Tufts Health Direct. Member Handbook

Transcription

1 2015 Tufts Health Direct Meber Handbook This health plan eets Miniu Creditable Coverage standards and will satisfy the individual andate that you have health insurance. Please see page 6 for additional inforation. Effective Date: January 1, 2015 Issue Date: January 1, 2015

2 Tufts Health Direct Coverage Area Fairhaven Mattapoisett Acushnet West Bridgewater Belont Chilark West Tisbury Oak Bluffs Tisbury Scituate Norwell Duxbury Kingston Rockland Whitan Brockton Avon Holbrook Cohasset Orange Warwick Blandford Chester Huntington Granville Southwick Tolland Granby Pelha Ashby Townsend Ashburnha Athol Barre Hardwick Hubbardston Oakha Petersha Royalston Westinster Winchendon New Braintree Holland Sturbridge Webster East Longeadow Longeadow Princeton Rutland Holden Sterling West Boylston Clinton Shrewsbury Berlin Upton Holliston Medway Seekonk Soerset Dover Millis Sharon Rehoboth Dighton Berkley Freetown Bridgewater Halifax Rochester Lakeville Middleborough Carver Plypton Wellesley New Bedford Littleton Groton Harvard Acton Westford Boxborough Concord Carlisle Billerica Tewksbury Andover Dracut Dunstable Pepperell Hudson Stow Bolton Braintree Canton Dedha Needha Norwood Westwood Winchester Stoneha Arlington Essex Ipswich Manchester by-the-sea Marblehead Merriac Rockport Salisbury Saugus Swapscott West Newbury Aquinnah Gosnold Nahant Montgoery Russell Westport Dartouth Norton Foxborough Plainville Attleboro North Attleboro Mansfield Douglas Sutton Mendon Grafton Hopkinton Westfield West Springfield Agawa New Sale Phillipston Tepleton Marlborough Maynard Southborough Westborough Sherborn Blackstone Northbridge Franklin Ashland Hopedale Milford Millville Paler Warren Monson Wales Charlton Oxford Ludlow Ayer Tyngsborough Chelsford Holyoke Springfield Chicopee Southapton Ware Gardner Fitchburg Leoinster Lunenburg Shirley Lancaster Boylston Worcester Paxton North Brookfield West Brookfield Brookfield East Brookfield Leicester Auburn Millbury Brifield Southbridge Dudley Northborough Raynha Chelsea Natick Weston Wayland Wrentha North Reading Reading Woburn Middleton Danvers Hailton Wenha Beverly Peabody Sale Lynn Topsfield Gloucester Bedford Watertown Lynnfield Newton Brookline Boston Milton Walpole Quincy Norfolk Medfield Stoughton Weyouth Easton Abington Taunton Swansea Fall River Provincetown Truro Wellfleet Eastha Orleans Chatha Dennis Yarouth Sandwich Mashpee Bourne Falouth Wareha Harwich Brewster Barnstable Winthrop East Boston Everett Revere Methuen Haverhill Lowell Aesbury Newbury Groveland Georgetown Boxford North Andover Melrose Medford Lincoln Cabridge Malden Wakefield Soerville Newburyport Lawrence Hull South Hadley Plyouth Spencer Bellingha East Bridgewater Lexington Wilington Burlington Hingha Edgartown Rowley Waltha Hapden Wilbraha Fraingha Hanover Marshfield Pebroke Hanson Belchertown Uxbridge Marion Randolph Nantucket Sudbury Easthapton Adas Becket Cheshire Clarksburg Florida Hinsdale Lee Lenox Monterey North Adas Otis Peru Pittsfield Sandisfield Savoy Sheffield Washington Windsor Buckland Ashfield Charleont Colrain Conway Erving Gill Hawley Heath Monroe Montague Northfield Rowe Shelburne Whately Chesterfield Cuington Goshen Plainfield Tyringha New Marlborough Great Barrington Wendell New Ashford Hancock Lanesborough Williastown Dalton Richond Egreont Alford Mount Washington Northapton Middlefield Worthington Bernardston Greenfield Williasburg Sunderland Hatfield Hadley Shutesbury Leverett West Stockbridge Stockbridge Deerfield Leyden Aherst Westhapton SOUTHERN CENTRAL WESTERN NORTHERN GREATER BOSTON Region border Coverage areas Service area border

3 Welcoe! This handbook is full of inforation 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 iportant inforation to keep handy. Contact us: , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays TTY: (for people with partial or total hearing loss) Web: Network-Health.org Mail: 101 Station Landing, Fourth Floor, Medford, MA We have bilingual staff available and we offer translation services in 200 languages. All translation services are free to ebers. Call us: If you ove or change your phone nuber Don t risk losing your health benefits because we can t find you. If you ove, you ust call the Health Connector and us to tell us your new address and phone nuber. You should also put the last naes of all Tufts Health Direct Mebers in your household on your ailbox. The post office ay not deliver ail fro the Health Connector or us to soeone whose nae is not listed on the ailbox. If you ove, call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.., and Tufts Health Plan Network Health at , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays, to update your contact inforation. Also, tell the Health Connector about any changes in your incoe, faily size, eployent status, or disability status; if you becoe pregnant; or if you have additional health insurance. To find out if other household ebers are eligible for an affordable health plan If other people in your hoe ay be eligible for an affordable health plan, we can help! Call us at They can also call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. If you want to change your Priary Care Provider (PCP) You can switch your PCP up to three ties a year for any reason by calling us at , or by visiting us at Network-Health.org. IN AN EMERGENCY GET CARE RIGHT AWAY: Take iediate action if you believe that you are in a life-threatening eergency situation. For edical or Behavioral Health (ental health and/or substance abuse) Eergencies, call 911 or go to the nearest eergency roo right away. For Behavioral Health Eergencies, you ay also call the local Eergency Services Progra (ESP) Provider in your area. Please call us at or visit us at Network-Health.org for a coplete list of eergency roos and ESPs in Massachusetts, or call the statewide directory at 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 to ask for a copy of the Provider Directory. Bring your Tufts Health Direct Meber ID card with you. Tell your PCP and, if applicable, your Behavioral Health Provider within 48 hours of an Eergency to get any necessary follow-up care. You don t need Prior Authorization for any eergency care, including abulance 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 proble that is serious but does not put your life in danger or risk peranent daage to your health, call your PCP or Behavioral Health Provider. Your PCP or Behavioral Health Provider can usually address these health probles. You can contact any of your Providers offices 24 hours a Day, seven Days a week. Make an appointent if your Provider asks you to coe in. If you request an Urgent Care appointent, your Provider ust see you within 48 hours. Meber Services hours: If you want to talk to a Meber Services representative who can answer your questions, call us at , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. We re also available at , 24 hours a Day, seven Days a week, to help with any edical or behavioral health questions or needs. 24/7 NurseLine: 888-MY-RN-LINE ( ) (TTY: ), for general health inforation and support, 24 hours a Day, seven Days a week 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 Network Health Meber Connect, and: Change your address or phone nuber Choose or change your PCP Use the secure essaging center to send us inforation and questions Get answers to your questions Download the fors to get your Tufts Health Direct EXTRAS Get iportant inforation, such as: How we ake sure you get the best care possible (Quality Manageent and Iproveent Progra) How we ake sure you get the right care in the right place (Utilization Manageent Progra). Note: We never reward our staff for denying care How we use inforation your Providers give us to decide what services you need to ake you better or keep you healthy (Utilization Review) How you can file a Grievance or an Appeal How you have the right to request an External Review if we deny an Appeal, as well as your other rights and responsibilities How we ay collect, use, protect, and release inforation about you and your health (your Protected Health Inforation) according to our privacy policy Learn uch ore!

4 2015 Tufts Health Public Plans, Inc. 4817A 11174

5 Table of contents Welcoe... 6 Translation and other forats Your Tufts Health Direct Evidence of Coverage Miniu creditable coverage and andatory health insurance requireent Cost sharing... 7 Preius Co-payents Deductibles Co-insurance Out-of-pocket Maxiu Benefit Year Getting the care you need... 9 Your Meber ID Card Eergency care Urgent Care Getting Hospital services Getting care after office hours Getting care away fro hoe Tufts Health Plan Network Health Providers...11 Getting inforation about Tufts Health Direct Providers Your PCP Specialists Second opinions Prior Authorization Standard Prior Authorizations Concurrent review Prior Authorization approvals and denials Reconsideration of an Adverse Deterination Continuity of Care...14 New Mebers Current Mebers Conditions for coverage of Continuity of Care Eligibility, enrollent, renewal, and disenrollent...15 Eligibility No Waiting Period or Pre-existing Condition Liitations Effective Coverage Date Renewing your coverage Disenrollent Health plan changes Continuing coverage for group Mebers...20 Continuation of group coverage under federal law (COBRA) Continuation of group coverage under Massachusetts law Covered Services Services we cover If you get a bill for a Covered Service Services not covered Care Manageent...34 Health and wellness support Disease anageent progras Transition of care Integrated care anageent Quality Manageent Utilization Manageent Utilization Review clinical guidelines and review criteria Experiental and/or investigational drugs and procedures Tufts Health Direct EXTRAS...40 How to resolve concerns...42 Inquiries Grievances Appeals External Review process Expedited External Reviews Questions or concerns? Your rights and responsibilities...46 Your Meber rights Your rights for privacy practices Advance Directives Your Meber responsibilities More inforation available to you Protecting your benefits...48 Our responsibilities Notice of Privacy Policy Multicultural Health Care Privacy Protection Policy When you have ore insurance...50 Coordination of Benefits Subrogation Meber cooperation Motor vehicle accidents and/or work-related injury/illness Glossary Benefit and Cost Sharing Suaries A great health plan at a great price Keep this handbook it has all the inforation you need to ake the ost of your ebership. If you have any questions, please call us at Mebers with partial or total hearing loss should call our TTY line at for assistance. 5

6 Welcoe You deserve great care. We want you to get the ost out of your Tufts Health Direct ebership. 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 Direct Mebers in all or parts of the following counties: Barnstable, Berkshire, Bristol, Essex, Hapden, Hapshire, Middlesex, Norfolk, Plyouth, Suffolk, and Worcester. For a coplete listing of our Providers, or to see a ap of our Service Area, please visit Network-Health.org. To help you understand what you need to know about your health plan, we have capitalized iportant words and ters throughout this Meber Handbook. You can find definitions for each in the Glossary starting on page 51. Tufts Health Public Plans, Inc. is licensed as a health aintenance organization in Massachusetts but does business under the nae Network Health. Translation and other forats Call us at , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays, if you: Have questions Need this docuent translated Need soeone to read this or other printed inforation to you Want to learn ore about any of our benefits or Covered Services We have bilingual staff available. And we offer translation services in 200 languages. All translation services are free to Mebers. Your Tufts Health Direct Evidence of Coverage This Meber Handbook, including the Benefit and Cost Sharing Suary for each Plan Level at the end of this handbook, your Preferred Drug List, and any aendents we ay send you, ake up your Evidence of Coverage. By signing and returning your enrollent application to us or the Health Connector, and choosing Tufts Health Direct as your health plan, you applied for coverage fro Tufts Health Plan Network Health. You also agree to all the ters and conditions of Tufts Health Direct that we and the Health Connector set forth, and to the ters and conditions of this handbook. This handbook explains your rights, benefits, and responsibilities as a Tufts Health Direct Meber. It also explains our responsibilities to you. If there are any ajor plan changes, we ll ail you a letter 60 days before the changes go into effect. Only an approved officer of Tufts Health Plan Network Health can change this Meber Handbook and only in writing. No other actions, including any exceptions we ake on a case-by-case basis, change this Meber Handbook. Miniu creditable coverage and andatory health insurance requireent Massachusetts law requires that Massachusetts residents, 18 years old and older, ust have health coverage that eets the Miniu Creditable Coverage standards that the Health Connector sets, unless waived by the Health Connector for affordability or individual hardship. For ore inforation, call the Health Connector at (TTY: ) or visit the Health Connector s website at MAhealthconnector.org. This health plan eets Miniu Creditable Coverage standards as part of the Massachusetts Health Care Refor Law and Miniu Essential Coverage standards under the federal Affordable Care Act. If you enroll in this plan, you will satisfy the statutory requireent that you have health insurance eeting 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. These docuents are a contract between you and Tufts Health Plan Network Health. 6 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a Day, seven Days a week. You can also visit us at Network-Health.org.

7 Cost sharing Preius Individuals and groups ay have to pay a Preiu for Tufts Health Direct coverage. A Preiu is a onthly bill you pay for your Tufts Health Direct benefits. If you are part of a group, you pay your eployer, who pays your Preiu. You ust send your Preiu by the due date stated on the bill every onth for your health benefits to go on. Please follow the payent directions on your bill when paying your Preius. If you have questions about your Preiu, please call the nuber listed on your bill. If an individual or group is late (delinquent) in paying required Preius, we, at our sole discretion, ay stop payent of Clais and/or Prior Authorization of services until we get the full Preiu payent. Note: The aount of Preiu an individual or group is required to pay ay change during the ter of this Meber Handbook. You will receive notice about any Preiu changes. We will send an annual notice with the Preiu that ust be paid. Federal Preiu Tax Credit and ConnectorCare plans You ight be eligible for a Federal Preiu Tax Credit if your household incoe is up to 400% of the Federal Poverty Level (FPL). The Departent of Health and Huan Services sets the FPL. If you are eligible for a tax credit, then the United States governent will pay part of your Tufts Health Direct Preius directly to Tufts Health Plan Network Health. You ight also be eligible for a lower-cost ConnectorCare plan if your household incoe is up to 300% of the FPL. If you are eligible, the state of Massachusetts will pay part of your Tufts Health Direct Preius directly to Tufts Health Plan Network Health. This would be in addition to any tax credits you ight qualify for, further decreasing your cost sharing. The Health Connector can help you find out if you are eligible for a ConnectorCare plan and/or Federal Preiu Tax Credit, and, if so, how uch. Co-payents Co-payents are set dollar aounts that are due when you get care or a service, or when billed by a Provider. You re responsible for paying all of the Co-payents listed in your Plan Level s Benefit and Cost Sharing Suary starting on page 58. You will need to pay a Co-payent for Covered Services, such as doctors visits, pharacy services, advanced iaging (MRIs, PET, CT scans), eergency roo visits, and care you get in the Hospital. Preventive services don t have any Co-payents. If you don t pay the Co-payent at the tie of your visit, you ll still owe the oney to the Provider. The Provider ay use a legal ethod to collect the oney fro you. We are not responsible for paying the Provider the Co-payent that you owe. Aerican Indians and Alaskan Natives do not need to pay Co-payents or Co-insurance for services received through the Indian Health Service. Aerican Indians and Alaskan Natives who ake less than 300% of the FPL never pay Co-payents and Co-insurance regardless of where a service is received. Deductibles Your Tufts Health Direct plan ay have an annual Deductible. The Deductible is the aount you pay for certain Covered Services in a Benefit Year before we will begin to pay for those Covered Services. Your Benefit and Cost Sharing Suary will show if you have any Deductible aounts. You ay have a edical Deductible, and a separate pharacy Deductible. Once you eet your annual Deductible, you ay still have to pay Co-payents and Co-insurance. Please see your Benefit and Cost Sharing Suary for inforation specific to your Plan Level. Individual Deductible: the aount an individual Meber pays each year for certain Covered Services before we as your health plan begin to pay for those services Faily Deductible: The faily Deductible applies to all ebers of a faily. Any aount a faily Meber pays is applied to the faily Deductible. Once the faily Deductible has been et during a Benefit Year, all Mebers in a faily will have et their Deductibles for the rest of that Benefit Year. For Health Connector plan-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 7

8 Not all services apply toward a Deductible. There are services that require a Co-payent, Co-insurance, those with no charge, and those that are subject to a Deductible. Co-payents do not count toward your Deductible. Notes: The following are not included in the Deductible: Co-payents, Co-insurance, prescription drug Deductibles (if applicable), Preius, and any payents you ake for noncovered services. Payents you ade for Covered Services you got before the start of a Benefit Year are not counted toward your Deductible in the current Benefit Year. At the start of each new Benefit Year, your Deductible accuulation will begin at zero and you will start building again toward your Deductible for the new Benefit Year. The aount credited toward a Meber s Deductible is based on our allowed aount on the date of service. Prescription drug Deductible Your plan ay have a separate Deductible for certain prescription drugs. This is the aount you pay for certain covered prescription drugs in a Benefit Year before we will begin to pay for those covered drugs. Once you eet your prescription Deductible, you pay only the applicable Co-payent or Co-insurance for those drugs for the reainder of the Benefit Year. Please see your Benefit and Cost Sharing Suary for inforation specific to your Plan Level. Individual prescription Deductible: the aount an individual Meber pays each Benefit Year for certain covered prescription drugs before we as your health plan begin to pay for those drugs Faily prescription Deductible: The faily prescription Deductible applies to all ebers of a faily. Any aount a faily Meber pays toward his or her prescriptions is applied to the faily prescription Deductible. Once the faily prescription Deductible has been et during a Benefit Year, all Mebers in a faily will have et their prescription Deductibles for the rest of that Benefit Year. Notes: Payents you ade for covered prescription drugs you got before the start of a Benefit Year are not counted toward your prescription Deductible in the current Benefit Year. At the start of each new Benefit Year, your prescription Deductible accuulation will begin at zero and you will start building again toward your prescription Deductible for the new Benefit Year. The aount credited toward a Meber s prescription Deductible is based on our allowed aount on the date of service. Co-insurance Co-insurance is a percentage of the total allowed aount that you ust pay for certain Covered Services. After you have et any Deductible you ay have, you will be responsible for that set percentage. We will be responsible for the rest of the cost. You pay the Co-insurance on the date of service. If your Plan Level requires Co-insurance, the Co-insurance percentages are listed in your Benefit and Cost Sharing Suary. Note: Co-insurance you paid for Covered Services you got before the start of a Benefit Year is not counted toward your Out-of-pocket Maxiu for your current Benefit Year. At the start of each new Benefit Year, your accuulation will begin at zero and you will start building again to your annual Out-of-pocket Maxiu for the new Benefit Year. Out-of-pocket Maxiu Your Tufts Health Direct plan ay have an Out-of-pocket Maxiu. This is the axiu aount of cost sharing you have to pay in a Benefit Year for ost Covered Services. The Out-of-pocket Maxiu is ade up of: Deductibles, Co-payents, and Co-insurance. However, it does not include: Any aount you pay for prescription drug Co-payents, prescription drug Co-insurance, and prescription Deductibles* Preius Meber costs that are ore than the allowed aount for Covered Services paid by the plan to Out-ofnetwork Providers Costs for noncovered services 8 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a Day, seven Days a week. You can also visit us at Network-Health.org.

9 Once you eet your Out-of-pocket Maxiu, you no longer pay Deductibles, Co-payents, or Co-insurance for the rest of that Benefit Year (except for prescription drug Co-payents, prescription drug Co-insurance, and prescription Deductibles*). * Unless your Benefit and Cost Sharing Suary states otherwise Individual Out-of-pocket Maxiu: the axiu aount of cost sharing an individual has to pay in a Benefit Year for ost Covered Services Faily Out-of-pocket Maxiu: Any aount a faily Meber pays is applied toward the faily Out-of-pocket Maxiu. Once the faily Out-of-pocket Maxiu has been et during a Benefit Year, all Mebers in a faily will have et their Out-of-pocket Maxiu for the rest of that Benefit Year. Note: Deductibles, Co-payents, and Co-insurance you paid before the start of a Benefit Year are not counted toward your Out-of-pocket Maxiu for your current Benefit Year. At the start of each new Benefit Year, your accuulation will begin at zero and you will start building again toward your annual Out-of-pocket Maxiu for the new Benefit Year. Benefit Year The Benefit Year is the consecutive 12-onth period during which: Health plan benefits are purchased and adinistered Deductibles, Co-insurance, and Out-of-pocket Maxius are calculated Most benefit liits apply Note: In soe cases, described below, your first Benefit Year will not be a full 12 onths. If your first Benefit Year is less than 12 onths, we will prorate your Deductibles and Out-of-pocket Maxius. This eans that your Deductibles and Out-of-pocket Maxius will be proportionately lower for a shorter Benefit Year. If you enrolled (due to a qualifying event) at any other tie of the year, your first Benefit Year begins on the date of the qualifying event and continues until Deceber 31, (This eans your first Benefit Year is not a full 12 onths.) See page 17 for ore inforation. For Subscribers enrolled through a group contract: Your Benefit Year begins on the group effective date (always the first of a calendar onth) and continues for 12 onths fro that date. (For exaple, if the group effective date is April 1, your Benefit Year runs fro April 1 to March 31.) If you are a new eployee who becae a Subscriber after the group effective date, your Benefit Year is the sae as the Benefit Year for all Subscribers in your group. That eans that your first Benefit Year will not be a full 12 onths. For new Dependents who are added during a Benefit Year (for exaple, a new baby or new spouse): The new Dependent s Benefit Year begins on his or her Effective Coverage Date and runs for the sae tie period as the Subscriber s Benefit Year. Getting the care you need Your Meber ID Card Always be sure to carry your Tufts Health Direct Meber ID Card. It has iportant inforation about you and your benefits that Providers and pharacists need. Each person in your faily with Tufts Health Direct will get a Tufts Health Direct Meber ID Card. Eergency care For edical and Behavioral Health (ental health and/or substance abuse) Eergencies, call 911, or go to the nearest eergency roo right away. Please call us at or use the Find a Doctor, Hospital, or Pharacy tool at Network-Health.org for a coplete list of eergency roos in Massachusetts. Bring your Tufts Health Direct Meber ID Card with you. For individual Subscribers: If you enrolled during an annual open enrollent period, your Benefit Year begins on your Effective Coverage Date and continues until Deceber 31, For Health Connector plan-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 9

10 You don t need approval fro us or your Provider to get eergency care. You can get eergency care 24 hours a Day, seven Days a week, wherever you are, even when you re traveling. We also cover eergencyrelated abulance transportation and post-stabilization care services, which is care to help you get better after an Eergency. A Provider will exaine and treat your eergency health needs before sending you hoe or oving you to another Hospital, if necessary. Tell us, your Priary Care Provider (PCP) and, if applicable, your Behavioral Health Provider what happened within 48 hours of an Eergency to get any needed follow-up care. If the eergency departent where you were seen notifies us or your PCP, then you don t need to tell us. Exaples of edical Eergencies: Chest pain Bleeding that won t stop Broken bones Seizures or convulsions Dizziness or fainting Poisoning or drug overdose Serious accident Sudden confusion Severe burn Severe headache Shortness of breath Voiting that won t stop Exaples of Behavioral Health (ental health and/or substance abuse) Eergencies: Violent feelings toward yourself or others Hallucinations Urgent Care 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. Provider offices have covering Providers who work after hours. A covering Provider is a Provider who can help you when your regular Provider is not available. If needed, ake an appointent to visit your Provider. Your Provider ust see you within 48 hours for Urgent Care appointents. If your condition becoes an Eergency before your PCP or Behavioral Health Provider sees you, call 911 or go to the eergency roo. Getting Hospital services If you need Hospital services for soething that isn t an Eergency, please ask your Provider to help you get these services. If you need Hospital services for an Eergency, don t wait. Call 911 or go to the nearest eergency roo right away. For Behavioral Health Eergencies, call 911, or go to the nearest eergency roo right away. Getting care after office hours Talk to your PCP to find out how to get care after noral business hours. Soe 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 probles seeing your PCP or any other Provider, please call us at You can also get free health support fro our 24/7 NurseLine to help you stay healthy 24 hours a Day, seven Days a week. Call 888-MY-RN-LINE ( ) (TTY: ) anytie. You can get help in any languages. The 24/7 NurseLine staff do not give edical advice and do not replace your PCP. Getting care away fro hoe If you re traveling and need eergency care, go to the nearest eergency roo. 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 eergency care, post-stabilization care services, and Urgent Care. 10 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a Day, seven Days a week. You can also visit us at Network-Health.org.

11 We won t cover: Tests or treatent 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 exas, flu shots, stitch reoval, and Behavioral Health (ental health and/or substance abuse) 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 ight ask you to pay for that care at the tie of service. If you re asked to pay for eergency care, post-stabilization care services, or Urgent Care that you get outside of our Service Area, you should show your Tufts Health Direct Meber ID Card. The Provider shouldn t ask you to pay. If you do pay for any of these services, you ay ask us to pay you back. You ay call our Meber Services Tea at for help with any bills that you ay get fro a Provider. Tufts Health Plan Network Health Providers Getting inforation about Tufts Health Direct Providers For the ost up-to-date inforation 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 Pharacy tool. For a copy of our online Provider Directory or to get inforation about a Provider, call our Meber Services Tea at Our online Provider Directory lists the following types of Tufts Health Direct Providers: Priary care sites Priary Care Providers (PCPs) Hospitals Specialty Providers Behavioral Health (ental health and/or substance abuse) Providers In our online Provider Directory, you can find iportant inforation like a Provider s address, phone nuber, hours of operation, handicap accessibility, and languages spoken. Our online Provider Directory also lists all Tufts Health Direct pharacies, facilities, ancillary Providers, hospital eergency services, and durable edical equipent suppliers. You can find this inforation at Network-Health.org. Your PCP As a Tufts Health Direct Meber, you ust choose a Priary Care Provider (PCP) who is in our Tufts Health Direct Network. Your PCP is the Provider you should call for any noneergency health care that you need. You will get the sae Medically Necessary Covered Services whether you choose a Nurse Practitioner, a Physician Assistant, or a doctor as your PCP, as long as they are services the Provider is legally authorized to practice. To choose a Tufts Health Direct PCP and to find out where the PCP s office is located, please use the Find a Doctor, Hospital, or Pharacy tool at Network-Health.org or call us at You can call your PCP s office 24 hours a Day, seven Days a week. If your PCP is not available, your PCP s office will direct you to soebody else who can help you. If you have probles contacting your PCP, or if you have any questions, please call our Meber Services Tea at Here s what your PCP can do for you: Give you regular checkups and health screenings, including Behavioral Health (ental health and/or substance abuse) screenings Make sure you get the health care you need Arrange necessary tests, laboratory procedures, or hospital visits Keep your edical records Recoend Specialists, when necessary Provide inforation on Covered Services that need Prior Authorization before you get treatent Write prescriptions, when necessary Help you get Behavioral Health (ental health and/or substance abuse) services, when necessary For Health Connector plan-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 11

12 PCP assignent If you don t choose a PCP upon enrollent with Tufts Health Plan Network Health, we ll choose one for you near to where you live and tell you your PCP s nae within 15 Days of joining. 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 or visiting Network-Health.org. Specialists Soeties you ay need to visit a Specialist, such as a cardiologist, deratologist, or ophthalologist. Tufts Health Plan Network Health also covers pediatric specialty care, including ental health care, by In-network pediatric Specialists. You can visit ost Specialists without Prior Authorization as long as the Specialist is In-network. To find a Tufts Health Direct Specialist, talk to your PCP. You can also call us at or visit Network-Health.org to search for a Specialist. You should discuss your need for a Specialist with your PCP first, and then call the Specialist to ake an appointent. If you choose to get services outside of our Network, 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 ore inforation about which services need Prior Authorization, please see your Plan Level s Benefit and Cost Sharing Suary section in this Meber Handbook. Referrals for specialty services Soe PCPs ay need to provide you with a Referral for certain specialty services. A Referral is a notification fro your PCP to us that you can get care fro a different Provider. The Referral helps your PCP better guide the care and services you get fro the doctors you see. These services include: Professional services, like a visit to a Specialist Outpatient Hospital visit Surgical day care Your first evaluation for: Speech Therapy Occupational Therapy Physical Therapy Your PCP ay approve a standing Referral for certain specialty care fro an In-network Provider if: Your PCP and the Specialist agree on a treatent plan for you of Medically Necessary Covered Services The Specialist regularly provides your PCP with any needed clinical and adinistrative inforation The Specialist s services provided are consistent with the ters in this Meber Handbook Reeber, your PCP, not you or the Specialist treating you, ust request any ore referrals you ay need. Second opinions Tufts Health Direct Mebers can get a second opinion fro a different Provider about a edical or behavioral health condition or proposed treatent and care plan. You don t need Prior Authorization to get a second opinion fro an In-network Provider about a edical or behavioral health issue or concern. You can see the ost up-to-date list of our In-network Providers at Network-Health.org. Please call us at for help or for ore inforation about picking a Provider to see for the second opinion. Prior Authorization Your Priary Care Provider (PCP) will work with your other Providers to ake 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 ore inforation about which services need Prior Authorization, please see your Plan Level s Benefit and Cost Sharing Suary section in this Meber Handbook or, for the ost 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 ay approve an Out-of-network Provider for you. Out-of-network Providers need Prior Authorization fro us before you can see the. Please visit us at Network-Health.org for the ost up-to-date list of our In-network Providers. 12 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a Day, seven Days a week. You can also visit us at Network-Health.org.

13 You don t need Prior Authorization for eergency health care, post-stabilization care services, In-network Faily-planning Services, and the first 12 Behavioral Health (ental health and/or substance abuse) therapy visits each Benefit Year. You can get eergency services fro any Massachusetts eergency care Provider. You can get Faily-planning Services and the first 12 outpatient Behavioral Health therapy visits fro any Tufts Health Direct-contracted Provider. You do not need Prior Authorization for care provided by an In-network obstetrician, gynecologist, certified nurse idwife, or faily practitioner for an annual preventive gynecologic health exaination, such as any follow-up care, aternity care, or treatent for an acute or eergency gynecological condition. And you won t have higher Co-payents or have ore cost sharing for getting these services without a Prior Authorization. When you need a Prior Authorization for a Behavioral Health service, a Licensed Mental Health Professional will ake the decision whether the ental health or substance abuse service is Medically Necessary. We will not apply treatent liitations or cost sharing to Behavioral Health services that we do not apply to edical services. If you becoe a Tufts Health Plan Network Health Meber by changing fro another Health Connector plan, and a Provider who does not contract with us is treating you, we ll review that treatent and ay let that Provider keep treating you. For ore inforation, please see the Continuity of Care section on page 14. Reeber, you ust get Prior Authorization fro us to keep seeing that Out-of-network Provider. Standard Prior Authorizations We ll ake an initial decision about a Prior Authorization within two business days of getting all necessary inforation. Necessary inforation includes, but is not liited to, the results of any face-to-face clinical evaluation, consults, second opinion, labs, and iaging and/or previous therapies. 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. Reeber: If we don t approve your seeing a Provider or having a procedure that requires Prior Authorization, we won t pay for the services you get. Concurrent review When you are a Hospital patient or are getting treatent for a condition that requires Authorization, we will review your situation to ensure that the right care is given in the right place. This is called a concurrent review. We ake concurrent review decisions within one business day of getting all the necessary inforation fro your Provider. Necessary inforation includes but is not liited to the results of any face-to-face clinical evaluation, consults, second opinion, labs, and iaging and/or previous therapies. The Hospital or your Provider ust notify us of an Eergency or urgent adission within 24 hours. If we approve a longer stay or extra services, we ll let the Hospital or your Provider know within one business day of receiving all necessary inforation. And we ll ail to you and fax to your Provider a confiration within one business day after that. The notification will include: The nuber of extended Days or the next review date The new total nuber of Days or services we ve approved The date of adission or start of services If we deny a longer stay or ore services, we ll let your Provider know within one business day. And we ll ail to you and fax to your Provider confiration of this Adverse Deterination within one business day after that. Ask your Provider for a copy of the Adverse Deterination before you leave the Hospital so that you ay Appeal the decision if you wish. You can keep getting the service at no cost to you until we notify you of our concurrent review decision. Prior Authorization approvals and denials If we approve 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 ust have an authorization letter fro us before giving you care in order to be paid back. If you need ore care than we approved, your Provider will ask us to approve ore services. If we approve the request for ore services, we ll send you, your Provider, and your Authorized Representative another authorization letter. For Health Connector plan-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 13

14 If we don t approve any of the services requested, approve only soe of the services requested, or don t approve the full aount, duration, or scope of the services requested, we ll send you, your Provider, and your Authorized Representative a denial or Adverse Deterination letter. We ll also send a notice if we decide to reduce, delay, or stop covering services that we have previously approved. The Adverse Deterination letter we send will include a clinical explanation for our decision and will: Identify specific inforation we used Discuss your syptos or condition, diagnosis, and the specific reasons why the evidence your Provider sent us fails to eet the relevant edical review criteria Specify alternate treatent options that we cover, if appropriate 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 starting on page 42. Reconsideration of an Adverse Deterination 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 ay use the appeal process described starting on page 42. You don t have to ask us to reconsider an Adverse Deterination before requesting a Standard Internal Appeal or Expedited Internal Appeal. Continuity of Care We support Continuity of Care for new and current Mebers. New Mebers If you are a new Tufts Health Plan Network Health Meber, we ll ake sure any care you are currently getting keeps going as soothly as possible. To ensure Continuity of Care, we ay be able to cover soe health services, including Behavioral Health (ental health and/or substance abuse) services, fro a Provider who isn t part of our Network, including fro a Nurse Practitioner. For exaple, we ay cover: Care you get fro your current OB/GYN if you are at least three onths pregnant (eaning you are starting your fourth onth, based on your expected due date). You can keep seeing your current OB/GYN until you have the baby and a follow-up checkup within the first six weeks of delivery Ongoing covered treatent or anageent of chronic issues (like dialysis, hoe health, cheotherapy, and radiation) for up to 30 Days, including previously approved services or Covered Services Ongoing care for up to 30 Days if the Provider is your PCP Care fro your Provider if you are terinally ill and in active treatent Care fro a Provider or Nurse Practitioner for up to 30 Days if no other health plan options offered by your eployer or group (if applicable) include this Provider Current Mebers If your PCP or another Provider is disenrolled fro our Network for reasons not related to quality of care or Fraud, or if they are no longer in practice, we ll ake every effort to tell you at least 30 Days before the disenrollent. To ensure Continuity of Care, we ay be able to cover soe health services, including Behavioral Health services, fro a Provider who isn t part of our Network, including fro a Nurse Practitioner. For exaple, we ay cover: Care you get fro your current OB/GYN if you are at least three onths pregnant (eaning you are starting your fourth onth, based on your expected due date). You can keep seeing your current OB/GYN until you have the baby and a follow-up checkup within the first six weeks of delivery 14 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a Day, seven Days a week. You can also visit us at Network-Health.org.

15 Ongoing covered treatent for a chronic or acute edical condition for up to 90 Days, or until that Provider copletes the active treatent, whichever coes first Ongoing care for up to 31 Days if the Provider is your Priary Care Provider (PCP) Care fro your Provider if you are terinally ill and in active treatent Your PCP ust ask us for and get Prior Authorization before you can see an Out-of-network Provider. You ay ask your PCP to ask for the Prior Authorization or to call our Meber Services Tea at 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 Meber-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 treatent with an Out-of-network Provider only if the provider agrees to our ters related to reiburseent, quality, Referrals, and additional Tufts Health Plan Network Heath policies and procedures. Conditions for coverage of Continuity of Care Services provided by a disenrolled Provider or an Out-ofnetwork Provider as described in this Continuity of Care section are covered only when you or your Provider obtains Prior Authorization fro us for the continued services, the services would otherwise be covered under this Meber Handbook, and the Provider agrees to: Accept payent fro us at the rates we pay In-network Providers Accept such payent as payent in full and not charge you any ore than you would have paid in cost sharing if the Provider was an In-network Provider Coply with our quality standards Provide us with necessary edical inforation related to the care provided Coply with our policies and procedures, including for Prior Authorization and providing Covered Services pursuant to a treatent plan we approve, if any Eligibility, enrollent, renewal, and disenrollent Eligibility The Health Connector deterines eligibility for Tufts Health Direct Subscribers and their Dependents. Subscribers and their Dependents ust eet these requireents to be enrolled in Tufts Health Direct through the Health Connector or directly with us. Eligible individuals include Massachusetts residents who live in our Service Area. Please contact the Health Connector for ore inforation about eligibility if you are applying for assistance paying for your health insurance coverage. We and the Health Connector ay require reasonable verification of eligibility fro tie to tie. If you eet the applicable eligibility requireents, we will accept you into Tufts Health Direct. You ay stay enrolled in Tufts Health Direct for as long as you keep eeting the eligibility requireents and your Preiu is paid. When we get notice of your enrollent fro the Health Connector, we will send you a Meber ID card and ore inforation about your plan. Acceptance into our plan is never based on your: Incoe Physical or ental condition Age Occupation Clais experience Duration of coverage Medical condition Gender Sexual orientation Religion Physical or ental disability Ethnicity or race Previous status as a Meber Pre-existing conditions Actual or expected health condition For Health Connector plan-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 15