Tufts Health Public Plans, Inc. is licensed as a health maintenance organization in Massachusetts, but does business under the name Network Health.

To help you understand what you need to know about your health plan, we have capitalized important words and terms throughout this Member Handbook. You can find definitions for each starting on page 38.

Translation and other formatsIf you have questions, need this document translated, need someone to read this or other printed information to you, or want to learn more about any of our benefits or Covered Services, call us at 888-257-1985 (TTY: 888-391-5535 for people with partial or total hearing loss), Monday through Friday, from 8 a.m. to 5 p.m. We can give you information in other formats, such as Braille, large type size, and American Sign Language video clips, and in different languages. We have bilingual staff available and we offer translation services in 200 languages. All translation services are free to Members.

Your Tufts Health Forward Evidence of CoverageThis Member Handbook, including the “Benefit and Co-payment Summary” for each Plan Type at the end of this handbook, your Preferred Drug List, and any amendments we may send you, make up your Evidence of Coverage. These documents are a contract between you and us. By signing and returning your enrollment application to the Health Connector, and choosing Tufts Health Plan – Network Health as your Commonwealth Care plan, you applied for coverage from us. You also agree to all the terms and conditions of Commonwealth Care that the Health Connector sets forth, and to the terms and conditions of this handbook.

This handbook explains your rights, benefits, and responsibilities as a Tufts Health Forward Member.

It also explains our responsibilities to you. If there are any major plan changes, we’ll notify you by mail 60 Days before the changes go into effect.

Only an authorized officer of Tufts Health Plan – Network Health can change this Member Handbook and only in writing. No other actions, including any exceptions we make on a case-by-case basis, change this Member Handbook.

Minimum creditable coverage and mandatory health insurance requirement Massachusetts law requires that Massachusetts residents, 18 years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards that the Health Connector sets, unless waived by the Health Connector based on affordability or individual hardship. For more information, call the Health Connector at 877-MA-ENROLL (877-623-6765) (TTY: 877-623-7773) or visit the Health Connector’s website at MAhealthconnector.org.

This health plan meets Minimum Creditable Coverage standards as part of the Massachusetts Health Care Reform Law. If you enroll in this plan, you will satisfy the statutory requirement that you have health insurance meeting these standards.

THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS.


7

• Severe burn

• Severe headache

• Shortness of breath

• Vomiting that won’t stop

Examples of Behavioral Health

Emergencies:

• Violent feelings toward yourself or others

• Hallucinations

For Urgent Care, call your Provider

An urgent situation is when you have a health

problem that needs attention right away but

you don’t believe you’re having an Emergency.

Examples are flu-like symptoms that are getting

worse or a cough or cold that is not getting better.

Call your PCP or Behavioral Health Provider if you need Urgent Care. You can contact any of your Providers’ offices 24 hours a day, seven days a week.

If appropriate, make an appointment to visit your Provider. Your Provider must see you within 48 hours for Urgent Care appointments. If your condition becomes an Emergency before your PCP or Behavioral Health Provider sees you, call 911 or go to the emergency room. If you have a Behavioral Health concern, you may also call your local ESP Provider.

You are covered for Post-stabilization Care ServicesAfter an Emergency, you may need Post-stabilization Care Services to help you get better and stay healthy. You can get these services at Hospitals and health care centers that provide emergency services. These services might include Inpatient Services, additional tests, and outpatient care. Please call us at 888-257-1985 or use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org for a complete list of emergency rooms and ESP Providers in Massachusetts. You can also call the statewide directory at 877-382-1609 to find the closest ESP to you. Call us at 888-257-1985 if you would like a printed copy of our Provider Directory, which also has this information.

Getting the care you need

In an Emergency, get care right away

An Emergency is when you believe your life or

health is in danger or would be if you do not get

immediate care.

For medical and Behavioral Health (mental health and/or substance abuse) Emergencies, call 911, or go to the nearest emergency room right away. For Behavioral Health Emergencies, you may also call the local Emergency Services Program (ESP) Provider in your area. Please call us at 888-257-1985, or visit us at Network-Health.org, for a complete list of emergency rooms and ESPs in Massachusetts, or call the statewide directory at 877-382-1609 to find the closest ESP to you. You can also find this list in our printed Provider Directory. Call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m., to ask for a copy of the Provider Directory.

Bring your Tufts Health Forward ID Card with you.

You don’t need approval from us or your Provider to get emergency care. You can get emergency care 24 hours a day, seven days a week, wherever you are, even when you’re traveling. We also cover emergency-related ambulance transportation and Post-stabilization Care Services, which is care to help you get better after an Emergency. A Provider will examine and treat your emergency health needs before sending you home or moving you to another Hospital, if necessary.

Tell your Primary Care Provider (PCP) and, if applicable, your Behavioral Health Provider what happened within 48 hours of an Emergency in order to get any necessary follow-up care.

Examples of medical Emergencies: • Chest pain

• Bleeding that won’t stop

• Broken bones

• Seizures or convulsions

• Dizziness or fainting

• Poisoning or drug overdose

• Serious accident

• Sudden confusion



8

that you need. You will receive the same Medically Necessary Covered Services whether you choose a nurse practitioner, a licensed physician assistant, or a doctor as your PCP. To choose a Tufts Health Forward PCP and to find out where the PCP’s office is located, please use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org or call us at 888-257-1985. You should choose a PCP in the region where you live.

You can call your PCP’s office 24 hours a day, seven days a week. If your PCP is not available, somebody else can help you. If you have problems contacting your PCP, or if you have any questions, please call our Member Services Team at 888-257-1985.

Here’s what your PCP can do for you:

• Give you regular checkups and health screenings, including Behavioral Health screenings

• Make sure you get the health care you need

• Arrange necessary tests, laboratory procedures, or hospital visits

• Keep your medical records

• Recommend Specialists, when necessary

• Provide information on Covered Services that need Prior Authorization (permission) before you get treatment

• Write prescriptions, when necessary

• Help you get Behavioral Health services, when necessary

PCP assignment

If you don’t choose a PCP within 15 Days of joining Tufts Health Plan – Network Health, we’ll choose one for you near to where you live and tell you your PCP’s name. We’ll also choose a PCP for you if the PCP you chose is not available. You can choose a different PCP by calling us at 888-257-1985 or visiting Network-Health.org.

Getting care after office hours

Talk to your PCP to find out how to get care after normal business hours. Some PCPs have longer office hours. If you need Urgent Care after regular business hours, call your PCP’s office. PCPs have covering Providers who work after hours. A covering Provider is a Provider who can help you when your PCP is not available. If you have any problems seeing your PCP or any other Provider, please call us at 888-257-1985.

Carry your Tufts Health Forward Member ID CardYour Tufts Health Forward Member ID Card has important information about you and your benefits that Providers and pharmacists need. Each person in your family with Tufts Health Forward will get a Tufts Health Forward Member ID Card.

Getting information about Tufts Health Forward ProvidersFor the most up-to-date information about Providers (doctors and other professionals who contract with us to provide health care), visit us at Network-Health.org and use the Find a Doctor, Hospital, or Pharmacy tool. For a copy of our Provider Directory, or to get information about a Provider, call our Member Services Team at 888-257-1985.

Our Provider Directory lists the following types of Tufts Health Forward Providers:

• Primary care sites

• Primary Care Providers (PCPs)

• Hospitals

• Specialty Providers

• Behavioral Health Providers

In our Provider Directory, you can find important information like a Provider’s address, phone number, hours of operation, handicap accessibility, and languages spoken.

Our Provider Directory also lists all Tufts Health Forward pharmacies, facilities, ancillary Providers, hospital emergency services, ESP Providers for Behavioral Health, and durable medical equipment suppliers. You can also find this information online at Network-Health.org.

Choose your Primary Care Provider (PCP)

A PCP is the Provider who manages your care.

You can choose a doctor, a nurse practitioner,

or a licensed physician assistant as your PCP.

As a Tufts Health Forward Member, you must choose a PCP who is in our Tufts Health Forward Network. Your PCP is the Provider you should call for any nonemergency health care


9

Standard Prior Authorizations

We’ll make an initial decision about a Prior Authorization within two business days of obtaining all needed information. We’ll let your Provider requesting the service know within 24 hours of our decision. We’ll let you know in writing within one business day if we deny Authorization, and within two business days if we approve Authorization.

Remember: If we don’t authorize your seeing a Provider or having a procedure that requires Prior Authorization, we won’t pay for the services you receive.

Concurrent review

When you are a Hospital patient, or are getting treatment for a condition, we will review your situation to ensure that the right care is given in the right place. This is called a concurrent review. We make concurrent review decisions within one business day of getting all the necessary information from your Provider. “Necessary information” includes the results of any face-to-face clinical evaluation or second opinion.

Your network Provider must notify us of an emergency or urgent admission within 24 hours. If we approve a longer stay or extra services, we’ll let your Provider know within one business day, and we’ll mail to you and fax to your Provider a confirmation within one business day after that. The notification will include the number of extended Days or the next review date, the new total number of Days or services we’ve approved, and the date of admission or start of services.

If we deny a longer stay or additional services, we’ll let your Provider know within one business day, and we’ll mail to you and fax to your Provider confirmation of this Adverse Determination within one business day after that.

You can continue getting the service at no cost to you until we let you know about our concurrent review decision.

Prior Authorization approvals and denials If we authorize the services, we will clearly tell you, your Provider, and your Authorized Representative, if you identify one, which services we agree to cover. The Provider providing the service must have an authorization letter from us before giving you care. If you need more care than we authorized, your Provider will ask us to authorize additional services. If we approve the request for additional services, we’ll send you, your Provider, and your Authorized Representative another authorization letter.

You can also get free health support from our NurseLine 24 hours a day, seven days a week, to help you stay healthy. Call 888-MY-RN-LINE (888-697-6546) (TTY: 800-942-1859) anytime. You can get help in many languages. Remember, the NurseLine staff do not give medical advice and do not replace your PCP.

When you need Prior AuthorizationYour PCP will work with your other Providers to make sure you get the care you need. For certain services, your PCP will need to ask us first for Prior Authorization before sending you to get those services. For more information about which services need Prior Authorization, please see your Plan Type’s “Benefit and Co-payment Summary” section in this Member Handbook or, for the most up-to-date list, visit us at Network-Health.org.

Your PCP knows when and how to ask us for Prior Authorization if it is required. When your PCP asks, we’ll decide if the service is Medically Necessary and if we have a qualified In-network Provider who can provide the service. If we don’t have an In-network Provider who can treat your health condition, we’ll authorize an Out-of-network Provider for you. Nonpreferred In-network Providers and Out-of-network Providers need Prior Authorization from us before you can see them. Please visit us at Network-Health.org for the most up-to-date list of our In-network Providers.

You don’t need Prior Authorization for emergency health care, Post-stabilization Care Services, Family-planning Services, and the first 12 in-network outpatient Behavioral Health visits. You can get emergency services from any Massachusetts emergency care provider. You can get Family-planning Services from any Commonwealth Care-contracted Family-planning Services provider. You do not need Prior Authorization for care provided by an in-network obstetrician, gynecologist, certified nurse midwife, or family practitioner for an annual preventive gynecologic health examination, including any follow-up care, maternity care, or treatment for an acute or emergency gynecological condition.

If you become a Tufts Health Plan – Network Health Member by changing from another Commonwealth Care plan, and a provider who does not contract with us is treating you, we’ll review that treatment and may let that provider continue to treat you. Remember, you must get Prior Authorization from us to continue seeing that Out-of-network Provider.



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Sometimes you may need to visit a Specialist, such as a cardiologist (heart doctor), dermatologist (skin doctor), or ophthalmologist (eye doctor). You can visit most Specialists without Prior Authorization as long as the Specialist is a Preferred In-network Specialist. To find a Tufts Health Forward Specialist, talk to your PCP. You can also call us at 888-257-1985 or visit Network-Health.org and use the Find a Doctor, Hospital, or Pharmacy tool to search for a Specialist. We also list Specialists in our Provider Directory; call us to get a copy. You should discuss your need to see a Specialist with your PCP first, and then call the Specialist to make an appointment.

If the Specialist your PCP wants to send you to is a Nonpreferred In-network Specialist or an Out-of-network Specialist, your PCP will need to ask us for Prior Authorization before sending you to see this Specialist. We may approve your PCP’s request, deny your PCP’s request, or ask your PCP to make a different Prior Authorization request. You can find out which Providers require Prior Authorization by using the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org, or by calling us at 888-257-1985.

Remember, if we don’t give written approval for you to see a Nonpreferred In-network or an Out-of-network Specialist, we won’t cover the services. If you still choose to get the services anyway, the Specialist will bill you and you will be responsible for paying the full cost of the care.

For more information about which services need Prior Authorization, please see your Plan Type’s “Benefit and Co-payment Summary” section in this Member Handbook.

Referrals for specialty services

Some PCPs may need to provide you with a Referral for certain specialty services. A Referral is a notification from your PCP to us that you can get care from a different Provider. The Referral helps your PCP better guide the care and services you get from the doctors you see. These services include:

• Professional services, like a visit to a Specialist

• Outpatient hospital visits

• Surgical day care

• Your first evaluation for:

m Speech Therapy

m Occupational therapy

m Physical therapy

If we don’t authorize any of the services requested, authorize only some of the services requested, or don’t authorize the full amount, duration, or scope of the services requested, we’ll send you, your Provider, and your Authorized Representative a denial or Adverse Determination letter. We’ll also send a notice if we decide to reduce, delay, or stop covering services that we have previously authorized.

The Adverse Determination letter we send will include a clinical explanation for our decision and will:

• Identify specific information we used

• Discuss your symptoms or condition, diagnosis, and the specific reasons why the evidence your Provider sent us fails to meet the relevant medical review criteria

• Specify alternate treatment options that we cover

• Reference and include applicable clinical practice guidelines and review criteria

• Tell you or your Authorized Representative how to ask for an Appeal, including an Expedited Internal Appeal

If you disagree with any of these decisions, you can request a Standard Internal Appeal. For details on requesting a Standard Internal Appeal, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31.

Reconsideration of an Adverse

Determination

If we have denied authorization for services, the Provider treating you can ask us to reconsider our decision. The reconsideration process will occur within one business day after we get the request. A clinical reviewer will conduct the reconsideration and talk to your Provider.

If we don’t change our decision, you, your Provider, or your Authorized Representative may use the appeals process described starting on page 32. You don’t have to ask us to reconsider an Adverse Determination before requesting a Standard Internal Appeal or Expedited Internal Appeal.

Seeing Specialists

Specialists are Providers who have extra training

and who focus on one kind of care or on one part

of the body.


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• Care you receive from your current OB/GYN, even if out-of-network, if you are at least three months pregnant (meaning you are starting your fourth month, based on your expected due date). You can continue seeing your current OB/GYN until you have the baby and a follow-up checkup within the first six weeks of delivery.

• Ongoing covered treatment for a chronic or acute medical condition for up to 90 Days, or until that Provider completes the active treatment, whichever comes first

• Ongoing care for up to 31 Days if the provider is your PCP

• Care from your provider if you are terminally ill

Your Provider must ask us for and get Prior Authorization before you can see an Out-of-network Provider. You may ask your Provider to ask for the Prior Authorization or to call our Member Services Team at 888-257-1985.

You can see an Out-of-network Provider:

• When a participating In-network Provider is unavailable because of location

• When a delay in seeing a participating In-network Provider, other than member-related delays, would result in interrupted access to Medically Necessary services

• If there isn’t a participating In-network Provider with the qualifications and expertise that you need to get and stay better

* We will allow you to continue treatment with an Out-of-network Provider only if the provider agrees to our terms related to reimbursement, quality, Referrals, and additional Tufts Health Forward policies and procedures.

You can get a second opinionTufts Health Forward Members can get a second opinion from a different Provider about a medical or behavioral health condition, or proposed treatment and care plan. You don’t need Prior Authorization to get a second opinion from an In-network Provider about a medical or behavioral health issue or concern. You can see the most up-to-date list of our In-network Providers at Network-Health.org. Please call us at 888-257-1985 for help or for more information about picking a Provider to see for the second opinion.

Your PCP may authorize a standing referral for certain specialty care from a Preferred In-network Provider if your PCP and the specialist agree on a treatment plan for you of Medically Necessary Covered Services. Remember, your PCP, not the Specialist treating you, must request any additional referrals you may need.

If your PCP needs to give a Referral for these services, your Member ID card will say “PCP Referral Required.” You should not be billed for any of these services if you get them from an In-network Provider.

You don’t need a PCP Referral for any outpatient Behavioral Health or OB/GYN services for an annual preventive gynecologic health examination, including any follow-up care, maternity care, or treatment for an acute or emergency gynecological condition.

We support Continuity of Care

New Members*

If you are a new Tufts Health Plan – Network Health Member, we’ll make sure any care you are currently getting continues to go as smoothly as possible. To ensure Continuity of Care, we may be able to cover some health services, including Behavioral Health services, from a provider who isn’t part of our Network. For example, we will cover:

• Care you receive from your current OB/GYN, even if out-of-network, if you are at least three months pregnant (meaning you are starting your fourth month, based on your expected due date). You can continue seeing your current OB/GYN until you have the baby and a follow-up checkup within the first six weeks of delivery.

• Ongoing covered treatment or management of chronic issues (like dialysis, home health, chemotherapy, and radiation) for up to 30 Days, including previously authorized services or Covered Services.

• Ongoing care for up to 30 Days if the provider is your PCP

• Care from your provider if you are terminally ill

Existing Members*

If your PCP or another Provider is disenrolled from our Network for reasons not related to quality of care or Fraud, or if they are no longer in practice, we’ll make every effort to tell you at least 30 Days before the disenrollment. For example, we may cover:



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Premiums (for Premium-paying Members)Some Commonwealth Care Plan Types require you to pay a Premium for your Commonwealth Care coverage. A Premium is a monthly bill you pay directly to the Health Connector for your Commonwealth Care benefits. Please don’t send your Premium payments to us. Each month, you’ll get a bill from the Health Connector. You must send your payment to the Health Connector so that they get it by the 25th day of that month. You must pay this bill every month for your health benefits to continue. Please follow the directions the Health Connector gives you for paying your Premiums and make your check or money order out to Commonwealth Care. Please mail your payments to:

Commonwealth Care P.O. Box 849175

Boston, MA 02284-9175

You may also pay your bill online. Please visit MAhealthconnector.org and click on “E-Pay.”

You may apply for a waiver or Premium-payment reduction if you believe you have an extreme financial hardship that affects your ability to pay. The Health Connector only considers certain events to create an extreme financial hardship. You may also qualify for a payment plan for your Premium. If you have any questions about your Premium, or want to learn more about these options, please contact Commonwealth Care’s customer service center at 877-MA-ENROLL (877-623-6765) (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

Co-paymentsYou’re responsible for paying all of the Co-payments listed in your Plan Type’s “Benefit and Co-payment Summary” starting on page 43 of this Member Handbook. If you can’t afford the Co-payment when you get a service, tell your Provider. You should never go without care you need because you can’t afford the Co-payment.

If you don’t pay the Co-payment at the time of your visit, you’ll still owe the money to the Provider. The Provider may use a legal method to collect the money from you. We are not responsible for paying the Provider the Co-Payment that you owe.

Getting hospital servicesIf you need hospital services for something that isn’t an Emergency, please ask your Provider to help you get these services. If you need hospital services for an Emergency, don’t wait. Call 911 or go to the nearest emergency room right away. For Behavioral Health Emergencies, call 911 or your local ESP Provider, or go to the nearest emergency room right away.

Getting care away from homeIf you’re traveling and need emergency care, go to the nearest emergency room. If you need Urgent Care, call your PCP’s office and follow your Provider’s directions. For other routine health care issues, call your PCP. For routine behavioral health issues, call your Behavioral Health Provider. If you’re outside of Tufts Health Plan – Network Health’s Service Area, including out of the country, we’ll only cover emergency care, Post-stabilization Care Services, and Urgent Care.

We won’t cover:

• Tests or treatment that your PCP asked for but that you decided to get outside of the Service Area

• Routine or follow-up care that can wait until you return to the Service Area, such as physical exams, flu shots, stitch removal, and Behavioral Health counseling

• Care that you knew you were going to get before you left the Service Area, such as elective surgery

When you get care outside of Tufts Health Plan – Network Health’s Service Area, the Provider might ask you to pay for that care at the time of service. If you’re asked to pay for emergency care, Post-stabilization Care Services, or Urgent Care that you get outside of our Service Area, you should show your Tufts Health Forward Member ID Card. The Provider shouldn’t ask you to pay. If you do pay for any of these services, you may ask us to reimburse you. You may call our Member Services Team at 888-257-1985 for help with any bills that you may get from a Provider.


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Pharmacy Co-payments

(Plan Type I, II, and III Members)

A Pharmacy Co-payment is a fixed amount you must pay for a covered pharmacy service. There is a yearly Co-payment Cap (or limit on what you will be charged) for pharmacy services. Please see your Plan Type’s “Benefit and Co-payment Summary” at the back of this handbook for your specific Plan Type Co-payments and Co-payment Caps.

Once you’ve been charged the maximum amount in Pharmacy Co-payments in a Benefit Year (July 1 – December 31), you no longer have to pay Pharmacy Co-payments. This is called a Pharmacy Co-payment Cap. We’ll send you a letter telling you that you have reached your Pharmacy Co-payment Cap and that you don’t have to pay any more Pharmacy Co-payments.

You can’t be charged additional Pharmacy Co-payments for the rest of the Benefit Year unless your Commonwealth Care Plan Type changes. If your Plan Type changes, you may have to start making Pharmacy Co-payments again, even if you had reached your Pharmacy Co-payment Cap. We’ll apply the Pharmacy Co-payments you have already paid to your new Plan Type’s Pharmacy Co-payment Cap amount.

Medical Co-payments

(Plan Type II and III Members)

A Medical Co-payment is a fixed amount you may have to pay for Covered Services other than pharmacy. You will need to pay a Co-payment for Covered Services, such as doctors’ visits, high-cost imaging (MRIs, PET, CT scans), emergency room visits, and care you get in the Hospital. These services that require Co-payments count toward your yearly Medical Co-payment Cap.

Once you’ve been charged the maximum amount in Medical Co-payments in a Benefit Year (July 1 – December 31), you no longer have to pay Medical Co-payments. This is called a Medical Co-payment Cap. We’ll send you a letter telling you that you’ve reached your Medical Co-payment Cap and that you don’t have to pay any more Medical Co-payments.

Co-payment waivers (Plan Type I and IIa* non-Premium-paying Members)You may apply for a co-payment waiver for up to 12 months if you believe you have an extreme financial hardship that affects your ability to pay Co-payments. The Health Connector considers only certain events to create extreme financial hardship. If you want to learn more about applying for a co-payment waiver, please call Commonwealth Care’s customer service center at 877-MA-ENROLL (877-623-6765) (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

* Plan Type IIa is the specific Plan Type (that may or may not have a Premium) for individuals who earn between 100% and 150% of the Federal Poverty Level. To get income examples for different family sizes for Plan Type IIa Members, or if you have any questions, please visit Network-Health.org or call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m.

Co-payment CapsThere’s a yearly limit on how much you have to pay in Co-payments. Once you reach your Plan Type’s limit, you cannot be charged more Co-payments unless your Plan Type changes. For more information about your specific Plan Type’s Co-payment Cap, and what to do when you’ve reached this cap, see the sections “Pharmacy Co-payments” and “Medical Co-payments” on this page.

Co-payment transfersThe Co-payments you pay during the Benefit Year (July 1 – December 31) count, even if you change health plans or your Plan Type changes. Because you don’t have to pay Co-payments after you reach your Co-payment Cap, you must call your old health plan to ask for a Co-payment Transfer Letter. You must send us this letter within 45 Days of your coverage start date. The letter will tell us how much you already paid in Co-payments during the Benefit Year (July 1 – December 31). If you didn’t meet your Co-payment Cap, you may still need to continue paying Co-Payments if your Plan Type changes or if you switch health plans. If you have any questions about this process, please call us at 888-257-1985.



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• Personalized health coaching Our health coaches are specially trained health professionals available Monday through Saturday, from 8 a.m. to 9 p.m., to talk to you about your immediate or everyday health concerns.

• Valuable health information We have easy-to-understand articles on thousands of health topics for you at Network-Health.org.

• Healthy reminders throughout the year Depending on your health needs, we may send you reminders about important tests or information you should discuss with your Providers.

Maternal and child health program

We work closely with you and your Providers to make sure you get ongoing prenatal care if you’re pregnant. We can also help coordinate care you need after you deliver. For information about the benefits and services we offer pregnant Tufts Health Forward Members, see page 22.

MassHealth offers important extra benefits for pregnant women and their babies. If you are pregnant, check with us or with MassHealth to see if you are eligible. If you are, you may transfer to our MassHealth plan, Tufts Health Together, for your health care coverage. If you’re not eligible for MassHealth, you will continue to be a Tufts Health Forward Member throughout your pregnancy.

24/7 NurseLine

We have a 24-hour NurseLine for help with health questions, seven days a week. When you call our 24/7 NurseLine at 888-MY-RN-LINE (888-697-6546) (TTY: 800-942-1859), you can talk with a caring and supportive licensed health care professional at no cost. Staff members can give you general health information and support on health care topics such as symptoms, diagnoses, treatments, tests, test results, and procedures your Provider orders. Staff members do not give medical advice and are not a replacement for your Provider.

Help with quitting smoking

Tufts Health Forward Members are eligible to receive free tobacco cessation counseling services and medications from In-network Providers, including nicotine replacement therapy. Members are covered for a minimum of 16 group and individual counseling sessions, without Prior Authorization, per Benefit Year (July 1 – December 31).

You can’t be charged additional Medical Co-payments for the rest of the Benefit Year unless your Commonwealth Care Plan Type changes from Plan Type II to Plan Type III. If you change from Plan Type II to Plan Type III, you will have to start making Medical Co-payments again, even if you had reached your Medical Co-payment Cap in your old Plan Type. We’ll apply the Medical Co-payments you’ve already paid to your new Plan Type’s Medical Co-payment Cap amount.

Care ManagementCare Management is everything we do to help keep you well and improve your health. Our care management services include helping you make and keep appointments, getting you health information, and coordinating your care with your Provider(s). There are four types of Care Management: health and wellness support; disease management; care coordination (transition of care and Behavioral Health [mental health and/or substance abuse] services); and integrated care management, which includes care coordination with complex care management, intensive clinical management (ICM), social care management, and clinical community outreach. Care Management doesn’t replace the care you get from your Primary Care Provider (PCP) or other Providers but helps support it. Please remember to continue to schedule regular and ongoing visits with your Providers.

Our care managers work with your Providers to coordinate your care and make sure you get the care you need when you need it. To help us do this, be sure to return the Your Health Form we send you. Call us at 888-257-1985 to talk to our care management team, Monday through Friday, from 8 a.m. to 5 p.m., or to our on-call service at night and on weekends.

Health and wellness support

Health coaching for chronic problems

We understand how important it is for you to feel in control of your health. Learning to take control of your health when you have an ongoing, chronic health problem (such as diabetes or asthma) can feel overwhelming. You can use our free health coaching services to help you. Learn how our health coaching can help you feel good about the health care decisions you make.

Visit us at Network-Health.org or call our 24/7 NurseLine at 888-MY-RN-LINE (888-697-6546) to find out about our health coaching services:


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Diabetes

Our diabetes program has staff members available to help you manage type 1, type 2, and gestational (when you’re pregnant) diabetes. Diabetes supplies and lab work are covered benefits, including hemoglobin HbA1c and lipids tests, as are yearly dilated eye exams. One of our diabetes clinicians can arrange your health care with your PCP and any Specialists you may need to see. You also can use our Behavioral Health and social care management programs. If you need it, you can take classes that are approved by the American Diabetes Association.

We stay in touch with our Members with diabetes. We may send you helpful information, such as information about why certain tests are important and how you can better manage diabetes. Additionally, we may call to remind you about yearly lab work and PCP appointments. Visiting Nurse Association (VNA) services are available to help you get any needed ongoing medical care. We also offer, when appropriate, diabetes education if you’re homebound. We work with Neighborhood Diabetes, an approved vendor for diabetic supplies. Their representatives can:

• Give you a free meter

• Visit you at home and teach you about using your meter

• Teach you less painful ways to test your blood

• Teach you about regular foot and eye care

• Teach you healthy eating habits

• Deliver supplies to your home for free

• Make sure you always have testing supplies when you need them

If you want to learn more, please call Neighborhood Diabetes at 877-398-3784. This program is free to Tufts Health Plan – Network Health Members.

For more information about the benefits and services we offer our Members who have diabetes, please see page 26.

Care coordination

Transition of care

When you leave a 24-hour care facility (like an acute-care Hospital, a Rehabilitation Hospital, a transitional care unit, or a Skilled Nursing Facility), our care managers will help you with a transition plan (the care you need to help you keep getting better). Our care managers will work with ancillary providers, like VNA and Durable Medical

Members are eligible for a 90-day supply of all FDA-approved medications used for tobacco cessation each time they attempt to quit, up to a maximum of twice per Benefit Year (July 1 – December 31). There is a Co-payment of $3.65 for pharmacy medications.

The Massachusetts Smokers’ Helpline 800-QUIT-NOW (800-784-8669) provides free phone counseling for quitting tobacco and can also tell you about in-person counseling available in your area. To get daily tips on quitting smoking in English and Spanish, call 800-9-GET-A-TIP (800-943-8284).

Disease management programs We want to help you get the best health care possible. We use Evidence-based guidelines (guidelines based on the best research) in our disease management programs. These programs help you live as healthfully as possible and feel your best. We have staff members who are experts on many health topics, so we can connect you with information and community resources you can really use. For more information, please visit us at Network-Health.org or call us at 888-257-1985. We have disease management programs for the following conditions:

Asthma

There’s a lot we can do to help keep asthma from keeping you down. Working with your Provider, we can help you avoid trips to the emergency room and live life to its fullest. With our free in-home asthma education program, we can even send a nurse to your home to help you get started. The nurse can give you information and tools to help you understand asthma and its causes, triggers, and symptoms. A visiting nurse can also help you learn how to spot the warning signs of a flare-up (attack) before it happens, look for problems in your home that may make your asthma worse, talk with you about an asthma action plan, review and educate you about your medications, and take other steps to make sure you get any other services you might need. The visiting nurse, with Prior Authorization from us, can also order supplies such as a mattress and pillow covers for you.

If you have asthma or think you have asthma, please contact our asthma program manager today at 888-257-1985.



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Together, we can help make sure you get the best care. We want to:

• Continue to improve your health and your family’s health

• Make sure you have timely and easy access to the appropriate level of Behavioral Health care

• Involve you in your treatment planning and recovery

• Make sure your care continues smoothly if you change Providers or plans

• Coordinate your care among your Providers and, with your consent, make sure that your PCP and Behavioral Health Providers share relevant information regarding diagnoses, medication, and/or treatment

At any time, if you’re having a Behavioral Health Emergency, call 911 or go to your local emergency room, or call your local Emergency Services Program (ESP) Provider. For a complete list of emergency rooms and ESP Providers throughout the state, please visit us at Network-Health.org or call us at 888-257-1985. To find the closest ESP Provider to you, call the statewide directory at 877-382-1609.

Integrated care managementWhen appropriate, our Behavioral Health, medical, and social care managers work closely with you and each other to coordinate the care you need. We call this an integrated care management model, and it is designed to make sure you get the best care and results possible.

Integrated care management can help if you have complex and/or specific medical needs and conditions. If you have a physical disability; special health condition like a high-risk pregnancy, cancer, or HIV/AIDS; a behavioral health problem; or any other chronic health condition, you can:

• Get health information from a care manager

• Find out what resources and benefits you can get

• Work with one of our care managers to coordinate your care with your Provider

Our team of dedicated health care professionals includes nurse practitioners, nurses, Behavioral Health clinicians, social care managers, and health advocates. This team understands how to work with you if you have special health care needs, and will make sure you get care in the right place — at home, at a Provider’s office, at a Hospital, in school, in person, or by phone — to help you get and stay healthy.

Equipment (DME) Providers, to make sure you get the services you need when you need them.

Transition of care services also include:

• Teaching you about your condition and medication

• Teaching you about your medications and making sure that you are taking the right ones

• Teaching you about managing your disease and its stages, if necessary

• Giving you individual and integrated care

• Developing a plan to help you get and use the services you need

• Improving your overall health

Your Provider can ask us to give you transition of care services by visiting Network-Health.org or calling us at 888-257-1985.

Behavioral Health (mental health and/

or substance abuse) care services

We have different levels of Behavioral Health services, based on what type and how many services you need, and/or any medical condition you may have. You can find a complete list of these services (including inpatient, outpatient, substance use disorder, and diversionary services) in the “Benefit and Co-payment Summary” at the end of this handbook. You don’t need Prior Authorization for the first 12 in-network outpatient Behavioral Health visits each Benefit Year (July 1 – December 31). You can find a list of Behavioral Health Providers who can provide these services at Network-Health.org. or you may call us at 888-257-1985.

Tufts Health Plan – Network Health’s Behavioral Health care managers are licensed clinicians who can help you by:

• Monitoring your treatment

• Reviewing your need for ongoing care

• Participating with your health care team on discharge planning

• Giving you information about community-based services


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• Have special needs or cultural issues that require multiple agencies to coordinate service delivery

Call us at 888-257-1985 if you want more information or have questions about Behavioral Health ICM and how we determine the care we authorize.

Social care management

Our social care management team can help you with more than health care issues. Social care managers are here to support you with anything in your life that could affect your health, including getting health care. Social care managers can help you:

• Apply for food stamps

• Ask for benefits like Supplemental Security Income (SSI) and Social Security and Disability Insurance (SSDI)

• Meet with and coordinate services with the Department of Transitional Assistance (DTA) and/or the Social Security Office

• Find emergency shelter

• Access community services in conjunction with services we provide

• Obtain information about programs that help pay for utilities (electricity or heat)

• Locate disability support groups

• Complete forms to provide a Member’s children with school-based services

• Set up transportation to and child care for medical appointments

• Access behavioral health resources

Call us at 888-257-1985 if you want more information or if you have questions about our social care management services.

Clinical community outreach

Our clinical community outreach program is a two- to six-week program that will help you become familiar and involved with the preventive health care services, health maintenance programs, and community resources that are available to you as a Tufts Health Plan – Network Health Member. Our clinical community outreach team can:

• Connect you to our programs that help you with any medical needs and conditions

• Help you find a doctor

• Support you in getting help with food, transportation, and/or housing

Our team will work with you to answer your questions, address your needs, develop a plan to get you feeling better, and monitor your health. Some care managers make home visits, explain how to manage a condition, and arrange for services and equipment. Other care managers may also help with any medical, behavioral health, social, and financial needs.

We provide four types of care management services:

• Complex care management

• Behavioral Health intensive clinical management (ICM)

• Social care management

• Clinical community outreach

Complex care management

Our complex care management program is for Members with hard-to-manage, unstable, and/or long-lasting medical conditions. Members in these programs get help from a team of dedicated health care professionals who can help them get and stay healthy, and identify, reduce, or remove social barriers to appropriate care.

Members with the following conditions may benefit from our complex care management services:

• Multiple health conditions

• Intensive-care needs

• Cancer

• HIV/AIDS

• Organ transplantation

• Severe disability or impairment

Our care managers can give you valuable information and help coordinate your care. Call 888-257-1985 to talk to a care manager.

Behavioral Health intensive clinical management (ICM)

We can offer you Behavioral Health ICM if you:

• Have severe behavioral health issues

• Have three or more Behavioral Health inpatient hospital admissions during a 12-month period

• Haven’t accessed or can’t access community-based services

• Experience a catastrophic event

• Have a history of multiple hospitalizations

• Are newly diagnosed with a major mental illness



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Services we cover

Nonpreferred In-network Providers and Out-of-

network Providers need Prior Authorization from

us before you can see them.

Outpatient medical care

Abortion services

We cover abortion services you get from a Tufts Health Forward Provider. We must give Prior Authorization, requested by your Primary Care Provider (PCP), for an abortion from a provider who does not participate in Tufts Health Forward’s Network.

Community health center visits and office visits

We cover community health center and office visits to Tufts Health Forward Providers for Primary Care or for specialty services. We must give Prior Authorization for office visits to all Out-of-network Providers and Nonpreferred In-network Providers. Call us at 888-257-1985 to find out more.

We cover community health center and office visits with/for:

• Your Primary Care Provider (PCP)

• Specialists

• Dental services, for Plan Type I Members (see page 46)

• Eye care (vision care)

Outpatient surgery

We cover surgical procedures performed in an outpatient surgical center or Hospital operating room. Some procedures require Prior Authorization.

Laboratory services

We cover laboratory services (including blood tests, urinalyses, Pap smears, and throat cultures) that your Provider orders to diagnose, treat, and prevent disease, and to maintain your health.

Radiology services

We cover radiology services, including X-rays, mammography, MRIs, PET, and CT scans. Some of these — MRIs, MRAs, CT scans, outpatient nuclear cardiology, and PET — require Prior Authorization for In-network and Out-of-network Providers. Call us at 888-257-1985 for more information.

• Make sure you know what benefits and EXTRAS you can get

We will look at your situation and will then move you to another care management program, if we think it’s necessary.

Call us at 888-257-1985 if you want more information or if you have questions about the clinical community outreach program.

Covered ServicesWe cover the Medically Necessary Covered Services listed in this handbook. If a service or service category is not specifically listed as covered, then it is not covered under this agreement. (See the section “Services Not Covered” on page 23.) The following section lists services we cover for Tufts Health Forward Members.

We’ll authorize, arrange, coordinate, and provide to Members all Medically Necessary Covered Services. The Covered Services for each of the Plan Types are listed in the section “Benefit and Co-payment Summary” starting on page 43. Check the summary for your Plan Type and for a list of services covered and Prior Authorization requirements for Tufts Health Forward Members. If you have any questions, call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m. We can give you more information about any of these Covered Services.

Covered Services are only covered if they are Medically Necessary. Medically Necessary services are those Covered Services that we determine consistent with generally accepted principles of medical practice, meaning that they’re the least intensive and most cost-effective available, and are:

• The most appropriate available supply or service for you based on potential benefits and harm to you

• Known to be effective in improving health outcomes based on scientific evidence, professional standards, and expert opinion

In addition to any limitations in the “Benefit and Co-payment Summary,” we may limit, or require Prior Authorization for, Covered Services on the basis of Medical Necessity.


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If we don’t approve the request for Prior Authorization, you or your Authorized Representative can Appeal the decision. For more information, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31. If you want more information about our pharmacy program, visit Network-Health.org or call us at 888-257-1985.

Preferred Drug List (PDL)

We use a PDL as our list of covered drugs. We update the PDL every three months. The PDL applies only to drugs you get at retail, mail-order, and specialty pharmacies, if covered under your Plan Type. The PDL doesn’t apply to drugs you get if you’re in the Hospital. For the most current PDL, please visit Network-Health.org or call us at 888-257-1985.

Exclusions

We don’t cover certain drugs. If it is Medically Necessary for you to take a drug that we don’t cover, your Provider must ask us for and get Prior Authorization before we’ll cover the drug. One of our clinicians will review the request. If we don’t approve the request for Prior Authorization, you or your Authorized Representative, if you identify one, can Appeal the decision. For more information, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31. If you want more information about our pharmacy program, please visit Network-Health.org or call us at 888-257-1985.

We don’t cover:

• Any drug products used for cosmetic purposes

• Contraceptive implants*

• Experimental and/or investigational drugs

• Immunization agents administered or dispensed at a pharmacy, except for the influenza virus vaccine when administered by a pharmacist between September 15 and March 31 at a participating pharmacy to members who are at least 18 years old*

• Infertility agents

• Medical supplies*

• Mifepristone (Mifeprex)*

• Any drugs related to gender reassignment surgery, specifically including, but not limited to, presurgery and postsurgery hormone therapy

* May be covered as a nonpharmacy benefit

Inpatient medical care

We cover 24-hour inpatient medical services delivered in a licensed Hospital setting with Prior Authorization.

Outpatient Behavioral Health (mental

health and/or substance abuse) services

We cover Medically Necessary mental health and/or substance abuse services provided in a face-to-face encounter in an ambulatory care setting, including:

• Individual, group, and family counseling

• Medication visits

• Community crisis counseling

• Family and case consultation

• Diagnostic evaluation

• Psychological testing

• Narcotic treatment services

• Electroconvulsive therapy

Inpatient Behavioral Health services

We cover Medically Necessary 24-hour clinical intervention services for mental health and/or substance abuse diagnoses delivered in a licensed Hospital setting.

Covered medications and pharmacy

Pharmacy program

We aim to provide high-quality, cost-effective options for drug therapy. We work with your Providers and pharmacists to make sure we cover the most important and useful drugs for a variety of conditions and diseases. We cover first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your doctor writes a prescription and it is filled at a pharmacy.

Our pharmacy program doesn’t cover all drugs and prescriptions. Some drugs must meet certain clinical guidelines before we can cover them. Your Provider must ask us for Prior Authorization before we’ll cover these drugs.

Prior Authorization for drugs

Some drugs always require Prior Authorization, which means your Provider must ask us for approval before we’ll cover the drug. One of our clinicians will review this request. We’ll cover the drug according to our clinical guidelines if:

• There is a medical reason you need the particular drug

• Depending on the drug, other drugs on the Preferred Drug List (PDL) have not worked



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CVS/caremark is our specialty pharmacy and it can provide you with these drugs. In addition to providing specific specialty drugs, CVS/caremark will:

• Deliver drugs to your home, Provider’s office, or any delivery address you choose (except for a P.O. box)

• Answer your questions

• Give you information, materials, and ongoing support to help you manage your health condition and take your drugs the right way

• Have staff pharmacists who can help you 24 hours a day, seven days a week

Visit Network-Health.org for a list of drugs that CVS/caremark provides. These drugs aren’t available at retail or mail-order pharmacies.

Generic drugs

Generic drugs have the same active ingredients and work the same as brand-name drugs. When generic drugs are available, we won’t cover the brand-name drug without giving Prior Authorization. If you and your Provider feel that a generic drug is not right for your health condition and that the brand-name drug is Medically Necessary, your Provider can ask for Prior Authorization. One of our clinicians will then review the request.

We’ll cover the brand-name drug according to our clinical guidelines if there is a medical reason you need the particular brand-name drug. If we don’t approve the request for Prior Authorization, you or your Authorized Representative can Appeal the decision. For more information, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31. If you want more information about our pharmacy program, visit Network-Health.org or call us at 888-257-1985.

New-to-market drugs

We review new drugs for safety and effectiveness before we add them to our PDL. A Provider who feels a new-to-market drug is Medically Necessary for you before we’ve reviewed it, can submit a request for Prior Authorization. One of our clinicians will review this request. If we approve the request, we’ll cover the drug according to our clinical guidelines. If we don’t approve it, you or your Authorized Representative can Appeal the decision. For more information, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31.

Step therapy program

Step therapy means that before we pay for a

certain second-level drug, you have to first try

first-level drugs of that type.

We cover some types of drugs only through our step therapy program. Our step therapy program requires you to try first-level drugs before we’ll cover another drug of that type. If you and your Provider feel a certain drug isn’t appropriate for treating your health condition, your Provider can ask us for Prior Authorization for the other drug. One of our clinicians will review the request and we’ll cover the drug according to our clinical guidelines if:

• There’s a medical reason you need the particular drug

• Depending on the drug, other drugs on the Preferred Drug List (PDL) haven’t worked

If we don’t approve the request for Prior Authorization, you or your Authorized Representative can Appeal the decision. For more information, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31. If you want more information about our pharmacy program, visit Network-Health.org or call us at 888-257-1985.

Quantity limits

To make sure the drugs you take are safe and that you are getting the right amount, we may limit how much you can get at one time. Your Provider can ask us for Prior Authorization if you need more than we cover. One of our clinicians will review the request. We’ll cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we don’t approve the request for Prior Authorization, you or your Authorized Representative can Appeal the decision. To learn more about appealing our decision, please see the section “How to resolve concerns with Tufts Health Plan – Network Health” starting on page 31. If you want more information, visit Network-Health.org or call us at 888-257-1985.

Specialty pharmacy program

A specialty pharmacy needs to supply you with some drugs, such as injectable and intravenous (IV) drugs often used to treat chronic conditions like hepatitis C or multiple sclerosis. These types of drugs need additional expertise and support. Specialty pharmacies have knowledge in these areas. These pharmacies can give extra support to members and Providers.


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Speech, hearing, and language disorders

We cover the diagnosis and treatment of speech, hearing, and language disorders when you get services from a registered therapist as part of a formal treatment plan for speech loss or impairment. There is a maximum combined 20-visit limit for physical, occupational, and Speech Therapies. See the previous section. In some cases, your PCP may need to give a Referral.

Other benefits

Durable Medical Equipment (DME)

We cover certain DME. Coverage includes but is not limited to the rental or purchase of medical equipment, some replacement parts, and repairs, with Prior Authorization.

Emergency transportation

We cover ground ambulance services in an Emergency. We cover nonemergency ambulance transportation only when Medically Necessary and when we give Prior Authorization. We don’t cover transportation to and from medical appointments. We cover Hospital-to-Hospital transfers, without Prior Authorization. We don’t cover emergency transportation by air without Prior Authorization.

Family-planning Services

We cover Family-planning Services. These services include family-planning medical and counseling services, follow-up health care, and education.

Hospice

We cover hospice care for terminally ill Members who agree with their Providers not to continue a curative treatment program. We cover a package of services, including nursing; medical and social services; provider care; counseling (for example, bereavement, dietary, spiritual); physical, occupational, and speech language therapies; homemaker/home health aide services; medical supplies; drugs; biological supplies; short-term inpatient care services; and institutional care services. The 100-Day limitation pertaining to care at a Skilled Nursing Facility and a Rehabilitation Hospital described on your Plan Type’s “Benefit and Co-payment Summary” does not apply to Members receiving hospice services.

Nutritional counseling

We cover nutritional counseling when Medically Necessary.

Rehabilitation services

We must give Prior Authorization for inpatient rehabilitation services.

Cardiac rehabilitation

We cover outpatient cardiac rehabilitation when Medically Necessary. Cardiac rehabilitation is the multidisciplinary treatment of people with documented cardiovascular disease. Prior Authorization is required.

Home health care

We cover certain home health services, including:

• Durable Medical Equipment (DME)

• Part-time or intermittent skilled nursing care

• Physical, occupational, and speech therapies

• Part-time or intermittent home health aide services

Prior Authorization is required.

Inpatient Skilled Nursing Facility

We cover daily Medically Necessary skilled nursing care in an inpatient setting for a maximum of 100 Days per Benefit Year (July 1 – December 31) at a Skilled Nursing Facility. The maximum number of Days is in combination with Days at an inpatient Rehabilitation Hospital. Prior Authorization is required. See the next section.

Inpatient Rehabilitation Hospital

We cover daily Medically Necessary rehabilitative services provided in an inpatient setting for a maximum of 100 Days per Benefit Year (July 1 – December 31) at an inpatient Rehabilitation Hospital. The maximum number of Days is in combination with Days at a Skilled Nursing Facility. Prior Authorization is required. See the previous section.

Short-term outpatient rehabilitation (physical, speech, and occupational therapies)

Physical and occupational therapies

We provide physical and occupational therapy coverage, with Prior Authorization or in some cases Referrals, for evaluation and restorative short-term treatment you need to attain your highest level of independent functioning. Care is provided in the timeliest manner possible and when we determine that the therapy will result in significant, sustained measurable improvement of your condition. We must give Prior Authorization for all rehabilitation therapy services, including ongoing treatment plans after the initial evaluation. There is a maximum combined 20-visit limit for physical, occupational, and Speech Therapies. See the next section.



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Supplies

We cover prescribed, Medically Necessary disposable medical supplies used to treat a specific medical condition, with Prior Authorization.

Vision care

We cover routine eye exams for Members once every 24 months (every 12 months for Members with diabetes) from ophthalmologists or optometrists who are part of our Network. We also cover one pair of eyeglasses every 24 months. You can choose from the free frame selection, or, if you choose any other frame, we pay up to a maximum of $80. For all Plan Types, Members with diabetes are eligible for and are strongly encouraged to get yearly vision exams.

Access to Covered Services Access to Covered Services is how fast you should be able to get the care you need.

Symptomatic care is care you get when you’re sick

or hurt.

Nonsymptomatic Care, also called Preventive Care,

is care you get when you’re well.

Your Providers must give you the care you ask for within the following time frames:

Medical services

• Emergency care: immediately

• Urgent Care: within 48 hours of you asking for an appointment

• Primary Care:

m Nonurgent Symptomatic Care: within 10 Days of you asking for an appointment

m Routine, Nonsymptomatic Care: within 45 Days of you asking for an appointment

• Specialty care:

m Nonurgent Symptomatic Care: within 30 Days of you asking for an appointment

m Routine, Nonsymptomatic Care: within 60 Days of you asking for an appointment

Organ transplant

We cover human organ transplants, with Prior Authorization. Transplants must be nonexperimental surgical procedures provided within the Tufts Health Plan – Network Health Provider Network. Coverage includes living and cadaver donor costs. We don’t cover donor charges for Members who donate organs to non-Members or recipients of transplants who aren’t Tufts Health Plan – Network Health Members. We don’t cover personal searches for solid organs or stem cell donation outside the organ bank.

Orthotics

We provide coverage for nondental braces and other mechanical or molded devices when Medically Necessary. We cover shoe inserts only for Members with diabetes, with Prior Authorization.

Oxygen and respiratory therapy equipment services

We cover oxygen and respiratory therapy equipment, including ambulatory liquid oxygen systems and refills, aspirators, compressor-driven nebulizers, intermittent positive pressure breathers, oxygen, oxygen gas, oxygen-generating devices, and oxygen-therapy equipment rental, with Prior Authorization.

Prenatal care

We provide inpatient and outpatient maternity benefits with precertification of the pregnancy by a Tufts Health Forward Provider. If you’re pregnant, call Tufts Health Plan – Network Health and the Health Connector as soon as your pregnancy is confirmed to be sure you get the best coverage for you and your baby.

We will cover one breast pump per lifetime of membership, and visits to lactation consultants.

Podiatry

We cover Medically Necessary nonroutine podiatry services for Members when a licensed in-network podiatrist performs the service. We cover routine foot care only for Members with diabetes.

Prosthetics

We cover certain prosthetic devices, including evaluation, fabrication, fitting, and the provision of the prosthesis, with Prior Authorization.


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• Some types of Durable Medical Equipment (DME):

m Elevators

m “Back-up” equipment

m Whirlpool equipment, used for soothing/comfort

m Hospital-type beds requiring installation in a home

m Hygienic equipment that does not serve a primary medical purpose

m Nonmedical equipment otherwise available to Members that does not serve a primary medical purpose

m Bed lifters, not primarily medical

m Nonhospital beds and mattresses

m Hospital-type beds in full, queen, and king sizes

m Cushions, pads, and pillows, except when Medically Necessary and we give Prior Authorization

m Pulse tachometers

• Educational testing and evaluations

• Exams a third party requires (e.g., physical, psychiatric, and psychological examinations or testing a third party such as an employer, court, or school requires)

• Experimental or investigational treatment

• Routine podiatry/foot care, except as noted on page 22

• Hearing aids

• Laser eyesight correction or any other eye surgery to treat a condition that another treatment besides surgery can correct

• Services from Out-of-network Providers, unless we give Prior Authorization (except emergency services, which never need Prior Authorization)

• Services from Nonpreferred In-network Providers, unless we give Prior Authorization (except emergency services, which never need Prior Authorization)

• Personal comfort items, including air conditioners, air purifiers, chair lifts, dehumidifiers, radios, telephones, and televisions

• Reversal of voluntary sterilization

• Any service or supply that is not Medically Necessary

• A Provider’s charge for shipping and handling, or copying of records

• Medications, devices, treatments, and procedures that have not been demonstrated to be medically effective

• Routine care, including routine prenatal care, when you’re outside our Service Area

• Services for which there would be no charge in the absence of insurance

Behavioral Health (mental health and/

or substance abuse) services

• Emergency care: immediately

• Emergency Services Program (ESP): immediately

• Urgent Care: within 48 hours of you asking for an appointment

• Other services: within 14 Days of you asking for an appointment

If you’re having any difficulty getting an appointment with your Provider, please call us at 888-257-1985.

If you get a bill for a Covered Service You shouldn’t get a bill for any Covered Services unless you obtained nonemergency services from an Out-of-network Provider or Nonpreferred In-network Provider without Prior Authorization. However, you may get a bill for Co-payments for some Covered Services. You will not be held responsible for paying for services that were not provided, including missed appointments. If you get a bill that you believe is a mistake, don’t pay it, and call us at 888-257-1985. We can help.

Services not covered• Acupuncture (except to treat substance abuse)*

• Biofeedback

• Chiropractic services

• Cosmetic services and procedures, unless required to restore bodily function or correct a functional physical impairment after an accidental injury, prior surgical procedure, or congenital/birth defect. (Prior Authorization is required. No benefits are provided solely for the purpose of making you look better, whether or not these services are meant to make you feel better about yourself or treat a mental condition.)

• Custodial care

• Diagnosis and treatment for infertility, including in-vitro fertilization and gamete intrafallopian tube transfer (GIFT) procedure

• Gender reassignment surgery and any services, drugs, or supplies related to such surgery



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Utilization Management Utilization Management (UM) is how we make

sure you get the right care and services in the

right place.

We base all UM decisions on how appropriate the care is and your coverage. We don’t reward Providers, UM clinical staff, or consultants for denying care. We don’t offer Network Providers, UM clinical staff, or consultants money or financial incentives that could discourage them from making a certain service available to you. Call us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m., if you want information or have questions about UM and how we determine the care we authorize.

Experimental and/or investigational drugs and procedures

Experimental and/or investigational procedures

are new kinds of care that we have to decide

whether to cover based on scientific evidence and

what doctors and other clinicians recommend.

As new technologies come up, we have a way to consider whether or not to cover new (experimental) procedures, including clinical trials. Before we decide to cover new procedures, equipment, and prescription drugs, we look at how safe they are and how well these treatments work. Our medical management team, led by our chief medical officer, makes all decisions on whether or not we cover experimental and/or investigational procedures, including clinical trials.

If you have questions about our pharmacy program or benefits, please call us at 888-257-1985.

• Special equipment you need for sports or job purposes

• Any nonemergency dental services, except those specifically covered for Plan Type I Members

• A service or supply which is not covered by or at the direction of a Tufts Health Forward Provider, except for emergency services

• Gym or health club memberships*

• Replacement of DME or prosthetics due to loss, intentional damage, or negligence

• Services for which we did not give required Prior Authorization

* While these services are not Covered Services, if you pay for them yourself, we will pay you back part of what you spend. For details, see the section “Tufts Health Forward EXTRAS” on page 25.

Quality ManagementWe are committed to delivering high-quality care that enables you to stay healthy, get better, or, if necessary, live with illness or disability. Our program is consistent with the Foundation for Accountability (FACCT) and the Institute of Medicine priority areas. Quality care refers to:

• Clinical quality

• Access to and utilization of care

• Coordination of care

• Member experience with care

We conduct a yearly member survey to evaluate your satisfaction with access to specialist services; Ancillary Services like lab tests, hospitalization services, and Durable Medical Equipment (DME); and other Covered Services.

If you have a concern about the quality of care you get from a Tufts Health Plan – Network Health Provider or the services we provide, please contact us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m.


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Tufts Health Forward EXTRASTo help you get and stay healthy, we reward you with Tufts Health Forward EXTRAS. See the following table for details about free and discounted EXTRAS and how to get them.

You must be a current, eligible Tufts Health Forward Member to get the EXTRAS we give our Members. However, some restrictions may apply, and we reserve the right to change or stop giving an EXTRA at any time.

Free and Discounted EXTRAS

What It Is How To Get It

$55 health rewards card If you see your doctor for a yearly checkup, you’ll earn a $55 health rewards card to spend on health-related purchases (like contact lens solution or bandages) at participating pharmacies, grocery stores, discount stores, and even the doctor’s office for Co-payments.

• Schedule a yearly checkup with your Primary Care Provider (PCP)

• Visit Network-Health.org or call us at 888-257-1985 to get the form you need your PCP to fill out and sign for the reward

• Fill out your information and bring the reward form to your yearly checkup

• Have your PCP sign and date the form to show that the visit took place

• Make a copy of the form to keep for yourself

• Mail the completed form to: Tufts Health Plan – Network Health Attn: Member Services 101 Station Landing, Fourth Floor Medford, MA 02155

• Watch your mail for your Health Rewards card, which should come in four to six weeks

• PLEASE NOTE: You must be a Tufts Health Plan – Network Health Member at the time of the doctor visit and when we process your reward form. You can get one health rewards card every 12 months. Note: Your card is valid for three months. A letter will arrive within a week of the benefit approval, which will indicate the 90-day period this card is valid.



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$25 diabetes health rewards card If you have diabetes, we want to help you manage it. We’ll give you a $25 health rewards card for completing five routine diabetes checkups:

• An eye exam

• Two blood sugar (HbA1c) tests

• A protein test

• A blood cholesterol test

• Call us at 888-257-1985 and ask to speak to a member of our staff. We’ll send you a form with a list of screenings to complete in a calendar year. Getting these screenings will help you manage your diabetes. You can also get the form at Network-Health.org.

• Visit your PCP, complete the tests, and fill out the form

• Have your PCP sign the form

• Make a copy of the form to keep for yourself

• Mail the completed form to: Tufts Health Plan – Network Health Attn: Member Services 101 Station Landing, Fourth Floor Medford, MA 02155

• Watch your mail for your $25 health rewards card, which should come in four to six weeks

• PLEASE NOTE: You must be a Tufts Health Plan – Network Health Member when you get the five screenings and when we process your form. You can get one $25 health rewards card every 12 months for completing the five screenings. Note: Your card is valid for three months. A letter will arrive within a week of the benefit approval, which will indicate the 90-day period this card is valid.


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Free Weight Watchers registration, plus $50 back on program costs

Any Member age 21 or older can join Weight Watchers with no fee. You will pay for weekly meetings, but every 12 months we will give you $50 to use toward those costs.

Too busy to attend meetings? Check out the Weight Watchers At Home Kit. You’ll get $10 off when you order it, PLUS we reimburse you $50 of the cost of the kit. Remember, you should discuss any diet or exercise program with your PCP before you begin.

• With your PCP’s approval, sign up for Weight Watchers meetings or order an At Home Kit by calling Weight Watchers at 800-710-4663

• Visit Network-Health.org or call us at 888-257-1985 to get the form you need for your reimbursement

• Make a copy of the form and Weight Watchers receipt to keep for yourself

• Mail the completed form and receipt to: Tufts Health Plan – Network Health Attn: Member Services 101 Station Landing, Fourth Floor Medford, MA 02155

• Watch your mail for your reimbursement of up to $50, which should come in six to eight weeks

• PLEASE NOTE: You must be a Tufts Health Plan – Network Health Member when you sign up for Weight Watchers or order the At Home Kit and when we process your form. Members age 21 and older can get one $50 reimbursement every 12 months.

Acupuncture reimbursement If you pay for services from a licensed acupuncturist, we will pay you back up to $150.

(PLEASE NOTE: Acupuncture is not a covered medical service, except to treat substance abuse, and you will be responsible for payment.)

• Visit any licensed acupuncturist

• Make sure you have your acupuncture receipt; be sure it shows the acupuncturist’s license number

• Visit Network-Health.org or call us at 888-257-1985 to get the form you need for your reimbursement

• Make a copy of the form and receipt to keep for yourself

• Mail the completed form and receipt to: Tufts Health Plan – Network Health Attn: Member Services 101 Station Landing, Fourth Floor Medford, MA 02155

• Watch your mail for your reimbursement of up to $150, which should come in six to eight weeks

• PLEASE NOTE: You must be a Tufts Health Plan – Network Health Member when you get acupuncture services and when we process your form. Members can get up to $150 reimbursement every 12 months.



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DisenrollmentThe Health Connector will provide us with information about member disenrollment. Please note: We will never request a Member’s disenrollment due to a negative change in his or her health, or because of the Member’s use of medical services, diminished mental capacity, or uncooperative behavior resulting from his or her special needs.

If you’re disenrolled from Commonwealth Care, we will continue to provide Covered Services to you through 11:59 p.m. on the last day of the month of your disenrollment.

Changing health plansThe Health Connector will give you information about the yearly Commonwealth Care open enrollment period. All existing Commonwealth Care members can change plans for any reason during the open enrollment period.

If you are a Plan Type I Member who was assigned to a health plan or provided a limited choice of health plans, you may not change plans at any other time during the year. For Plan Type II and III Members, the Health Connector gives you 60 Days from the date of your health plan enrollment to change your plan. After 60 Days, you can only change plans during the open enrollment period. The Health Connector will let all Plan Type Members change health plans outside of the open enrollment period in certain instances, such as if you move and your new address is outside of your health plan’s service area.

Outside of the open enrollment period, all Plan Type I, II, and III Members can change health plans for the following reasons:

• You move and your new address is outside of your health plan’s service area

• You prove to the Health Connector that a) you have a medical condition and continued enrollment in your health plan will result in a lack of continuity of care and b) your health plan has not given you access to providers who meet your health care needs over time, even after you ask the health plan for help

• Your Primary Care Provider (PCP) is no longer a contracted provider with your health plan

• Your health care access has been negatively affected by an important change in your health plan’s group of providers, such as your health plan’s loss of a contract with a Hospital, health center, Provider group, or Specialty Provider group

Coverage

Renewing your coverageEach year, most Commonwealth Care members, including Tufts Health Forward Members, must renew their Commonwealth Care benefits. You must fill out an Eligibility Review Verification (ERV) form. You should get this form in the mail at least one month before your coverage ends. Make sure you fill it out and mail it back to the state at the address on the form with proof of your income as soon as you can. If you don’t, you risk losing your Commonwealth Care and Tufts Health Forward coverage.

If you have questions about how to complete the ERV form, need help filling out the ERV form, or lose your ERV form, we can help. Call our Renewal Helpline at 877-849-0545. You can also call MassHealth’s customer service at 888-665-9993, from 8 a.m. to 5 p.m.

Effective Coverage DateThe Effective Coverage Date is the date you become a Member of Tufts Health Forward and are eligible to get Covered Services from Tufts Health Forward Providers. Your coverage will start at 12:01 a.m. on the first day of the month your enrollment in Commonwealth Care begins.

Protecting your benefitsHelp reduce health care Fraud and abuse, and protect the Commonwealth Care program for everyone. Examples of Fraud or abuse are:

• You lend your ID Card to someone else

• You get prescriptions in an improper way

• Your doctor bills us for services you didn’t get

To report potential health care Fraud and abuse, or if you have questions, please call us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m., or email [email protected]. We don’t need your name or member information. You can also call our confidential hotline anytime at 800-826-6762, or send an anonymous letter to us at:

Tufts Health Plan – Network Health Attn: Fraud and Abuse 101 Station Landing, Fourth Floor Medford, MA 02155


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If you disagree with an action we take, such as an Adverse Determination, or with the quality of your care, or with our administrative operations, you have the right to request a Standard Internal Appeal or file a Grievance with us. We describe our Grievance and Standard Internal Appeal processes starting on page 31 of this handbook.

As a Tufts Health Plan – Network Health Member, you have the right to• Be treated with respect and dignity by all Providers, regardless of your race, ethnicity, creed, religious belief, sexual orientation, or source of payment for care

• Get Medically Necessary treatment, including emergency care

• Get the delivery of services in a culturally competent manner

• Make decisions about your medical care

• Get information about us and our services, Primary Care Providers (PCPs), Specialists, other Providers, and your rights and responsibilities

• Have a candid discussion of appropriate or Medically Necessary treatment options for your condition(s) regardless of cost or benefit coverage

• Work with your PCP, Specialists, and other Providers to make decisions about your health care

• Accept or refuse medical or surgical treatment

• Call your PCP’s and/or Behavioral Health (mental health and/or substance abuse) Provider’s office 24 hours a day, seven days a week

• Expect that your health care records are private, and that we abide by all laws regarding confidentiality of patient records and personal information, in recognition of your right to privacy

• Get a second opinion for proposed treatments and care

• File a Grievance to express dissatisfaction with your Providers and the quality of care or services you get

• Appeal a denial or Adverse Determination we make for your care or services

• Be free from any form of restraint or seclusion used as a means of coercion, discipline, or retaliation

• Ask for more information or explanation on anything included in this Member Handbook, either orally or in writing

• Your Commonwealth Care Plan Type eligibility changes

• You are homeless and that status is reported to the Health Connector

• The enrollment materials the Health Connector sent to you were returned to them without being delivered

If you have any questions about your membership in Tufts Health Forward or need help getting an appointment to see a Provider, please call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m.

If you want to change your health plan, please contact the Commonwealth Care’s customer service at 877-MA-ENROLL (877-623-6765) (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.

Your rights and responsibilities

Your right to appealIf you disagree with an action taken by the Health Connector regarding your insurance coverage, you may submit an Appeal Request Form to the Health Connector and ask for a hearing before an impartial hearing officer. You have the right to appeal the following actions taken by the Health Connector:

• The Health Connector’s decision on your request to change your health plan

• Your disenrollment from a health plan or Commonwealth Care for nonpayment of Premiums or for any other reason

• The Health Connector’s decision on a Premium or Co-payment Waiver-Reduction Application because of extreme financial hardship

• The Health Connector’s determination of when you have reached your Co-payment Cap (yearly limit on Co-payments)

To appeal one of these actions, you can request an Appeal Request Form from Commonwealth Care’s customer service center at 877-MA-ENROLL (877-623-6765) (TTY: 877-623-7773), Monday through Friday, from 8 a.m. to 6 p.m.



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With Advance Directives, you also have the right to:

• Make decisions about your medical care

• Get the same level of care, and be free from any form of discrimination, whether or not you have an Advance Directive

• Get written information about your Provider’s Advance Directive policies

• Have your Advance Directive in your medical record

Our Providers will comply with state law concerning Advance Directives. We also educate staff members and people they interact with in the community about Advance Directives.

As a Tufts Health Plan – Network Health Member, you have the responsibility to• Treat all Providers with respect and dignity

• Keep appointments, be on time, or call if you’ll be late or need to cancel an appointment

• Give us, your PCP, Specialists, and other Providers complete and correct information about your medical history, medicine you take, and other matters about your health

• Ask for more information from your PCP and other Providers if you don’t understand what they tell you

• Participate with your PCP, Specialists, and other Providers to understand and help develop plans and goals to improve your health

• Follow plans and instructions for care that you’ve agreed to with your Providers

• Understand that refusing treatment may have serious effects on your health

• Contact your PCP or Behavioral Health Provider within 48 hours after you visit the emergency room, for follow-up care

• Change your PCP or Behavioral Health Provider if you aren’t happy with your current care

• Voice your concerns and complaints clearly

• Tell us if you have access to any other insurance

• Tell us if you suspect potential Fraud and/or abuse

• Tell us and the Health Connector about any address, phone, or PCP changes

• Tell us if you’re pregnant

• Ask for a duplicate copy of this Member Handbook at any time

• Get written notice of any significant and final changes to our Provider Network, including but not limited to PCP, Specialist, Hospital, and facility terminations that affect you

• Ask for and get copies of your health plan records and ask that we amend or correct the records, if necessary

• Ask your Provider for a copy of your medical record; your provider may charge you a small fee

• Get the services listed in the “Benefit and Co-payment Summary” at the end of this Member Handbook

• Make recommendations about our member rights and responsibilities policy

• Get this Member Handbook and other Tufts Health Plan – Network Health information translated into your preferred language or in your preferred format

Advance DirectivesAdvance Directives are written instructions, sometimes called a living will or durable power of attorney, for health care. Advance Directives are recognized under Massachusetts law and relate to getting health care when a person isn’t capable of making a decision. If you’re no longer able to make decisions about your health care, having an Advance Directive can help. These written instructions will tell your Providers how to treat you if you aren’t able to make your own health care decisions.

In Massachusetts, if you’re at least 18 years old and of sound mind, you can make decisions for yourself. You may also choose someone as your health care agent or health care proxy. Your health care agent or proxy can make health care decisions for you in the event that your Providers determine you’re unable to make your own decisions.

As a Tufts Health Plan – Network Health Member, you have certain rights that relate to an Advance Directive. To choose a health care agent or proxy, you must fill out a Health Care Proxy form, available from your Provider or Tufts Health Plan – Network Health. You can also request a Health Care Proxy form from the Commonwealth of Massachusetts. Write to the address below and send a self-addressed and stamped envelope to:

Commonwealth of Massachusetts Executive Office of Elder Affairs 1 Ashburton Place, Room 517

Boston, MA 02108


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GrievancesIf you are dissatisfied about something Tufts Health Plan – Network Health has done or not done, you have the right to file a Grievance. This means you can tell us why you are dissatisfied, and we will look into the situation and resolve it. (If you are dissatisfied about an Adverse Determination, you may request an Appeal; see the next section.)

You may file a Grievance up to 180 Days after the action or inaction that is of concern to you. You may file a Grievance for any reason, including:

• If you’re dissatisfied with the quality of care or services you get

• If one of your Providers or one of our employees is rude to you

• If you believe one of your Providers or one of our employees did not respect your rights

• If you disagree with our decision to extend the time frame for making an Authorization or a Standard Internal or Expedited Internal Appeal decision

• If you disagree with our decision not to expedite an Appeal request

Your Authorized Representative, if you identify one, can file a Grievance for you. You can appoint an Authorized Representative by sending us a signed Tufts Health Forward Authorized Representative Form. You can get a form at Network-Health.org or by calling our Member Services Team at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m. If we don’t get your signed Tufts Health Forward Authorized Representative Form within 30 Days of someone other than you filing a Grievance on your behalf, we’ll dismiss the Grievance.

How to file a Grievance

You or your Authorized Representative may file a Grievance in the following ways:

Telephone — call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m.

TTY/TTD — people with hearing loss can call our TTY line at 888-391-5535, Monday through Friday, from 8 a.m. to 5 p.m.

Mail — mail a Grievance to Tufts Health Plan – Network Health, Attn: Grievance Specialist, 101 Station Landing, Fourth Floor, Medford, MA 02155

Email — email a Grievance via the “Contact us” section of our website at Network-Health.org

Additional information available to youYou can learn about other Members’ experiences with Tufts Health Plan – Network Health by calling us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m. Types of available information include Tufts Health Forward voluntary and involuntary disenrollment rates.

You can also get information about us from:

• The Massachusetts Board of Registration in Medicine at massmedboard.org, which may be able to give you information about Providers licensed to practice in Massachusetts

• The Office of Patient Protection (OPP), located within the Health Policy Commission, which can also provide information to you about your rights as a managed care member and about the External Review process, and:

m A list of sources of independently published information assessing Members’ satisfaction and evaluating the quality of health care services we offer

m The percentage of Providers who voluntarily and involuntarily ended contracts with us during the previous calendar year, and the three most common reasons for voluntary and involuntary Provider disenrollment

m The percentage of premium revenue we spend for health care services our Members got during the most recent year for which information is available

m A summary report on Appeals, including the number of Appeals filed, the number of Appeals approved internally, the number of Appeals denied internally, and the number of Appeals withdrawn before resolution

How to resolve concerns with Tufts Health Plan – Network HealthInquiriesAn Inquiry is any question or request that you may have about how we work. As a Tufts Health Plan – Network Health Member, you have the right to make an Inquiry at any time. We’ll resolve your Inquiries immediately or, at the latest, within one business day of the day we get it. We’ll let you know the resolution the day we resolve your Inquiry.



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Fax — request a Standard Internal Appeal by faxing us at 781-393-2643

In person — visit our office at 101 Station Landing (Medford, Mass.), Monday through Friday, from 8 a.m. to 5 p.m.

Although you have 180 Days to request a Standard Internal Appeal, we encourage you to act as soon as possible.

We’ll let you know we got your Standard Internal Appeal request by sending you a written notice within one business day, or 48 hours, whichever is less.

Other people who can request an Appeal for you

Your Authorized Representative can request an Appeal for you. You need to tell us in writing if your Authorized Representative will request an Appeal for you.

You can appoint an Authorized Representative by sending us a signed Tufts Health Forward Authorized Representative Form. You can get a form by calling our Member Services Team at 888-257-1985. You can also find this form at Network-Health.org.

Please note: If someone tries to request an Appeal, including an Expedited Internal Appeal, for you and you did not already send us an Authorized Representative Form for that person, we’ll tell you in writing that a request has been made and will send you a copy of the Authorized Representative Form to sign and return to us. We won’t take further action until we get the signed Authorized Representative Form. If you don’t send the form, we’ll dismiss the request, unless it is an Expedited Internal Appeal requested by a Provider.

Continuation of services during the Appeal process

If you’ve been getting a Covered Service and we stop covering the service, we’ll continue the disputed coverage at our expense through the end of the Appeal process, as long as you or your Authorized Representative request the Appeal in a timely manner. Ongoing coverage or service includes only services that we authorized.

Fax — fax a Grievance to us at 781-393-7440

In person — visit our office at 101 Station Landing (Medford, Mass.), Monday through Friday, from 8 a.m. to 5 p.m.

Once you file a Grievance, we will:

• Tell you or your Authorized Representative that we got your Grievance by sending you a written notice within one business day

• Look into and resolve your Grievance within 30 Days from when we get your Grievance

• Ask to extend the time frame by mutual written agreement if we need more information. The additional time will not be more than 30 Days.

• Tell you or your Authorized Representative in writing of the outcome of your Grievance, which will include the information we considered and explain our decision

• Provide interpreter services, if necessary

AppealsAs a Tufts Health Forward Member, you or your Authorized Representative has the right to request an Appeal if you disagree with any Adverse Determination.

How to request a Standard Internal

Appeal

You or your Authorized Representative may request a Standard Internal Appeal within 180 Days of an Adverse Determination in the following ways:

Telephone — call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m.

TTY/TTD — people with hearing loss can call our TTY line at 888-391-5535, Monday through Friday, from 8 a.m. to 5 p.m.

Mail — mail a request for a Standard Internal Appeal, with a copy of the notice of Adverse Determination and any additional information about the Standard Internal Appeal, to us at: Tufts Health Plan – Network Health, Attn: Appeals Specialist, 101 Station Landing, Fourth Floor, Medford, MA 02155

Email — request a Standard Internal Appeal by email via the “Contact us” section of our website at Network-Health.org


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• If you’re terminally ill, we must review your Grievance or Standard Internal Appeal within five days, unless the request is for urgently needed services, in which case we must issue a decision within 72 hours.

We’ll issue a decision within 48 hours*, or in less time for Durable Medical Equipment (DME) when the Provider specifies a reasonable time. If the Expedited Internal Appeal upholds the denial of coverage or treatment regarding terminal illness, we’ll allow you or your Authorized Representative to ask for a conference. We’ll schedule the conference within 10 business days of getting a request. The conference will be held within five business days of the request if the treating Provider determines, after consulting with a Tufts Health Plan – Network Health medical director, that the effectiveness of the proposed treatment or supplies, or any alternative treatment or supplies, would be greatly reduced if not provided at the earliest possible date. You and/or your Authorized Representative can attend the conference.

* Please note: Any Appeal, including an Expedited Internal Appeal, not properly acted on by Tufts Health Plan – Network Health within the time limits specified will be decided in your favor. Time limits include any extensions made by mutual written agreement between you or your Authorized Representative and Tufts Health Plan – Network Health.

Written notice of Appeal decisions

We will tell you our Appeal decisions in writing. For Adverse Determinations, this notice will include a clinical explanation for the decision, and will:

• Give specific information upon which we based an Adverse Determination

• Discuss your symptoms or condition, diagnosis, and the specific reasons why the evidence submitted doesn’t meet the relevant medical review criteria

• Specify alternate treatment options we cover

• Reference and include applicable clinical practice guidelines and review criteria

• Let you or your Authorized Representative know your options to further Appeal our decision, including procedures for requesting an External Review and an expedited External Review

Standard Internal Appeal time frames

We’ll review and make a decision about your Standard Internal Appeal request within 30 Days* from the date we get your request.

Reviewing medical records as part of

the Standard Internal Appeal

You may send us written comments, documents, or other information relating to your Standard Internal Appeal. If we need to review additional medical records, the Standard Internal Appeal period of 30 Days begins when you, or your Authorized Representative, send us a signed authorization for release of medical records and treatment information, as required. If you don’t provide this authorization within 30 Days of our getting the Standard Internal Appeal request, we may issue a decision on the Standard Internal Appeal without reviewing some or all of the medical records. You have the right to review your case file, which includes information like medical records and other documents and records we considered during the Appeal process.

Expedited Internal Appeals

If a Provider thinks that our standard time frame of 30 Days could seriously harm your life, health, or ability to get back to maximum function, or if it will cause you severe pain that can’t be adequately managed without the requested service, then you or your Authorized Representative may request an Expedited (fast) Internal Appeal. You or your Authorized Representative may request an Expedited Internal Appeal from us orally, in writing, or in person, rather than requesting a Standard Internal Appeal. You or your Authorized Representative may also request an expedited External Review from the Massachusetts Office of Patient Protection (OPP) at the same time you request an Expedited Internal Appeal. For more information, please see the sections on expedited external reviews starting on page 34.

There are three situations when we may review a Standard Internal Appeal in a fast manner, and each situation has a certain time requirement in which we must decide the Appeal:

• If you’re a patient in a Hospital, we must issue a decision before you’re discharged from the Hospital

• If a Provider tells us in writing that a delay in getting the requested service or supply would result in risk of substantial harm to you, we must issue a decision within 72 hours



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• Result from our issuing a Final Adverse Determination (you won’t need a Final Adverse Determination from us if we fail to act within the timelines for the Appeal or if you filed for an expedited External Review from the OPP and an Expedited Internal Appeal from us at the same time)

The OPP will screen your request for an External Review within five business days of receiving the request. Once your case is deemed eligible for External Review, the OPP will submit it to the External Review Agency. The External Review Agency will then send you a written decision within 45 Days.

Expedited External ReviewsYou may request an expedited External Review if your Provider tells the OPP in writing that a delay in providing the care would result in a serious threat to your health. The OPP will screen your review within 72 hours of receiving the request from us. Expedited External Reviews are resolved within four business days from when the External Review Agency gets the referral from the OPP. You may request an expedited External Review at the same time you request an Expedited Internal Appeal from Tufts Health Plan – Network Health.

When your External Review involves a decision by us to end a previously authorized service

If the External Review involves ending ongoing coverage of services, you may apply to the OPP to keep getting the services during the External Review. You need to make the request before the end of the second business day after you get our Final Adverse Determination. If the External Review Agency decides you should keep getting the service because there could be substantial harm to you if the service ends, we’ll keep covering the service until the External Review is decided, no matter what the final External Review decision is.

How to contact the OPP

If you have questions about your rights as a Member or questions about the External Review process, you can contact the OPP at 800-436-7757 or by fax at 617-624-5046, or visit the OPP’s website at mass.gov/hpc/opp.

Reconsideration of a Standard

Internal Appeal

If you’re unhappy with our decision about your Standard Internal Appeal, you or your Authorized Representative may ask for a Reconsideration of our decision. You can also waive your right to a Reconsideration and request an External Review directly from the OPP. You or your Authorized Representative must request a Reconsideration within 30 Days of our denial of your Appeal.

When you or your Authorized Representative asks for a Reconsideration, we must agree in writing to a new time period for review, but it won’t be more than 30 Days from our agreement to review the Appeal decision. If we deny your Reconsideration, you may request an External Review from the OPP. The time period for requesting an External Review begins on the date you get our Reconsideration decision.

External Review process If you get a Final Adverse Determination from us, you have the opportunity to request an External Review from the OPP.

You or your Authorized Representative is responsible for starting the External Review process. We’ll enclose an External Review form any time we issue a Final Adverse Determination. To start the review, send the required form to the OPP within 120 Days of getting our Final Adverse Determination.

Health Policy Commission Office of Patient Protection 2 Boylston Street, Sixth Floor Boston, MA 02116

If you’ve been getting a Covered Service and we end coverage of the service, the disputed coverage will continue at our expense through the end of the Appeal process, as long as you request an External Review within the second business day of getting your Final Adverse Determination. If the External Review Agency decides you should keep getting the service because there could be substantial harm to you if the service ends, we’ll keep covering the service until the External Review is decided, no matter what the final External Review decision is.

The OPP will screen all requests for External Reviews to see if they:

• Meet the requirements of the External Review

• Don’t involve a service or benefit we specify in this Member Handbook as excluded from coverage


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called Coordination of Benefits. Through this Coordination of Benefits, you’ll often get your health insurance coverage as usual through us. If you have other health insurance, our coverage will always be secondary when the other plan provides you with health care coverage, unless the law states something different. In other situations, such as for care we don’t cover, an insurer other than us may be able to cover you. If you have additional health insurance, please call us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m., to find out how payment will be handled.

If you have comprehensive health insurance with another health plan, including Medicare, you can’t get Commonwealth Care benefits. If you fit this category, the Health Connector will disenroll you from Tufts Health Plan – Network Health. The Health Connector will notify you about this.

SubrogationIf another person’s action or omission injures you, your Tufts Health Forward benefits will be subrogated. Subrogation means that we may use your right to recover money from the person(s) who caused the injury or from any insurance company or other party. If another person or party is, or may be, liable to pay for services related to your illness or injury that we paid for or provided, we’ll subrogate and succeed to all your rights to recover against such person or party 100% of the value of services we pay for or provide.

Your Provider should submit all claims incurred as a result of any Subrogation case before any settlement. We may deny Claims for services rendered before a settlement that your Provider doesn’t submit before that settlement is reached.

In the event another party reimburses any medical expense we pay for, we are entitled to recover from you 100% of the amount you got for such services from us. Attorney’s fees and/or expenses you incur won’t reduce the amount you must pay back to us.

To enforce our Subrogation rights under this Member Handbook, we’ll have the right to take legal action, with or without your consent, against any party to recover the value of services we provide or cover for which that party is, or may be, liable. Nothing in this Member Handbook may be interpreted to limit our right to use any means provided by law to enforce our rights to Subrogation under this plan.

We need you to follow all requirements for Prior Authorization even when third-party liability exists. Authorization isn’t a guarantee of payment.

You may also contact the OPP by email at [email protected] or by mail at:

Health Policy Commission Office of Patient Protection 2 Boylston Street, Sixth Floor Boston, MA 02116

Questions or concerns?

If you have questions or concerns about the Grievance and/or Appeal process, please call our Member Services Team at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m.

When you have additional insuranceYou must tell us if you have any other health insurance coverage in addition to Commonwealth Care. You must also let us know when there are any changes in your additional insurance coverage. The types of additional insurance you might have include:

• Coverage from an employer’s group health insurance for employees or retirees, either for yourself or your spouse

• Coverage under Workers’ Compensation because of a job-related illness or injury

• Coverage from Medicare or other public insurance

• Coverage for an accident where no-fault insurance or liability insurance is involved

• Coverage you have through veteran’s benefits

• “Continuation coverage” that you have through COBRA (COBRA is a law that requires employers with 20 or more employees to let employees and their dependents keep their group health coverage for a time after they leave their group health plan under certain conditions.)

We’re the payer of last resort for medical services involving Coordination of Benefits and third-party liability or Subrogation. Please see the following sections for more information.

Coordination of BenefitsWhen you have other health insurance coverage, we work with your other insurance to coordinate your Tufts Health Forward benefits. The way we work with the other companies depends on your situation. This process is



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Notice of Privacy PolicyWe’re committed to protecting your rights and privacy. Our Notice of Privacy Policy describes how we may use and disclose your Protected Health Information (PHI), and how you can access this information. Please review this section carefully. You can also read the Notice of Privacy Practices at Network-Health.org, or get another copy by calling us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m.

Our responsibilitiesWe are required by law to maintain the privacy of your individually identifiable health information, known as PHI, across our organization, including oral, written, and electronic PHI. We ensure the privacy of your PHI in a number of ways. For example, employees don’t discuss your PHI in public areas. We monitor breaches of security. We keep any paper PHI in secure spaces. We must follow the terms of this notice (or any revised notice) when using or disclosing your PHI. We may revise this notice at any time. If we do, changes will apply to all of your PHI that we maintain, and we’ll make a copy of the revised notice available at Network-Health.org or upon request.

Uses and disclosures without your authorization

We may use and disclose your PHI without your written authorization for the following purposes, or as otherwise permitted or required by law:

• Treatment — to help Providers provide, coordinate, or manage your care (for example, we may share your PHI with another Provider to coordinate a Prior Authorization)

• Payment — to help us, or other health plans and Providers with whom you have or had a relationship, get payment of Premiums for your health coverage, and meet our responsibility to provide your Commonwealth Care benefits

• Health care operations — to help us, or other health plans and Providers with whom you have or had a relationship, improve the quality and cost effectiveness of the care we deliver

• Disclosure to the Health Connector — to operate, monitor, audit, and administer benefits, or to report suspected Commonwealth Care Member and/or Provider Fraud

Member cooperationAs a Tufts Health Forward Member, you agree to cooperate with us in using our Coordination of Benefits and Subrogation rights. This means you must complete and sign all necessary documents to help us use our rights, and you must notify us before settling any claim arising out of injuries you sustained by any liable parties for which we have provided coverage. You must not do anything that might limit our right to full reimbursement.

We ask that you:

• Give us all information and documents we ask for

• Sign any documents we think are necessary to protect our rights

• Promptly assign us any money you get for services that we’ve provided or paid for

• Promptly let us know of any possible Coordination of Benefits or Subrogation potential

You also must agree to do nothing to prejudice or interfere with our rights to Coordination of Benefits or Subrogation. If you aren’t willing to help us, you may have to pay for any expenses we may incur, including reasonable attorneys’ fees, in enforcing our rights under this plan. Nothing in this Member Handbook may be interpreted to limit our right to use any means provided by law to enforce our rights to Coordination of Benefits or Subrogation under this plan.

Motor vehicle accidents and/or work-related injury/illnessIf you’re in a motor vehicle accident, you must use all of your auto insurance carrier’s medical coverage, including Personal Injury Protection (PIP) and/or medical payment coverage, before we’ll consider paying for any of your expenses. You must send us any explanation of payment or denial letters from an auto insurance carrier for us to consider paying a Claim that your Provider sends to us.

In the case of a work-related injury or illness, the Workers’ Compensation carrier will be responsible for those expenses first. You must send to us any explanation of payment or denial letters from the Workers’ Compensation carrier for us to consider paying a Claim that your Provider sends us.


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• Public health — to prevent or control disease, injury, or disability; to report child abuse or neglect; to report information about a product or activity under the jurisdiction of the U.S. Food and Drug Administration; and if authorized by law, to notify a person about any exposure to a communicable disease

• Health oversight — to respond to a health oversight agency responsible for ensuring compliance with the rules of government benefit programs, such as Medicare or Medicaid, or other regulatory programs for which health information is necessary for determining compliance

• Legal proceedings — to respond to a legal order or other lawful process in a judicial or administrative proceeding

• Law enforcement — to respond to the police or other law enforcement officials as required by law or to be in compliance with a court order or other process authorized by law

• Health or safety — to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public

• Specialized government functions — to respond to units of the government with special functions, such as the U.S. military or the U.S. Department of State

• Legal compliance — to comply with applicable federal or state laws and regulations

• Workers’ Compensation — to comply with Workers’ Compensation laws

• Outreach activities — to engage in a face-to-face encounter initiated by you; to give you EXTRAS or to communicate with you about our benefits or services relating to your treatment, Care Management or coordination, or alternative treatments, therapies, Providers, or health care settings

Uses and disclosures that require your written authorization

We won’t use and disclose your PHI without your written approval for the following purposes, unless otherwise allowed or required by law:

• Marketing activities — we must get written authorization to use your PHI in any and all marketing activities, except in a face-to-face encounter or to give you a promotional gift

• Your highly confidential information — we won’t release your PHI relating to alcohol and/or drug abuse treatment, HIV/AIDS, sexually transmitted diseases, genetic testing, pregnancy termination, child abuse, abuse of an adult with a disability, psychotherapy notes, certain mental health or social work communications, or sexual assault counselor communications, except as required or permitted by law

You may change your mind and tell us you no longer approve of our using and disclosing your PHI at any time by writing to us. This exclusion won’t apply to information you’ve already released.

Your rights for privacy practicesYou have the right to:

• Ask us in writing to restrict use or disclosure of your PHI. We may not be able to comply with all requests.

• Ask us in writing to communicate your PHI to you in the way or at the location of your choice. We must comply with any reasonable request.

• Inspect and copy your PHI. If we decline your request, you can appeal our decision.

• Request changes, corrections, or deletions to your PHI that you believe are incorrect or incomplete. We may not be able to comply with all requests.

• Request an accounting of certain PHI disclosures, excluding disclosures made earlier than six years before the date of your request. If you request an accounting more than once during any 12-month period, fees may apply.

• Get a paper copy of this notice at any time.

• Request further information or file a complaint by contacting our privacy officer. You may also file a written complaint regarding your privacy rights with the director of the Office for Civil Rights of the U.S. Department of Health and Human Services. Our privacy officer will provide you with the correct address for the director. We won’t retaliate against you if you file a complaint with us or the Office of Civil Rights.



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For details or to find out how to exercise your rights, visit Network-Health.org, call us at 888-257-1985, or contact:

Tufts Health Plan – Network Health Attn: Privacy Officer 101 Station Landing, Fourth Floor Medford, MA 02155 Email: [email protected]

GlossaryAdvance Directive is a legal document, sometimes called a living will, durable power of attorney for health care, or health care proxy, with written instructions that you create to manage your care if you are no longer capable of making decisions about your own health care. A living will gives instructions for treatment in the case of life-saving or life-sustaining situations. A health care proxy or a durable power of attorney for health care lets you choose someone specifically to make decisions for you if you become ill or incapacitated.

An Adverse Determination is a decision, based on a review of information you provide to us or our designated utilization review organization, to deny, reduce, modify, or end an admission, continued inpatient stay, experimental/investigational service, or any other services, for failing to meet the requirements for coverage, based on Medical Necessity, appropriateness of health care setting, and level of care or effectiveness.

Ancillary Services are tests, procedures, imaging, and support services (such as lab tests and radiology services) you get in a health care setting that help your Provider diagnose and/or treat your condition.

Appeal — see Standard Internal Appeals or Expedited Internal Appeal.

Authorization — see Prior Authorization.

Authorized Representative is someone you authorize in writing to act on your behalf regarding a specific Grievance, Appeal, or External Review by the Office of Patient Protection (OPP). If you’re unable to pick an Authorized Representative, your Provider, a guardian, conservator, or holder of a power of attorney may be your Authorized Representative. You can give your Authorized Representative a standing authorization to act on your behalf if you make this request in writing. This standing authorization will remain in effect until

you revoke it. If you’re a minor, and you’re able by law to consent to a medical procedure, you may appeal our denial of the medical procedure without parent or guardian consent. In that case, you can also pick an Authorized Representative without parent or guardian consent.

Behavioral Health (mental health and/or substance abuse) services include visits, consultations, counseling, screenings, and assessments for mental health and/or substance abuse, as well as inpatient, outpatient, detoxification, and diversionary services.

The “Benefit and Co-payment Summary” is the section included at the end of this Member Handbook to provide a general description of your Tufts Health Forward Plan Type’s Covered Services. It lists benefits, Co-payment amounts if any, and any limits on the benefits your policy covers.

A Benefit Year is the period from July 1 to December 31.

Care Management is how we regularly evaluate, coordinate, and help you with your medical, Behavioral Health (mental health and/or substance abuse), and/or social care needs. Through Care Management, we do our best to make sure you can access high-quality, cost-effective, and appropriate care; get information about disease prevention and wellness; and help you get and stay healthy.

A Claim is a bill your Provider sends us to ask us to pay for services you get.

The Commonwealth Care Health Insurance Program (Commonwealth Care) is run by the state’s Health Connector. It is a subsidized insurance program for uninsured adults with incomes that fall within certain guidelines and who meet other qualifications.

Continuity of Care is how we make sure you keep getting the care you need when your doctor is no longer in our Network, or when you first become a Member and you were getting care from another doctor who is not in our Network.

Coordination of Benefits is how we get money from other sources to pay for your health care needs when you have coverage from more than one insurer.

A Co-payment is a fixed amount you may have to pay for a covered pharmacy or medical service. See also Medical Co-payment and Pharmacy Co-payment.


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A Co-payment Cap is a limit on the amount of Co-payments you can be charged each Benefit Year (July 1 – December 31).

Covered Services are the services and supplies Tufts Health Forward and Commonwealth Care cover. The “Benefit and Co-payment Summary” we include in this Member Handbook includes all of your Covered Services and supplies.

Day means a calendar day, unless business day is specified.

Diabetic Specialty Care is care a Specialist provides to treat diabetes.

Durable Medical Equipment (DME) is equipment that can stand repeated use, is primarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in the home.

Effective Coverage Date means the date on which you become a Member of Tufts Health Forward and are eligible to get Covered Services from Tufts Health Forward Providers.

An Emergency or Emergency Medical Condition is a medical condition, whether physical, behavioral, related to substance use disorder, or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd (e)(1)(B).

Emergency Services Program (ESP) Providers are treatment centers that provide Behavioral Health (mental health and/or substance abuse) emergency services 24 hours a day, seven days a week, per Massachusetts state requirements.

Evidence-based means there is clinical proof that this treatment option is an appropriate way to help you.

Evidence of Coverage (EOC), also referred to as the Member Handbook, means this document, developed by Tufts Health Plan – Network Health and filed with the Health Connector and the Office of Patient Protection (OPP), that details covered services provided by Tufts Health Forward, including, without limitation, any certificate, contract, or agreement of health insurance, including riders, amendments, endorsements, and any other supplementary inserts or a summary plan description issued to a Member.

An Expedited Internal Appeal is an oral or written request for a fast review of an Adverse Determination when your life, health, or ability to attain, maintain, or regain maximum function will be at risk if we follow our standard time frames when reviewing your request. We will review Expedited Internal Appeals and make a decision about a request within 72 hours.

External Review is a request for an External Review Agency to review Tufts Health Plan – Network Health’s final Standard Internal Appeal decision.

An External Review Agency is an accredited company under contract with the Office of Patient Protection and separate from Tufts Health Plan – Network Health that looks at decisions made by Tufts Health Plan – Network Health about a member’s coverage. Providers who work at the designated External Review Agency review all appropriate medical records according to objective, evidence-based medical standards to make a final decision about a Member’s Final Adverse Determination.

Family-planning Services include birth control methods, exams, counseling, education, pregnancy testing, follow-up health care, and some lab tests.

Federal Poverty Level, or FPL, is the income standard that the federal government issues yearly that the Health Connector uses to determine Commonwealth Care eligibility.

Final Adverse Determination is an Adverse Determination made after you have exhausted all remedies available through Tufts Health Plan – Network Health’s formal appeal process.

Fraud is when someone dishonestly gets services or payment for services but doesn’t have a right to them. An example of Fraud is Members lending their Tufts Health Forward Member ID Cards to other people so they can get health care or pharmacy services.



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A Grievance is any expression of dissatisfaction by you or your Authorized Representative, if you identify one, about any action or inaction by Tufts Health Plan – Network Health other than an Adverse Determination. Reasons to file Grievances may include, but aren’t limited to, the quality of care or services provided, rudeness on the part of a Provider or employee of Tufts Health Plan – Network Health, failure to respect your rights, a disagreement you may have with our decision not to approve a request to speed up a Standard Internal Appeal, a disagreement with our request to extend the time frame for resolving an authorization decision or an Appeal, and the retroactive ending of coverage due to fraud.

A Hospital is any licensed facility that provides medical and surgical care for patients who have acute illnesses or injuries and that the American Hospital Association lists as a Hospital or The Joint Commission accredits.

A Tufts Health Plan – Network Health Identification Card (ID Card) is the card that identifies you as a Member of Tufts Health Forward. Your Member ID card includes your name and your Member identification number, and must be shown to Providers before you get services.

In-network Provider is a Provider or Specialist that Tufts Health Plan – Network Health contracts with to provide Covered Services to Members.

Inpatient Services are services that need at least one overnight stay in a hospital setting. This generally applies to services you get in licensed facilities, such as Hospitals and Skilled Nursing Facilities.

An Inquiry is any question or request you have for us.

A Medical Co-payment is a fixed amount you may have to pay for a covered service other than pharmacy.

Medically Necessary or Medical Necessity are services that are, within reason, intended to prevent, diagnose, stop the worsening of, improve, correct, or cure conditions that endanger your life, cause suffering or pain, cause physical deformity or malfunction, may cause or worsen a disability, or could result in making you very sick; and for which no other medical service or site of service could give you the same result, is available and suitable for you, and is more conservative or less costly. Medically Necessary services must be of a quality that meets professionally recognized standards of health care, and must be validated by records including evidence of such Medical Necessity and quality.

A Member is anyone enrolled in a Tufts Health Plan – Network Health plan by choice or by assignment by the Health Connector, or its designees.

Your Member Handbook is this document that details Covered Services you get with Tufts Health Forward. It is our agreement with you, and includes any riders, amendments, or other documents that add to the details of Covered Services.

Member Services Team is the team at Tufts Health Plan – Network Health that handles all of your questions about policies, procedures, requests, and concerns. You can reach our Member Services Team at 888-257-1985. For people with partial or total hearing loss, you can reach our Member Services Team at our TTY line: 888-391-5535. We are available Monday through Friday, from 8 a.m. to 5 p.m.

Member Premium Contribution is the monthly financial contribution that some Commonwealth Care members pay for Commonwealth Care coverage.

Network or Provider Network is the collective group of health care Providers who have contracted with Tufts Health Plan – Network Health to provide Covered Services.

Nonpreferred In-network Providers are Providers or Specialists you can’t see unless we give Prior Authorization. If you see a Nonpreferred In-network Provider or Specialist without Prior Authorization, we may not cover the cost.

Nonsymptomatic Care is care not associated with any visible health signs. Examples include well visits and physical examinations. See also Preventive Care.

Nonurgent Symptomatic Care is care associated with visible health signs and symptoms, but not requiring immediate health attention. Examples include visits for recurrent headaches or fatigue.

Our Notice of Privacy Policy tells you about how we may use and disclose your Protected Health Information (PHI). We include our Notice of Privacy Policy in this Member Handbook.


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24/7 NurseLine is our help line for health questions, 24 hours a day, seven days a week. When you call our 24/7 NurseLine at 888-MY-RN-LINE (888-697-6546), you can talk with a caring and supportive health care professional at any hour and at no cost. Staff members can give you information and support on health care issues like symptoms, diagnoses, and test results as well as treatments, tests, and procedures your Provider has ordered. Staff members don’t give medical advice or replace your Provider.

An Office of Patient Protection (OPP) External Review is a written request to the OPP for review of Tufts Health Plan – Network Health’s final Standard Internal Appeal decision.

An Out-of-network Provider is a provider or specialist we don’t contract with to provide covered services to Members.

Outpatient Medical Care refers to the services provided in a Provider’s office, a day surgery or ambulatory care unit, an emergency room or outpatient clinic, or other location. Outpatient services include all services that aren’t inpatient services.

A Pharmacy Co-payment is a fixed amount you will be asked to pay for a covered pharmacy service.

Plan Type refers to a scope of medical services, other benefits, or both, that are available to eligible individuals who meet specific Commonwealth Care eligibility criteria. Plan Types consist of Plan Type I, Plan Type II, and Plan Type III.

Post-stabilization Care Services are covered services that help you get better and stay healthy after an Emergency health condition. You can get Post-stabilization Care Services at Hospitals and all health care centers that provide emergency services.

Preferred In-network Providers are Providers you can see without your PCP first asking for Prior Authorization.

Premium — see Member Premium Contribution.

Preventive Care includes a variety of services for adults, women, and children, such as annual physicals, blood pressure screenings, immunizations, behavioral assessments for children, and many other services to help keep you from getting sick.

Primary Care is the arrangement of coordinated, comprehensive, medical services you get during a first visit with a provider and at any time after. Primary Care involves an initial medical history intake, medical diagnosis and treatment, Behavioral Health (mental health and/or substance abuse) screenings, communication of information about illness prevention, health maintenance, and authorizations.

A Primary Care Provider (PCP) is a health care professional qualified to provide general medical care for common health care problems who supervises, coordinates, prescribes, or otherwise provides or proposes health care services; initiates Referrals for Specialist care; and maintains continuity of care within the scope of practice. PCPs who are doctors must practice one of the following specialties: family practice, internal medicine, general practice, adolescent and pediatric medicine, or obstetrics/gynecology (for women only). PCPs must be board-certified or eligible for board certification in their area of specialty. You may also choose a nurse practitioner or a licensed physician assistant as a PCP if the nurse practitioner or licensed physician assistant is a participating Provider in our Network. PCPs for people with disabilities, including people with HIV/AIDS, may include practitioners in other specialties.

Prior Authorization is a process that determines if you need a specific health care service or where you can get a specific health care service. Tufts Health Plan – Network Health must authorize certain types of services and Providers before you can get the service or see the Provider. We take into account the benefit, any benefit limits, the Provider’s network status, and other factors as we make our decision.

Protected Health Information (PHI) is any information (oral or written) about your past, present, or future physical or mental health or condition, or about your health care, or payment for your health care. PHI includes any individually identifiable health information, which includes any health information that a person could use to identify you.

A Provider is an appropriately credentialed and licensed individual, facility, agency, institution, organization, or other entity that has an agreement with Tufts Health Plan – Network Health, or its subcontractor, to deliver the Covered Services under this contract.



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The Provider Directory is a publication that lists Tufts Health Forward’s contracted health care facilities and professionals, including PCPs, Specialists listed by specialty, Hospitals, emergency rooms and Emergency Services Program Providers, pharmacies, Ancillary Services, and Behavioral Health (mental health and/or substance abuse) services. You can call us at 888-257-1985 to get a Provider Directory.

Quality Management is the process we use to monitor and improve the quality of care our Members get.

A Reconsideration of a Standard Internal Appeal is a request by you or your Authorized Representative, if you identify one, for us to review our Standard Internal Appeal decision a second time. We will review and make a decision about a Reconsideration of a Standard Internal Appeal request within 30 calendar days of the date we get the request.

A Referral is notification from your Primary Care Provider (PCP) to us that you can get care from a different Provider.

A Rehabilitation Hospital is a facility licensed to provide therapeutic services to help patients restore function after an illness or injury. These facilities provide occupational, physical, and Speech Therapy and skilled nursing care services.

Service Area is the geographical area within which Tufts Health Plan – Network Health has developed a Network of Providers to provide adequate access to Covered Services and is authorized by the Health Connector to enroll Members.

Skilled Nursing Facility is a licensed inpatient facility that provides skilled nursing to Members who don’t require or no longer require the services of an acute-care Hospital.

A Specialist is a doctor who is trained to provide specialty medical services. Examples include cardiologists (heart doctors), obstetricians (doctors who take care of pregnant women), and dermatologists (skin doctors), or for Behavioral Health (mental health and/or substance abuse) services, a psychologist, psychiatrist, or social worker.

Speech Therapy refers to the evaluation and treatment of speech, language, voice, hearing, and fluency disorders.

A Standard Internal Appeal is an oral or written request for Tufts Health Plan – Network Health to review any Adverse Determination. We will review and make a decision about a Standard Internal Appeal request within 30 calendar days of the date we get the request.

Subrogation is the procedure under which Tufts Health Plan – Network Health can recover the full or partial cost of benefits paid from a third person or entity, such as an insurer.

Urgent Care includes services that aren’t emergency or routine.

Utilization Management is our constant process of reviewing and evaluating the care you get to make sure that it is appropriate and what you need.

Utilization Review is our process of reviewing information from doctors and other clinicians to help us decide what services you need to get better or stay healthy. Our formal review methods help us monitor the use of — or evaluate the clinical necessity, appropriateness, or efficiency of — Covered Services, procedures, or settings. The review methods may include but aren’t limited to ambulatory review, prospective review, second opinion, certification, concurrent review, Care Management, discharge planning, or retrospective review.

Workers’ Compensation is insurance coverage employers maintain under state and federal law to cover employees’ injuries and illnesses under certain conditions.

Your Health Form is a series of questions we ask Members so that we can get their most up-to-date health information.


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Tufts Health Forward Benefit and Co-payment Summary

Plan Type I

This “Benefit and Co-payment Summary” gives you information about your Tufts Health Forward benefits. For some of these benefits, you will have to pay a small fee (Co-payment). Some services have limits and/or yearly Co-payment Caps.

Please note: You don’t have to pay a Co-payment for Preventive Care services such as physical examinations, Family-planning Services, contraceptives, health screenings, or vaccinations. For a complete listing of the types of Preventive Care services covered, please visit the U.S. Preventive Services Task Force website: uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.

A Benefit Year runs from July 1 to December 31. The services that you can get and the fees for those services are different depending on your Plan Type. To see which Plan Type you have, check your Tufts Health Plan – Network Health ID card, or call us at 888-257-1985, Monday through Friday, 8 a.m. to 5 p.m. Make sure you review the services you’re eligible for under the “Benefit and Co-payment Summary” for your Plan Type.

You’re responsible for paying the Co-payment amounts listed in this “Benefit and Co-payment Summary.” If you can’t afford the Co-payment at the time you get the service, tell your Provider. You should never go without services that you need because you can’t afford the Co-payment. If you don’t pay the Co-payment at the time of your visit, you will still owe the money to the Provider. The Provider may use a legal method to collect the money from you. Tufts Health Plan – Network Health won’t pay the Provider for the Co-payment that you owe.

This summary gives you a general understanding of your benefits. If you want more information about your benefits, see the section “Covered Services” on page 18. This Member Handbook also has a list of services that aren’t covered.

You must go to Providers (doctors, Hospitals, and other health care professionals) who are part of the Tufts Health Forward Provider Network to get services. For Primary Care, you must see the Primary Care Provider (PCP) you’re assigned to. To choose your PCP, check on your assigned PCP, or change your PCP, please visit us at Network-Health.org, or call us at 888-257-1985. If you want to see providers who aren’t part of the Tufts Health Forward Provider Network, we must give Prior Authorization.

The Tufts Health Forward Provider Network can change at any time. Always check with Tufts Health Plan – Network Health for the most up-to-date information.

If you have questions about your Tufts Health Forward benefits, or if you need help choosing or changing your PCP or locating a Network Provider, call us at 888-257-1985. The Tufts Health Plan – Network Health Member Services Team can help you Monday through Friday, from 8 a.m. to 5 p.m.

All nonemergency out-of-network visits need Prior Authorization.



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COVERED SERVICES CO-PAYMENTS BENEFIT LIMITS & NOTES

OUTPATIENT MEDICAL CARE

Abortion Services No Co-payment

Community Health Center Visits• Primary Care Provider (PCP)

• Specialist

No Co-payment

No Co-payment

Office Visits• Primary Care Provider (PCP)

• Specialist

• Dental Services

• Eye Care (vision care)

No Co-payment

No Co-payment

No Co-payment

No Co-payment

Coverage for routine eye exams for Members once

every 24 months (once every 12 months for diabetics)

from network ophthalmologists or optometrists. One

pair of eyeglasses every 24 months is also covered;

choose from free frame selection, or choose any other

frame up to a maximum credit of $80.

Diabetic Specialty Care No Co-payment

Outpatient Surgery(outpatient hospital/ambulatory surgery centers)

No Co-payment

Lab No Co-payment

X-ray Services No Co-payment Prior Authorization required for some services

High-cost Imaging Services (MRI, CT, PET) No Co-payment Prior Authorization required

INPATIENT MEDICAL CARE

Inpatient Medical CareRoom and Board

(includes deliveries/surgery/radiology

services/labs)

No Co-payment Inpatient medical care covered according to Medical

Necessity and subject to Prior Authorization

PHARMACY

PharmacyMedication via Pharmacy

Medication via Mail

$1 generic drugs and over-the-counter

drugs (Tier 1)

$3.65 preferred brand-name drugs (Tier 2)

$3.65 nonpreferred brand-name drugs

(Tier 3)

$1 generic drugs and select

over-the-counter medications (Tier 1)

$3.65 preferred brand-name drugs (Tier 2)

$3.65 nonpreferred brand-name drugs

(Tier 3)

1-month supply

Co-payments are for first-time prescriptions

and refills

Select over-the-counter medications may be covered

with a prescription

Supplies for diabetes and asthma are covered with a

prescription and don’t have a Co-payment

3-month supply

Co-payments are for first-time prescriptions and refills

Select over-the-counter medications may be covered

with a prescription

Supplies for diabetes are covered and don’t have a

Co-payment

EMERGENCY CARE

Emergency Care No Co-payment

MENTAL HEALTH AND/OR SUBSTANCE ABUSE

Inpatient Mental Health and/or Substance Abuse

No Co-payment Inpatient mental health and/or substance abuse

services covered according to Medical Necessity

and subject to Prior Authorization

Outpatient Mental Health and/or Substance AbuseMethadone Treatment (dosing, counseling, labs)

No Co-payment

No Co-payment

After 12 visits per Benefit Year (July 1 – December 31),

Prior Authorization required

REHABILITATION SERVICES

Cardiac Rehabilitation No Co-payment Requires Prior Authorization

Home Health Care No Co-payment Requires Prior Authorization

Inpatient Skilled Nursing FacilityInpatient Rehabilitation Hospital or Chronic Disease Hospital

No Co-payment

No Co-payment

Maximum of 100 calendar days total per Benefit Year

(July 1 – December 31) at either (or at a combination

of) inpatient Skilled Nursing Facility or inpatient

Rehabilitation Hospital; requires Prior Authorization

Short-term Outpatient RehabilitationPhysical/Occupational/Speech Therapy

No Co-payment

No Co-payment

Requires Prior Authorization


Plan Type I


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Members excluded from paying Pharmacy Co-paymentsYou don’t need to pay a Co-payment for your prescription drugs if:

• You’re pregnant, or during the 60 calendar days after the month your pregnancy ended

• You’re a patient in a nursing facility; chronic-disease, acute, or Rehabilitation Hospital; or intermediate care facility for the mentally retarded

• You’re receiving hospice care

• You’re obtaining family-planning supplies

• You have already met the Co-payment Cap for the current Benefit Year (July 1 – December 31), unless your eligibility changes from Plan Type I to Plan Type II or Plan Type III

Be sure to tell the pharmacist if you’re excluded from Co-payments when you drop off your prescriptions, especially if you are pregnant.


OTHER BENEFITS

Ground Ambulance No Co-payment Emergency transport only; nonemergency transport

covered if Medically Necessary and with Prior

Authorization; see page 21

Breastfeeding services No Co-payment Includes one breast pump, breastfeeding supplies,

and lactation consultants

Dental No Co-payment For detailed list of covered dental

services, see page 46

Durable Medical Equipment (DME)• Supplies

• Prosthetics

• Oxygen and Respiratory Therapy Equipment

• Via Pharmacy

No Co-payment

No Co-payment

No Co-payment

No Co-payment

No Co-payment

May require Prior Authorization; your Provider should

check with Tufts Health Plan – Network Health

Hospice No Co-payment Requires Prior Authorization

Orthotics No Co-payment Requires Prior Authorization; shoe

inserts for diabetics only

Podiatry No Co-payment Medically Necessary nonroutine foot care covered

Routine foot care services for diabetics only

Vision No Co-payment Coverage for routine eye exams for Members once

every 24 months (once every 12 months for diabetics)

from network ophthalmologists or optometrists. One

pair of eyeglasses every 24 months is also covered;

choose from free frame selection, or choose any

other frame up to a maximum credit of $80.

Wellness• Family Planning

• Nutritional Counseling

• Prenatal Care

• Nurse Midwife

No Co-payment

No Co-payment

No Co-payment

No Co-payment

Doesn’t require Prior Authorization




CO-PAYMENT MAXIMUMS

Yearly Co-payment Maximum per Benefit Year per Member

Pharmacy $200



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Services not coveredSee the section “Services Not Covered” on page 23 for the list of services not covered.

Dental Services for Plan Type ITufts Health Plan – Network Health has arranged with DentaQuest, a dental services benefits manager, to administer covered dental benefits for Plan Type I Members only. Through DentaQuest, Tufts Health Plan – Network Health covers the same adult dental services that are covered by the MassHealth Dental Program for adults. You must go to a DentaQuest-participating dental services professional for all covered dental services, and some of these dental services require prior approval to be covered. Also, there are certain dental services that aren’t covered at all (like orthodontic services). For a complete list of services that aren’t covered or require prior approval, please call DentaQuest at 800-209-6280 (TTY: 800-466-7566).

The following is a brief summary of covered dental services.

Diagnostic dental services are covered to your plan maximum with the following

frequencies:

Diagnostic services are tests and other things a doctor or dentist does or sends you to have (like X-rays

and lab tests) to help find out why you’re sick or hurting.

Preventive services, including a cleaning and exam, covered twice per Benefit Year (July 1 – December 31).

X-rays

• A complete series of X-rays or a panoramic X-ray, covered every three years

• Periapical X-rays, up to a complete series, covered with no limitation

• Four bitewings, covered every year

Extractions

Emergency care visits

Some oral surgery (like biopsies and soft-tissue surgery)


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Plan Type II

This “Benefit and Co-payment Summary” gives you information about your Tufts Health Forward benefits. For some of these benefits, you will have to pay a fee (Co-payment). Some services have limits and yearly Co-payment Caps.




This summary gives you a general understanding of your benefits. If you want more information about your benefits, see the section “Covered Services” on page 18. This Member Handbook also has a list of services that aren’t covered.







48



Abortion Services $50 Co-payment


• Specialist

$10 Co-payment

$18 Co-payment


• Specialist


$10 Co-payment

$18 Co-payment

$10 Co-payment


every 24 months (once every 12 months for

diabetics) from network ophthalmologists or

optometrists. One pair of eyeglasses every

24 months is also covered; choose from free frame

selection, or choose any other frame up to a

maximum credit of $80.

Diabetic Specialty Care $10 Co-payment Co-payment is for services to diabetic Members by

a Specialist (other than routine services provided

by a podiatrist, see Podiatry)


$50 Co-payment

Lab No Co-payment

X-ray Service No Co-payment Prior Authorization required for some services

High-cost Imaging Services (MRI, CT, PET) $30 Co-Payment Prior Authorization required




services/labs)

$50 Co-payment Co-payments waived if transferred from another

inpatient unit

Inpatient medical care covered according to

Medical Necessity and subject to Prior

Authorization

PHARMACY


Medication via Mail



$20 preferred brand-name drugs (Tier 2)

$40 nonpreferred brand-name drugs (Tier 3)





1-month supply


and refills

Select over-the-counter medications may be

covered with a prescription

Supplies for diabetes and asthma are covered and

don’t have a Co-payment

3-month supply


and refills




Co-payment

EMERGENCY CARE

Emergency Care $50 Co-payment Co-payment waived if admitted to an

inpatient unit of a Hospital



$50 Co-payment Inpatient mental health and/or substance abuse

services covered according to Medical Necessity

and subject to Prior Authorization

Co-payment waived if transferred from another

inpatient unit


$10 Co-payment

No Co-payment

After 12 visits per Benefit Year,

(July 1 – December 31) Prior Authorization required

Plan Type II


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Inpatient Skilled Nursing FacilityInpatient Rehabilitation Hospital

No Co-payment

$50 Co-payment

Maximum of 100 calendar days total per Benefit

Year (July 1 – December 31) at either (or at a

combination of) inpatient Skilled Nursing Facility

or inpatient Rehabilitation Hospital


inpatient unit


$10 Co-payment

$10 Co-payment

Maximum of 20 sessions (combined) of

physical therapy, occupational therapy, and

Speech Therapy with Prior Authorization

OTHER BENEFITS

Ground Ambulance No Co-payment Emergency transport only; nonemergency

transport covered if Medically Necessary and with

Prior Authorization; see page 21

Breastfeeding services No Co-payment Includes one breast pump, breastfeeding

supplies, and lactation consultants

Durable Medical Equipment (DME) • Supplies

• Prosthetics


• Via Pharmacy

No Co-payment

No Co-payment

No Co-payment

No Co-payment

No Co-payment

May require Prior Authorization; your Provider

should check with Tufts Health Plan –

Network Health


Orthotics No Co-payment Requires Prior Authorization; shoe inserts for

diabetics only

Podiatry $10 Co-payment (nonroutine diabetic)

$18 Co-payment (nondiabetic)

$5 Co-payment

Medically Necessary nonroutine foot care covered


Vision $10 Co-payment (optometrist)

$18 Co-payment (ophthalmologist)


every 24 months (once every 12 months for

diabetics) from network ophthalmologists or

optometrists. One pair of eyeglasses every

24 months is also covered; choose from free frame

selection, or choose any other frame up to a

maximum credit of $80.



• Prenatal Care

• Nurse Midwife

No Co-payment

No Co-payment

No Co-payment

No Co-payment





CO-PAYMENT CAP


Pharmacy

All other Co-payments

$400

$600



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• You’re a patient in a nursing facility; chronic-disease, acute, or Rehabilitation Hospital; or intermediate-care facility for the mentally retarded



• You have already met the Co-payment Cap for the current Benefit Year (July 1 – December 31), unless your eligibility changes from Plan Type II to Plan Type III


Members excluded from paying all other Co-paymentsYou don’t need to pay a Co-payment for all other services if you have already met the Co-payment Cap for the current Benefit Year (July 1 – December 31), unless your eligibility changes from Plan Type II to Plan Type III. If your Plan Type changes, we will apply any Medical Co-payments you have already paid to your new Plan Type’s Co-payment Cap amount.



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Plan Type III

This “Benefit and Co-payment Summary” gives you information about your Tufts Health Forward benefits. For some of these benefits, you will have to pay a fee (Co-payment). Some services have limits and yearly Co-payment Caps.




This summary gives you a general understanding of your benefits. If you want more information about your benefits, see the section“Covered Services” on page 18. This Member Handbook also has a list of services that aren’t covered.







52



Abortion Services $100 Co-payment


• Specialist

$15 Co-payment

$22 Co-payment


• Specialist


$15 Co-payment

$22 Co-payment

$20 Co-payment

Coverage for routine eye exams for Members

once every 24 months (once every 12 months

for diabetics) from network ophthalmologists

or optometrists. One pair of eyeglasses every

24 months is also covered; choose from free

frame selection, or choose any other frame up

to a maximum credit of $80.

Diabetic Specialty Care $20 Co-payment Co-payment is for services to diabetic Members by a

Specialist (other than routine services provided by a

podiatrist, see Podiatry)


$125 Co-payment

Lab No Co-payment

X-ray Services No Co-payment Prior authorization required for some services

High-cost Imaging Services (MRI, CT, PET) $60 Co-payment Prior Authorization required




services/labs)

$250 Co-payment Co-payments waived if transferred from another

inpatient unit

Inpatient medical care covered according to Medical

Necessity and subject to Prior Authorization

PHARMACY


Medication via Mail

$12.50 generic drugs and select








1-month supply

Co-payments are for first-time prescriptions and

refills



Supplies for diabetes and asthma are covered and

don’t have a Co-payment

3-month supply


and refills




Co-payment

EMERGENCY CARE

Emergency Care $100 Co-payment Co-payment waived if admitted to an

inpatient unit of a Hospital



$250 Co-payment Inpatient mental health and substance abuse

services covered according to Medical Necessity and

subject to Prior Authorization


inpatient unit


$15 Co-payment

No Co-payment

After 12 visits per Benefit Year

(July 1 – December 31), Prior Authorization required

Plan Type III


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Inpatient Skilled Nursing Facility (SNF)Inpatient Rehabilitation Hospital

No Co-payment

$250 Co-payment

Maximum of 100 calendar days total per

Benefit Year (July 1 – December 31) at either

(or at a combination of) inpatient Skilled Nursing

Facility or inpatient Rehabilitation Hospital


inpatient unit


$20 Co-payment

$20 Co-payment

Maximum of 20 sessions (combined) of physical

therapy, occupational therapy, and Speech Therapy

with Prior Authorization

OTHER BENEFITS

Ground Ambulance No Co-payment Emergency transport; nonemergency transport

covered if Medically Necessary and with Prior

Authorization; see page 21

Breastfeeding services No Co-payment Includes one breast pump, breastfeeding supplies,

and lactation consultants

Durable Medical Equipment (DME) • Supplies

• Prosthetics


• Via Pharmacy

10% of cost

10% of cost

10% of cost

10% of cost

No Co-payment

May require Prior Authorization; your Provider

should check with Tufts Health Plan –

Network Health


Orthotics No Co-payment Requires Prior Authorization; shoe

inserts for diabetics only

Podiatry $20 Co-payment (nonroutine diabetic)

$22 Co-payment (nondiabetic)

$10 Co-payment

Medically necessary nonroutine foot care covered


Vision $20 Co-payment (optometrist)

$22 Co-payment (ophthalmologist)

Coverage for routine eye exams for members

once every 24 months (once every 12 months

for diabetics) from Network ophthalmologists

or optometrists. One pair of eyeglasses every

24 months is also covered; choose from free

frame selection, or choose any other frame up

to a maximum credit of $80.



• Prenatal Care

• Nurse Midwife

No Co-payment

No Co-payment

No Co-payment

No Co-payment





CO-PAYMENT CAP


Pharmacy

All other Co-payments

$650

$1,200



54



• You’re a patient in a nursing facility; chronic-disease, acute, or Rehabilitation Hospital; or intermediate-care facility for the mentally retarded



• You have already met the Co-payment Cap for the current Benefit Year (July 1 – December 31)

• Your eligibility changes from Plan Type III to Plan Type II and you have already met the new Plan Type’s Co-payment Cap for the current Benefit Year (July 1 – December 31)


Members excluded from paying all other Co-paymentsYou don’t need to pay a Co-payment for all other services if:

• You have already met the Co-payment Cap for the current Benefit Year (July 1 – December 31)

• Your eligibility changes from Plan Type III to Plan Type II and you have already met the new Plan Type’s Co-payment Cap for the current Benefit Year (July 1 – December 31)


Documents

Tufts Health Forward Member Handbook · Don’t risk losing your health benefits because we can’t find you. If you move, you must call the Commonwealth Health Insurance ... Management