Tufts Health Unify Member Handbook

Transcription

1 2015 Tufts Health Unify Member Handbk H7419_4818A CMS Accepted

2 Tufts Health Unify Member Handbk January 1, 2015 December 31, 2015 Yur Health and Drug Cverage under the Tufts Health Unify Medicare-MassHealth Plan This handbk tells yu abut yur cverage under Tufts Health Unify thrugh December 31, It explains health care services, behaviral health cverage, prescriptin drug cverage, and lng-term services and supprts. Lng-term services and supprts prvide the care yu need at hme and may reduce yur chances f ging t a nursing facility r hspital. This is an imprtant legal dcument. Please keep it in a safe place. Tufts Health Unify (Medicare-MassHealth Plan) is ffered by Tufts Health Plan Netwrk Health. When this member handbk says we, us, r ur, it means Tufts Health Plan Netwrk Health. When it says the plan r ur plan, it means Tufts Health Unify. Yu can ask fr this handbk in ther frmats, such as Braille r audi. Call (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. Disclaimers Tufts Health Unify is a health plan that cntracts with bth Medicare and MassHealth t prvide benefits f bth prgrams t enrllees. Limitatins and restrictins may apply. Fr mre infrmatin, call Tufts Health Unify member services r read the Tufts Health Unify Member Handbk. This means that yu may have t pay fr sme services and that yu need t fllw certain rules t have Tufts Health Unify pay fr yur services. Benefits, List f Cvered Drugs, and pharmacy and prvider netwrks may change frm time t time thrughut the year and n January 1 f each year. Yu can get this dcument in Spanish r speak with smene abut this infrmatin in ther languages fr free. Call The call is free. Usted puede btener este dcument en españl hablar cn alguien sbre esta infrmación en trs idimas sin cst algun. Llame al Esta llamada es gratis. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 1

3 Chapter 1: Getting started as a member Table f cntents A. Welcme t Tufts Health Unify... 2 B. What are Medicare and MassHealth... 3 C. What are the advantages f this One Care plan... 4 D. What is Tufts Health Unify s service area... 4 E. What makes yu eligible t be a plan member... 5 F. What t expect when yu first jin a health plan... 5 G. What is a persnal care plan... 6 H. Des Tufts Health Unify have a mnthly plan premium... 6 I. Abut the Member Handbk... 6 J. What ther infrmatin will yu get frm us... 6 Yur Tufts Health Unify member ID card... 7 Prvider and Pharmacy Directry... 7 List f Cvered Drugs... 8 K. Hw can yu keep yur membership recrd up t date... 8 D we keep yur persnal health infrmatin private... 9 A. Welcme t Tufts Health Unify Tufts Health Unify is a One Care: MassHealth plus Medicare plan. A One Care plan is made up f dctrs, hspitals, pharmacies, prviders f lng-term services and supprts (LTSS), and ther health care prviders. In a One Care plan, a care manager will wrk with yu t develp a plan that meets yur specific health needs. A care manager will als help yu manage all yur prviders, services, and supprts. They all wrk tgether t give yu the care yu need. Tufts Health Unify was apprved by the Cmmnwealth f Massachusetts and the Centers fr Medicare & Medicaid Services (CMS) t prvide yu services as part f One Care. One Care is a pilt prgram run by Massachusetts and the federal gvernment t prvide better health care fr peple wh have bth Medicare and MassHealth (Medicaid). This pilt prgram lets the state and federal gvernment test new ways t imprve hw yu receive yur Medicare and MassHealth health care services. 2

4 Tufts Health Unify Member Handbk Chapter 1: Getting started as a member With Tufts Health Plan Netwrk Health, yu get mre frm yur health plan. We partner with a netwrk f primary care prviders (PCPs), hspitals, and ther prviders acrss Massachusetts t bring yu high quality, affrdable health care cverage under several gvernment-run prgrams, including Medicare and Medicaid. By jining Tufts Health Unify, yu have access t a netwrk f trusted dctrs and specialists acrss the state, a friendly and helpful member services team, great services, and infrmatin in yur wn language. Our plan is designed t meet the needs f peple wh have Medicare and Medicaid benefits. Tufts Health Unify will make sure these prgrams wrk tgether t get yu the care yu need. B. What are Medicare and MassHealth Medicare Medicare is the federal health insurance prgram fr: Peple 65 years f age r lder Sme peple under age 65 with certain disabilities Peple with end-stage renal disease (kidney failure) MassHealth MassHealth is the name f the Massachusetts Medicaid prgram. MassHealth is run by the federal gvernment and the state. MassHealth helps peple with limited incmes and resurces pay fr medical csts and lng-term services and supprts and medical csts. It als cvers extra services and drugs that are nt cvered by Medicare. Each state has its wn Medicaid plan. That means that each state decides what cunts as incme and resurces and wh qualifies fr Medicaid in that state. Each state als decides which services are cvered, and what thse services cst. States can decide hw t run their wn Medicaid prgrams as lng as they fllw the federal rules. Medicare and the Massachusetts Executive Office f Health and Human Services (EOHHS) must apprve Tufts Health Unify each year. Yu can get Medicare and MassHealth services thrugh ur plan as lng as: Yu are eligible t participate in One Care; We still ffer the plan in yur cunty; and Medicare and EOHHS apprve the plan. Even if ur plan stps perating, yur eligibility fr Medicare and MassHealth services wuld stay the same. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 3

5 C. What are the advantages f this One Care plan Yu will nw get all yur cvered Medicare and MassHealth services frm Tufts Health Unify. This includes prescriptin drugs. Yu d nt have t pay extra t jin this health plan. Tufts Health Unify will help make yur Medicare and MassHealth benefits wrk better tgether and wrk better fr yu. Here are sme f the advantages f having Tufts Health Unify as yur health plan. Yu will have a care team made up f peple yu chse. A care team is a grup f peple that will get t knw yur needs and wrk with yu t help yu create and carry ut a care plan. Yur care team will talk with yu abut the services that are right fr yu. Yu will have a care manager. This persn will wrk with yu, the health plan, and yur care team t make sure yu get the care yu need. If yu need lng-term services and supprts (LTSS), yu will als have an independent living and lng-term services and supprts (IL-LTSS) crdinatr. Lng-term services and supprts are fr peple wh need help ding everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. An IL-LTSS crdinatr will help yu find and get the right LTSS services. Bth the care manager and IL-LTSS crdinatr wrk with yur care team t make sure yu get the care yu need. Yu will be able t take charge f yur wn care with help frm yur care team and care manager. The care team and care manager will wrk with yu t cme up with a care plan specially designed t meet yur health needs. It will help yu receive and rganize yur care. The care team will be in charge f managing the services yu need. Fr example: Yur care team will make sure that yur dctrs knw abut all yur medicines s they can reduce any side effects. Yur care team will make sure that all yur dctrs and ther prviders see yur test results. Yur care team will help yu get appintments with dctrs and ther prviders wh can help yu with any disability accmmdatins yu need. D. What is Tufts Health Unify s service area Our service area includes these cunties in Massachusetts: Sufflk and Wrcester. Tufts Health Unify is nly fr peple wh live in ur service area. If yu mve utside f ur service area, yu cannt stay in this plan. 4

6 Tufts Health Unify Member Handbk Chapter 1: Getting started as a member E. What makes yu eligible t be a plan member Yu are eligible fr ur plan as lng as yu: Live in ur service area; and Have bth Medicare Part A and Medicare Part B and eligible fr Part D; and Are eligible fr MassHealth Standard r MassHealth CmmnHealth; and Are nt enrlled in a MassHealth Hme and Cmmunity-based Services (HCBS) waiver; and Yu dn t have ther health insurance. F. What t expect when yu first jin a health plan If Tufts Health Unify is a new plan fr yu, yu can keep seeing yur dctrs and getting yur current services fr 90 days r until yur care plan is cmplete. If yu are taking any Medicare Part D prescriptin drugs when yu jin ur plan, yu can get a temprary supply. We will help yu t transitin t anther drug if necessary. Within the first 90 days f yur enrllment in the plan, yu will receive a health-assessment. After the assessment, yu and yur Care Team will meet and develp yur Persnal Care Plan. Shrtly after yu becme a Tufts Health Unify member, yur care manager will reach ut t yu t schedule an in-persn appintment fr this health needs assessment. Yur care manager will crdinate yur care team by wrking with yu and all f yur health and scial care prviders. Yur care team may include yur medical care prviders (such as a primary care prvider r a mental health r substance abuse cunselr), pharmacy prfessinals, and scial care managers. Yur care team may als include advcates, family members, caregivers, friends, mentrs, and/r peer supprts. Based n yur health needs assessment, yur care manager will als help yu cnnect with and crdinate any additinal nnmedical resurces yu may need, including: Lng-term services and supprts (LTSS), such as day habilitatin r persnal care assistants Cmmunity supprt services, such as peer supprt and cunseling Scial care management, such as transprtatin t medical appintments After the first 90 days, yu will need t see dctrs and ther prviders in the Tufts Health Unify netwrk. A netwrk prvider is a prvider wh wrks with the health plan. See Chapter 3, Sectin B, page 21 fr mre infrmatin n getting care frm netwrk prviders. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 5

7 G. What is a persnal care plan After yur health assessment, yur care team will meet with yu t talk abut the health services yu need and want. Tgether, yu and yur care team will make a care plan. A Persnal Care Plan lists the services yu will get, and hw yu will get them. A Persnal Care Plan includes the services that yu need fr yur physical and mental health care and lng-term services and supprts. The prviders yu see and medicatins yu take will be a part f yur Persnal Care Plan. Yu will be able t list yur health, independent living and recvery gals and cncerns and steps t address them. Yur One Care plan will wrk with yu at all times and will wrk with yur family, friends, and advcates if yu chse. Yu will be at the center f the prcess f making yur Persnal Care Plan. Every year, yur care team will wrk with yu t update yur care plan in case there is a change in the health services yu need and want. Yur persnal care plan can als be updated as yur gals r needs change thrughut the year. H. Des Tufts Health Unify have a mnthly plan premium Yu will nt pay any mnthly premiums t Tufts Health Unify fr yur health cverage. If yu pay a premium t MassHealth fr CmmnHealth, yu must cntinue t pay the premium t MassHealth t keep yur cverage. I. Abut the Member Handbk This Member Handbk is part f ur cntract with yu. This means that we must fllw all f the rules in this dcument. If yu think we have dne smething that ges against these rules, yu may be able t appeal, r challenge, ur actin. Fr infrmatin abut hw t appeal, see Chapter 9, Sectin 5.3, page 114, r call 800-MEDICARE ( ). The cntract is in effect fr the mnths yu are enrlled in Tufts Health Unify between January 1, 2015 and December 31, J. What ther infrmatin will yu get frm us Yu shuld have already gtten a Tufts Health Unify member ID card, the Prvider and Pharmacy Directry, and the List f Cvered Drugs. 6

8 Tufts Health Unify Member Handbk Chapter 1: Getting started as a member Yur Tufts Health Unify member ID card Under ur plan, yu will have just ne card fr yur Medicare and MassHealth services, including lng-term services and supprts (LTSS) and prescriptin drugs. Yu must shw this card when yu get any services r prescriptins. Here is a sample card t shw yu what yurs will lk like: If yur card is damaged, lst, r stlen, call member services at right away. We will send yu a new card. As lng as yu are a member f ur plan, yu shuld nt use yur red, white, and blue Medicare card r yur MassHealth card t get services. Keep thse cards in a safe place, in case yu need them later. Prvider and Pharmacy Directry The Prvider and Pharmacy Directry lists the prviders and pharmacies in the Tufts Health Unify netwrk. While yu are a member f ur plan, yu must use netwrk prviders t get cvered services. Yu can request a new Prvider and Pharmacy Directry at any time by calling member services at Yu can als use ur Find a Dctr, Hspital, r Pharmacy tl t quickly find prviders. Just g t TuftsHealthUnify.rg. Our nline tl has the mst up-t-date infrmatin fr the prviders in If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 7

9 ur netwrk. Bth member services and the website can give yu the mst up-t-date infrmatin abut changes in ur netwrk prviders. What are netwrk prviders Netwrk prviders are dctrs, nurses, and ther health care prfessinals that yu can g t as a member f ur plan. Netwrk prviders als include clinics, hspitals, skilled nursing facilities, and ther places, such as chirpractic r hspice facilities, LTSS, hspital emergency services, emergency services prgram prviders fr behaviral health that prvide health services in ur plan. They als include hme health agencies, durable medical equipment suppliers, and thers wh prvide gds and services that yu get thrugh Medicare r MassHealth. Netwrk prviders have agreed t accept payment frm ur plan fr cvered services as payment in full. Yu will nt have t pay anything mre fr cvered services. What are netwrk pharmacies Netwrk pharmacies are pharmacies (drug stres) that have agreed t fill prescriptins fr ur plan members. Use the Prvider and Pharmacy Directry t find the netwrk pharmacy yu want t use. Yu must fill yur prescriptins at ne f ur netwrk pharmacies if yu want ur plan t help yu pay fr them. Call member services at fr mre infrmatin r t get a cpy f the Prvider and Pharmacy Directry. List f Cvered Drugs The plan has a List f Cvered Drugs (r Frmulary). We call it the Drug List fr shrt. It tells which prescriptin drugs are cvered by Tufts Health Unify. The Drug List als tells yu if there are any rules r restrictins n any drugs, such as a limit n the amunt yu can get. See Chapter 5, Sectin C, page 75 fr mre infrmatin n these rules and restrictins. Each year, we will send yu a cpy f the Drug List. T get the mst up-t-date infrmatin abut which drugs are cvered, visit TuftsHealthUnify.rg r call K. Hw can yu keep yur membership recrd up t date Yu can keep yur membership recrd up t date by letting us knw when yur infrmatin changes. The plan s netwrk prviders and pharmacies need t have the right infrmatin abut yu. They use yur membership recrd t knw what services and drugs yu get and hw much they will cst yu, if anything. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. 8

10 Tufts Health Unify Member Handbk Chapter 1: Getting started as a member Let us knw if any f these situatins apply t yu: If yu have any changes t yur name, address, r phne number If yu get ther health insurance cverage, like cverage frm yur emplyer, yur spuse s emplyer, r wrkers cmpensatin If yu have any liability claims, such as claims frm an autmbile accident If yu are admitted t a nursing facility r hspital If yu get care in an ut-f-area r ut-f-netwrk hspital r emergency rm If there s a change in wh yur caregiver (r anyne else respnsible fr yu) is If yu are part f a clinical research study If any f yur infrmatin changes, please let us knw by calling member services at (TTY: ). Yu can als make changes t yur membership recrd by signing up fr Netwrk Health Member Cnnect, ur nline self-service tl. Netwrk Health Member Cnnect helps yu t take charge f yur health care, 24 hurs a day, seven day a week, and makes it easy t: Access yur care plan and cnnect with yur care manager Update yur cntact infrmatin and rder a new member ID card Chse r change yur primary care prvider (PCP) Review medical histry, including prescriptin medicatins, prcedures, immunizatins, and dctrs visits Share yur infrmatin with yur family, caregiver, PCP, r thers Check the status f a claim r an authrizatin D we keep yur persnal health infrmatin private Yes. Laws require us t keep yur medical recrds and persnal health infrmatin private. We make sure that yur health infrmatin is prtected. Fr mre infrmatin abut hw we prtect yur persnal health infrmatin, see Chapter 8, Sectin D, page 94. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 9

11 Chapter 2: Imprtant phne numbers and resurces Table f cntents A. Hw t cntact Tufts Health Unify member services Cntact member services abut Questins abut the plan Cverage decisins abut yur health care Appeals abut yur health care Cmplaints abut yur health care Cverage decisins abut yur drugs Appeals abut yur drugs Cmplaints abut yur drugs Questins abut payment fr health care r drugs yu already paid fr B. Hw t cntact yur care manager Cntact yur care manager abut Questins abut yur health care Questins abut getting medical services, behaviral health services, and lng-term services and supprts (LTSS) Questins abut available benefits Questins abut transprtatin C. Hw t cntact the 24/7 NurseLine Cntact the 24/7 NurseLine abut Questins abut yur health care D. Hw t cntact the behaviral health crisis line Cntact the behaviral health crisis line if E. Hw t cntact the State Health Insurance Assistance Prgram (SHIP) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 10

12 Tufts Health Unify Member Handbk Chapter 2: Imprtant phne numbers and resurces Cntact SHINE abut Questins abut yur Medicare health insurance SHINE cunselrs can F. Hw t cntact Medicare G. Hw t cntact MassHealth H. Hw t cntact the quality imprvement rganizatin (QIO) Cntact the QIO abut Questins abut yur health care I. Hw t cntact the One Care Ombudsman (OCO) A. Hw t cntact Tufts Health Unify member services CALL This call is free. Seven days a week, frm 8 a.m. t 8 p.m. Yu can als ask fr this infrmatin in ther frmats, such as Braille r large print. We have free interpreter services fr peple wh d nt speak English. TTY This call is free. This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. Seven days a week, frm 8 a.m. t 8 p.m. WRITE WEBSITE Tufts Health Plan Netwrk Health Attn: Member Services 101 Statin Landing, Furth Flr Medfrd, MA TuftsHealthUnify.rg Cntact member services abut: Questins abut the plan Cverage decisins abut yur health care If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 11

13 A cverage decisin abut yur health care is a decisin abut either yur benefits and cvered services r the amunt f yur health services we will cver. T learn mre abut cverage decisins, see Chapter 9, Sectin 4, page 109. Appeals abut yur health care An appeal is a way t ask us t change a cverage decisin. T learn mre abut making an appeal, see Chapter 9, Sectin 5.3, page 114. Cmplaints abut yur health care Yu can call member services t make a cmplaint abut us r any prvider (including a nnnetwrk r netwrk prvider). A netwrk prvider is a prvider wh wrks with the health plan. Yu can als make a cmplaint abut the quality f the care yu gt t us r t the quality imprvement rganizatin (see Sectin H belw). If yur cmplaint is abut a cverage decisin abut yur health care, yu can make an appeal by calling member services. (See the sectin abve and Chapter 9.) Yu can als send a cmplaint abut Tufts Health Unify right t Medicare. Yu can use an nline frm at r call 800-MEDICARE ( ) t ask fr help T learn mre abut making a cmplaint abut yur health care, see Chapter 9, Sectin 10, page 143. Cverage decisins abut yur drugs A cverage decisin abut yur drugs is a decisin abut yur benefits and cvered drugs, r the amunt we will pay fr yur drugs. This applies t yur Part D drugs, MassHealth prescriptin drugs, and MassHealth ver-thecunter drugs. MassHealth drugs are nted in the Drug List with an asterisk. Fr mre n cverage decisins abut yur prescriptin drugs, see Chapter 9, Sectin 6.4, page

14 Tufts Health Unify Member Handbk Chapter 2: Imprtant phne numbers and resurces Appeals abut yur drugs T learn mre abut making an appeal abut yur prescriptin drugs, see Chapter 9, Sectin 6.5, page 128. Cmplaints abut yur drugs Yu can make a cmplaint abut us r any pharmacy. This includes a cmplaint abut yur prescriptin drugs. If yur cmplaint is abut a cverage decisin abut yur prescriptin drugs, yu can make an appeal. (See the Sectin 6.4, page 125.) Yu can send a cmplaint abut Tufts Health Unify right t Medicare. Yu can use an nline frm at r call 800-MEDICARE ( ) t ask fr help. Fr mre infrmatin n making a cmplaint abut yur prescriptin drugs, see Chapter 9, Sectin 10, page 143. Questins abut payment fr health care r drugs yu already paid fr Fr mre infrmatin abut paying a bill yu have received r t ask us hw t pay yu back fr services r prescriptin drugs, see Chapter 7, page 87. If yu ask us t pay a bill and we deny any part f yur request, yu can appeal ur decisin. See Chapter 9, Sectin 5.3, page 114 fr mre n appeals. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 13

15 B. Hw t cntact yur care manager Yur Tufts Health Unify care manager is the ne main persn wh wrks with yu and all f yur ther care prviders t make sure that yu get the care yu need. Shrtly after yu jin Tufts Health Unify, a member f the care management team will call yu t set up yur initial in-persn cmprehensive health assessment. Once yur health assessment is cmplete, yu will be assigned a Tufts Health Unify care manager and given his r her cntact infrmatin. If yu wish t speak t smene in care management befre cmpleting yur initial health needs assessment, yu may call and ask t speak t a care manager. As a member, yu may request t change yur care manager at any time, by phne, , r in writing. CALL This call is free. Seven days a week, frm 8 a.m. t 8 p.m. We have free interpreter services fr peple wh d nt speak English. TTY This call is free. This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. Seven days a week, frm 8 a.m. t 8 p.m. WRITE WEBSITE Tufts Health Plan Netwrk Health Attn: Member Services 101 Statin Landing, Furth Flr Medfrd, MA TuftsHealthUnify.rg Cntact yur care manager abut: Questins abut yur health care Questins abut getting medical services, behaviral health services, and lng-term services and supprts (LTSS) Questins abut available benefits Questins abut transprtatin 14

16 Tufts Health Unify Member Handbk Chapter 2: Imprtant phne numbers and resurces C. Hw t cntact the 24/7 NurseLine Our NurseLine is available 24 hurs a day, seven days a week, t prvide yu with general health infrmatin and supprt, including fr any medical and behaviral health (mental health and/r substance abuse) questins that yu may have. CALL TTY This call is free. 24 hurs a day, seven days a week We have free interpreter services fr peple wh d nt speak English This call is free. This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. 24 hurs a day, seven days a week Cntact the 24/7 NurseLine abut: Questins abut yur health care Getting educatinal materials regarding yur cnditin Obtaining advice n yur health/cnditin, symptm assessment fr an illness r injury yu may be experiencing D. Hw t cntact the behaviral health crisis line CALL TTY This call is free. Seven days a week, frm 8 a.m. t 8 p.m. We have free interpreter services fr peple wh d nt speak English This call is free. This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. Seven days a week, frm 8 a.m. t 8 p.m. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 15

17 Cntact the behaviral health crisis line if: Yu need help during a mental health crisis E. Hw t cntact the State Health Insurance Assistance Prgram (SHIP) The State Health Insurance Assistance Prgram (SHIP) gives free health insurance advice t peple with Medicare. In Massachusetts, the SHIP is called SHINE (Serving the Health Insurance Needs f Everyne). SHINE is nt cnnected with any insurance cmpany r health plan. CALL 800-AGE-INFO ( ) TTY WRITE WEBSITE (Massachusetts nly) This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. Call the number abve fr the address f the SHINE prgram in yur area. Cntact SHINE abut: Questins abut yur Medicare health insurance SHINE cunselrs can: Help yu understand yur rights; Help yu understand yur plan chices; Answer yur questins abut changing t a new plan; Help yu make cmplaints abut yur health care r treatment; and Help yu fix prblems with yur bills. 16

18 Tufts Health Unify Member Handbk Chapter 2: Imprtant phne numbers and resurces F. Hw t cntact Medicare Medicare is a federal health insurance prgram. It cvers peple 65 years f age r lder; sme peple under age 65 with disabilities; and peple with end-stage renal disease (ESRD permanent kidney failure requiring dialysis r a kidney transplant). The federal agency in charge f Medicare is the Centers fr Medicare & Medicaid Services (CMS). CALL 800-MEDICARE ( ) Calls t this number are free, 24 hurs a day, seven days a week. TTY WEBSITE This call is free. This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. medicare.gv This is the fficial website fr Medicare. It gives yu up-t-date infrmatin abut Medicare. It als has infrmatin abut hspitals, nursing hmes, physicians, hme health agencies, and dialysis facilities. It includes bklets yu can print right frm yur cmputer. Yu can als find Medicare cntacts in yur state by selecting Frms, Help & Resurces and then clicking n Phne numbers & websites. The Medicare website has the fllwing tl t help yu find plans in yur area: Medicare Plan Finder: This tl prvides persnalized infrmatin abut Medicare prescriptin drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) plicies in yur area. Select Find health & drug plans. If yu dn t have a cmputer, yur lcal library r senir center may be able t help yu visit this website using its cmputer. Or yu can call Medicare at the number abve and tell them what yu are lking fr. They will find the infrmatin n the website, print it ut, and send it t yu. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 17

19 G. Hw t cntact MassHealth MassHealth helps with the cst f medical and lng-term services and supprts (LTSS) fr peple with limited incmes and resurces. Yu are enrlled in Medicare and in MassHealth. If yu have questins abut the help yu get frm MassHealth, the cntact infrmatin is belw. CALL TTY This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. WRITE WEBSITE MassHealth Custmer Service 55 Summer Street Bstn, MA [email protected] mass.gv/masshealth H. Hw t cntact the quality imprvement rganizatin (QIO) Massachusetts has a quality imprvement rganizatin (QIO) called Livanta. This is a grup f dctrs and ther health care prfessinals wh help imprve the quality f care fr peple with Medicare. The QIO is nt cnnected with ur plan. T get the cntact infrmatin fr the QIO, please call MassHealth Custmer Service. CALL TTY This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. FAX WRITE WEBSITE Appeals: All ther reviews: Livanta BFCC-QIO Prgram 9090 Junctin Drive, Suite 10 Annaplis Junctin, MD BFCCQIOArea1.cm 18

20 Tufts Health Unify Member Handbk Chapter 2: Imprtant phne numbers and resurces Cntact the QIO abut: Questins abut yur health care Yu can make a cmplaint abut the care yu have received if: Yu have a prblem with the quality f care; Yu think yur hspital stay is ending t sn; r Yu think yur hme health care, skilled nursing facility care, r cmprehensive utpatient rehabilitatin facility (CORF) services are ending t sn. I. Hw t cntact the One Care Ombudsman (OCO) The One Care Ombudsman (OCO) is an independent prgram that can help yu if yu have questins, cncerns, r prblems related t One Care. Yu can cntact the OCO t get infrmatin r assistance. The OCO s services are free. The OCO can answer yur questins r refer yu t the right place t find what yu need. The OCO can help yu address a prblem r cncern with One Care r yur One Care plan, Tufts Health Unify. The OCO will listen, investigate the issue, and discuss ptins with yu t help slve the prblem. The OCO helps with appeals. An appeal is a frmal way f asking yur One Care plan, MassHealth, r Medicare t review a decisin abut yur services. The OCO can talk with yu abut hw t make an appeal and what t expect during the appeal prcess. Yu can call, write, r visit the OCO at its ffice. CALL (tll free) MassRelay This number is fr peple wh are deaf, hard f hearing, r speech disabled. Yu must have special telephne equipment t call it. WRITE WEBSITE One Care Ombudsman 11 Dartmuth Street, Suite 301 Malden, MA [email protected] necarembuds.rg If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 19

21 Chapter 3: Using the plan s cverage fr yur health care and ther cvered services Table f cntents A. Abut services, cvered services, prviders, and netwrk prviders B. Rules fr getting yur health care, lng-term services and supprts (LTSS), and ther services cvered by the plan C. Yur care manager and lng-term services and supprts (LTSS) crdinatr D. Getting care frm yur primary care prvider, specialists, ther netwrk prviders, and utf-netwrk prviders E. Hw t get lng-term supprts and services (LTSS) F. Hw t get behaviral health (mental health and/r substance abuse) services G. Hw t get self-directed care H. Hw t get dental and visin services I. Hw t get cvered services when yu have a medical emergency r urgent need fr care J. What if yu are billed directly fr the full cst f services cvered by ur plan K. Hw are yur health care services cvered when yu are in a clinical research study L. Hw are yur health care services cvered when yu are in a religius nnmedical health care institutin M. Rules fr wning durable medical equipment (DME) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 20

22 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services A. Abut services, cvered services, prviders, and netwrk prviders Services include medical care, behaviral health care, lng-term services and supprts (LTSS), supplies, prescriptin and ver-the-cunter drugs, equipment, and mre. Cvered services are any f these services that ur plan pays fr. Cvered services are listed in the Benefits Charts in Chapter 4, Sectin D, page 40. Prviders are dctrs, nurses, behaviral health specialists, and ther peple wh give yu services and care. The term prviders als includes hspitals, hme health agencies, clinics, and ther places that give yu health care services, medical equipment, and lng-term services and supprts (LTSS). Netwrk prviders are prviders wh wrk with the health plan. These prviders have agreed t accept ur payment as full payment. B. Rules fr getting yur health care, lng-term services and supprts (LTSS), and ther services cvered by the plan Tufts Health Unify cvers services cvered by Medicare and MassHealth. This includes behaviral health, lng-term services and supprts, and prescriptin and ver-the-cunter drugs. Tufts Health Unify will pay fr the health care and services yu get if yu fllw the plan rules that fllw. The care yu get must be a plan benefit. This means that it must be included in the plan s Benefits Charts. (The chart is in Chapter 4, Sectin D, page 40 f this handbk.) The care must be medically necessary. Medically necessary means that the services are reasnable and necessary: Fr the diagnsis and treatment f yur illness r injury, r T imprve the functining f a malfrmed bdy member, r Otherwise medically necessary under Medicare law. In accrdance with Medicaid law and regulatin, and per MassHealth, services are medically necessary if: They culd be reasnably calculated t prevent, diagnse, prevent the wrsening f, alleviate, crrect, r cure cnditins that endanger yur life; cause yu If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 21

23 suffering r pain; cause physical defrmity r malfunctin; threaten t cause r t aggravate a disability; r result in illness r infirmity; and There is n ther medical service r place f service that is available, wrks as well, and is suitable fr yu that is less expensive. The quality f medically necessary services must meet prfessinally recgnized standards f health care, and medically necessary services must als be supprted by recrds, including evidence f such medical necessity and quality. Yu must have a netwrk primary care prvider (PCP). As a plan member, yu must chse a netwrk prvider t be yur PCP. T learn mre abut chsing a PCP, see page 21. In mst cases, ur plan must give yu apprval befre yu can use ther prviders in the plan s netwrk. This is called a referral. T learn mre abut referrals, see page 24. Yu d nt need a referral frm yur PCP fr emergency care r urgently needed care. Yu can als get ther kinds f care withut having a referral frm yur PCP r ur plan. T learn mre abut this, see page 24. Please nte: In yur first 90 days with ur plan, yu may cntinue t see yur current prviders, at n cst t yu, if they are nt a part f ur netwrk. During the first 90 days, yur care manager will cntact yu t help yu find prviders in ur netwrk and t schedule a health needs assessment. Within the first 90 days f yur enrllment in the plan, yu will receive a health-assessment. After the assessment, yu and yur Care Team will meet and develp yur Care Plan. After the 90-day transitin perid r nce yur care plan is cmplete, we will n lnger cver yur care if yu chse t see ut-f-netwrk prviders. Yu must get yur care frm netwrk prviders. Usually, the plan will nt cver care frm a prvider wh des nt wrk with the health plan. But smetimes this rule des nt apply. The plan cvers emergency r urgently needed care frm an ut-f-netwrk prvider. T learn mre abut what emergency r urgently needed care mean, see pages 31 and 33. If yu need care that ur plan cvers and ur netwrk prviders cannt give it t yu, then yu can get the care frm an ut-f-netwrk prvider with prir authrizatin (permissin) frm us. In this situatin, we will cver the care at n cst t yu. T learn abut getting prir authrizatin t see an ut-f-netwrk prvider, see page 28. The plan cvers kidney dialysis services when yu are utside the plan s service area fr a shrt time. Yu can get these services at a Medicare-certified dialysis facility. 22

24 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services If yu need family-planning services, yu may receive thse services frm any One Care plan prvider r frm any MassHealth-cntracted family-planning services prvider. When yu first jin the plan, yu can cntinue seeing the prviders yu see nw fr 90 days r until an alternative care plan has been agreed upn. There are exceptins in which yu may cntinue t see yur prvider beynd 90 days. Fr example: If yu are currently in treatment r management f chrnic issues (like dialysis, hme health, chemtherapy, and/r radiatin), including previusly authrized services r cvered services, yu may be able t keep seeing him r her fr up t anther 90 calendar days. If yur prvider is yur pregnancy care prvider and yu are in yur secnd r third trimester f pregnancy, yu may be able t keep seeing him r her up t and including yur first pstpartum visit (within the first six weeks f delivery). If yu are terminally ill, yu may be able t keep seeing him r her while yu are sick. C. Yur care manager and lng-term services and supprts (LTSS) crdinatr What is care crdinatin Care crdinatin means that ur behaviral health, medical, and cmmunity service prviders and scial care managers wrk clsely with each ther, with yur primary care prvider, and with yu t crdinate the care yu need. We use care managers t make sure yu get the best pssible care and results. Yur care manager can help yu: Make the transitin between different care settings, such as frm the hspital back hme, r t an intermediate nursing facility Cnnect with an LTSS crdinatr t find ut what resurces and benefits yu can get in yur cmmunity Manage yur care with yur prviders and ther health care and scial services agencies wrking t imprve yur health Hw can a member cntact his r her care manager r LTSS crdinatr Shrtly after yu jin Tufts Health Unify, a member f the care management team will call yu t set up yur initial in-persn cmprehensive health assessment. Once yur health assessment is cmplete, a Tufts Health Unify care manager is assigned t yu and yu are given cntact infrmatin t reach this persn. If yu wish t speak t a care manager prir t cmpleting yur initial health assessment, yu may call If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 23

25 Yur care manager can als help yu reach yur LTSS crdinatr. Hw can a member change his r her care manager A member may request t change his r her care manager at any time, by phne, , r in writing. D. Getting care frm yur primary care prvider (PCP), specialists, ther netwrk prviders, and ut-f-netwrk prviders Getting care frm a PCP Yu must chse a PCP t prvide and manage yur care. What is a PCP, and what des a PCP d fr yu What is a PCP A PCP is the prvider wh manages yur care. What types f prviders may be a PCP Yu can chse a dctr, nurse practitiner, r physician assistant as yur PCP. PCPs must practice ne f the fllwing specialties: family practice, internal medicine, general practice, adlescent and pediatric medicine, r bstetrics/gyneclgy (fr wmen nly). PCPs must be bard-certified r eligible fr bard certificatin in their area f specialty. What is the rle f a PCP in crdinating cvered services Yur PCP is the prvider yu shuld call fr any kind f health care yu need, unless yu are having an emergency. Yu can call yur PCP s ffice 24 hurs a day, seven days a week. If yur PCP is nt available, smene else will be able t help yu. Yur PCP: Gives yu regular checkups and health screenings, including behaviral health (mental health and/r substance abuse) screenings Makes sure yu get the health care yu need Arranges necessary tests, labratry prcedures, r hspital visits Keeps yur medical recrds Recmmends specialists, when needed Prvides infrmatin n cvered services that need prir authrizatin befre yu get treatment Prescribes medicatins, when necessary Helps yu get behaviral health services, when necessary What is the rle f a PCP in making a referral Yur PCP prvides yu with any needed referrals befre yu get treatment. 24

26 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services What is the rle f a PCP when yu need prir authrizatin (apprval befre yu can get a service) Yur PCP will ask us fr apprval when yu need a service r when yu need t get care frm anther netwrk r ut-f-netwrk prvider r lcatin. Can a clinic be yur PCP N. Yu must chse a netwrk dctr, nurse practitiner, r physician assistant as yur PCP. Hw d yu chse yur PCP T find a PCP and see where the PCP s ffice is lcated, please visit TuftsHealthUnify.rg and use the Find a Dctr, Hspital, r Pharmacy tl. Yu can als call us t help yu find and chse a PCP. If yu dn t chse a PCP within 10 calendar days f jining Tufts Health Unify, we ll chse a PCP we think is right fr yu and let yu knw yur PCP s name and cntact infrmatin. We ll als chse a PCP fr yu if the PCP yu chse is nt available. Yu can always chse a different PCP. Changing yur PCP Yu may change yur PCP fr any reasn, at any time. Als, it s pssible that yur PCP might leave ur plan s netwrk. In that case, yu wuld have t find a new PCP. T change yur PCP: Call us at When yu call ur member services, yur PCP changes take effect immediately. Or yu can visit TuftsHealthUnify.rg and use Netwrk Health Member Cnnect, ur nline self-service tl. All PCP changes made nline take effect within 24 hurs. If yur PCP r anther prvider is disenrlled frm ur netwrk fr reasns nt related t quality f care r fraud, r if they are n lnger in practice, we ll make every effrt t tell yu at least 30 calendar days befre the disenrllment. Whenever pssible, we may be able t cntinue t cver sme f yur health care services if the fllwing cnditins apply t yu: If the prvider, including a PCP, is actively treating a chrnic r acute medical cnditin, yu may be able t keep seeing him r her thrugh the current perid f active treatment r fr up t 90 calendar days after we tell yu he r she is n lnger part f ur netwrk. If the prvider is yur PCP, yu may be able t keep seeing him r her fr up t 31 calendar days after the PCP is disenrlled. If the prvider is yur pregnancy care prvider and yu are in yur secnd r third trimester f pregnancy, yu may be able t keep seeing him r her thrugh delivery and a fllw-up checkup within the first six weeks f delivery. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 25

27 If yu are terminally ill, yu may be able t keep seeing yur prvider while yu are sick. We will allw yu t get cntinued treatment by an ut-f-netwrk prvider nly if the prvider agrees t ur terms related t payment, quality, referrals, and ther plicies and prcedures. Yu must call us at and tell us yu want t keep seeing this prvider. Services yu can get withut first getting apprval frm yur PCP In mst cases, yu need a PCP referral t see any prvider that is nt yur PCP. A PCP referral is apprval frm ur plan. Smetimes yu d nt need a referral. Yu can get services like the nes listed belw withut first getting a referral r authrizatin frm yur PCP: Emergency services frm netwrk r ut-f-netwrk prviders within the U.S. and its territries Urgently needed care frm netwrk prviders Urgently needed care frm ut-f-netwrk prviders when yu can t get t netwrk prviders (fr example, when yu are utside the plan s service area but within the U.S. and its territries) Kidney dialysis services that yu get at a Medicare-certified dialysis facility when yu are utside the plan s service area (please call member services befre yu leave the service area; we can help yu get dialysis while yu are away) Flu shts as lng as yu get them frm a netwrk prvider Rutine wmen s health care this includes breast exams, screening mammgrams (X-rays f the breast), Pap tests, pelvic exams as lng as yu get them frm a netwrk prvider Pst-stabilizatin care services Emergency transprtatin, including land and air and specialty care transprt between facilities The first 12 utpatient behaviral health therapy visits each benefit year as lng as yu get them frm a netwrk prvider Labratry services t maintain health and diagnse, treat, and prevent disease, including bld tests, urinalysis, Pap smears, thrat cultures, and vaccines nt cvered by the Department f Public Health Hw t get care frm specialists and ther netwrk prviders A specialist is a dctr wh prvides health care fr a specific disease r part f the bdy. There are many kinds f specialists. Here are a few examples: Onclgists care fr patients with cancer. Cardilgists care fr patients with heart prblems. Orthpedists care fr patients with bne, jint, r muscle prblems. 26

28 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services Yu can visit mst specialists withut prir authrizatin as lng as the specialist is a netwrk prvider. What is the rle (if any) f the PCP in referring members t specialists and ther prviders If yu need a specialist, yu shuld discuss yur need with yur PCP first. Yur PCP can recmmend smene and will request prir authrizatin, if necessary. What is the prcess fr getting prir authrizatin If the specialist yu need t see requires prir authrizatin, yur PCP will ask us fr permissin. We may apprve yur PCP s request, deny yur PCP s request, r ask yur PCP t make a different prir authrizatin request. If we dn t give written apprval fr yu t see an ut-f-netwrk prvider, we wn t cver the services. Yu have the right t appeal that decisin. (See Chapter 9 fr mre infrmatin.) If yu still chse t get the services, yu will be respnsible fr payment. See the Benefits Charts n Chapter 4, Sectin D, page 40 fr infrmatin abut which services require prir authrizatin. Des the selectin f a PCP result in being limited t specific specialists r hspitals t which that PCP refers (i.e., sub netwrks r referral circles) Sme Tufts Health Unify members may need their PCP t give them a PCP referral fr certain specialty services. A PCP referral is a written ntificatin frm yur PCP t us that yu can get care frm a different prvider. The PCP referral helps yur PCP better guide the care and services yu get frm the prviders yu see. What if a netwrk prvider leaves ur plan A netwrk prvider yu are using might leave ur plan. If ne f yur prviders des leave ur plan, yu have certain rights and prtectins that are summarized belw: Even thugh ur netwrk f prviders may change during the year, we must give yu uninterrupted access t qualified prviders. We will give yu at least 30 days ntice s that yu have time t select a new prvider. We will help yu select a new qualified prvider t cntinue managing yur health care needs. If yu are underging medical treatment, yu have the right t request, and we will wrk with yu t ensure, that the medically necessary treatment yu are receiving is nt interrupted. Whenever pssible, we may be able t cntinue t cver sme f yur health care services if the fllwing cnditins apply t yu: If the prvider, including a PCP, is actively treating a chrnic r acute medical cnditin, yu may be able t keep seeing him r her thrugh the current perid f active treatment, r fr up t 90 calendar days after we tell yu he r she is n lnger part f ur netwrk. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 27

29 If the prvider is yur pregnancy care prvider and yu are in yur secnd r third trimester f pregnancy, yu may be able t keep seeing him r her thrugh delivery and a fllw-up checkup within the first six weeks f delivery. If yu are terminally ill, yu may be able t keep seeing yur prvider while yu are sick. We will allw yu t get cntinued treatment by an ut-f-netwrk prvider nly if the prvider agrees t ur terms related t payment, quality, referrals, and ther plicies and prcedures. Yu must call us at and tell us yu want t keep seeing this prvider. After the specific perid f cntinuity f care is up, yu can cntinue t get care frm a netwrk prvider. T chse a new prvider, call us at Yu can als visit TuftsHealthUnify.rg and use the Find a Dctr, Hspital, r Pharmacy tl t search fr a prvider. If an urgent situatin arises, call yur PCP r behaviral health prvider. Yu can cntact any f yur prviders ffices 24 hurs a day, seven days a week. If apprpriate, make an appintment t visit yur prvider. Yur prvider must see yu within 48 hurs fr urgent care appintments. If yur cnditin gets wrse befre yur PCP r behaviral health prvider sees yu, call 911 r g t the emergency rm. If yu believe we have nt replaced yur previus prvider with a qualified prvider r that yur care is nt being apprpriately managed, yu have the right t file a cmplaint. If yu find ut ne f yur prviders is leaving ur plan, please cntact us s we can assist yu in finding a new prvider and managing yur care. T chse a new prvider, call us at Yu can als visit TuftsHealthUnify.rg and use the Find a Dctr, Hspital, r Pharmacy tl t search fr a prvider. Hw t get care frm ut-f-netwrk prviders Yur prvider must ask us fr and get prir authrizatin befre yu see an ut-f-netwrk prvider. Yu may ask yur prvider t ask fr prir authrizatin r call ur member services team at Nte: Yu d nt need t get prir authrizatin t see an ut-f-netwrk prvider fr emergency care. Yu can see an ut-f-netwrk prvider if: A participating netwrk prvider is unavailable because f lcatin A delay in seeing a participating netwrk prvider, ther than a member-related delay, wuld result in interrupted access t medically necessary services There is nt a participating netwrk prvider with the qualificatins and expertise that yu need t address yur health care needs It is best t ask an ut-f-netwrk prvider t bill the plan first. But if yu have already paid fr the cvered services, we will reimburse yu fr ur share f the cst fr cvered services. Or if an ut-f-netwrk prvider sends yu a bill that yu think we shuld pay, yu can send it t us 28

30 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services fr payment. See Chapter 7, Sectin A, page 87 fr infrmatin abut what t d if yu receive a bill r if yu need t ask fr reimbursement. Nte: If yu g t an ut-f-netwrk prvider, the prvider must be eligible t participate in Medicare r MassHealth. We cannt pay a prvider wh is nt eligible t participate in Medicare r MassHealth. If yu g t a prvider wh is nt eligible t participate in Medicare r MassHealth, yu must pay the full cst f the services yu get. Prviders must tell yu if they are nt eligible t participate in Medicare r MassHealth. E. Hw t get lng-term services and supprts (LTSS) During yur 90-day initial health assessment perid, yur Tufts Health Unify care manager will arrange fr an LTSS crdinatr in yur area t participate in yur health assessment. An LTSS crdinatr is an independent resurce fr yu t cntact and have n yur care team. This persn is an expert in LTSS in yur area, and he r she can help identify any scial and cmmunity issues and make apprpriate referrals t cmmunity-based rganizatins. An LTSS crdinatr helps yu get services that keep yu living independently in yur hme. Yur Tufts Health Unify care manager will discuss the LTSS crdinatrs in the area and wrk with yu t select ne that is the best fit fr yu. This LTSS crdinatr may cntinue n as part f yur care team, but if yu decide nt t include ne n yur care team at the beginning, yu can still request an LTSS crdinatr at a later time. Yu can cntact yur Tufts Health Unify care manager t learn mre abut LTSS. F. Hw t get behaviral health (mental health and/r substance abuse) services Yur Tufts Health Unify care manager can help yu cnnect with behaviral health services in yur area. Yu can als use ur nline Find a Dctr, Hspital, r Pharmacy tl t lcate netwrk prviders in yur area. G. Hw t get self-directed care Self-directed care gives a persnal care attendant (PCA) decisin-making ability ver certain member services. The PCA takes direct respnsibility t manage these services, but yu can self-direct these services. This means yu can hire r fire, train, and manage the PCA s timesheets, etc. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 29

31 PCA services are prvided t assist and supprt members with disabilities living independently in the cmmunity. This includes members with special health care needs. PCA services can be prvided: In the member s hme r in the cmmunity, when nrmal life activities take the member utside the hme Fr chrnic r permanent disability that prevents a member frm perfrming persnal care When there is a need fr physical (hands-n) assistance with at least tw f seven activities f daily living (ADLs), such as mbility, bathing/grming, dressing/undressing, passive range-f-mtin exercises, taking medicatins, eating, and tileting Yu may receive self-directed care with prir authrizatin. Within the first 90 days f jining the plan, yu will need t cmplete a health needs assessment. Fllwing the cmpletin f that assessment, the care manager and the lng-term services and supprts (LTSS) crdinatr will assess yur immediate need fr a PCA. If yu already have an existing PCA, this service will nt be disrupted during the initial 90 days f enrllment. If the assessment results determine a need fr PCA services, then we will pay fr the services. If the health needs assessment determines that n PCA is needed, then we will n lnger pay fr these services. Yu have the right t appeal this decisin. (See Chapter 9 fr mre infrmatin.) Yur care manager will help yu access persnal care management (PCM) agencies and fiscal intermediary (FI) prviders t ensure members are prvided with the mst apprpriate care t meet their needs. H. Hw t get dental and visin services Our members have access t quality dental and visin care. Dental ur dental care is prvided thrugh DentaQuest. Yu must g t a DentaQuest-participating dental services prfessinal fr all cvered dental services. We cver tw cleanings per year and ne X-ray panel every tw years. Other dental services, like rthdntic and prsthetic services are cvered. Yu may need t get a prir authrizatin befre we cver sme f these services. Fr mre infrmatin n yur dental benefits, please call DentaQuest at (TTY: ). Visin we cver rutine eye exams fr members nce every 12 mnths frm phthalmlgists r ptmetrists wh are part f ur netwrk. We als cver ne pair f eyeglasses every 24 mnths. Once yu ve gtten an eye exam frm a prvider, bring yur visin prescriptin t a participating EyeMed prvider and yu ll receive savings n eyewear. T find a participating EyeMed prvider, visit eyemedvisincare.cm and then click n the members sectin. Yu can als call EyeMed at fr mre infrmatin. 30

32 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services I. Hw t get cvered services when yu have a medical emergency r urgent need fr care Getting care when yu have a medical emergency What is a medical emergency A medical emergency is a medical cnditin with symptms such as severe pain r serius injury. The cnditin is s serius that, if it desn t get immediate medical attentin, anyne with an average knwledge f health and medicine culd expect it t result in: Placing the persn s health at serius risk; r Serius harm t bdily functins; r Serius dysfunctin f any bdily rgan r part; r In the case f a pregnant wman, an active labr, meaning labr at a time when either f the fllwing wuld ccur: There is nt enugh time t safely transfer the member t anther hspital befre delivery. The transfer may pse a threat t the health r safety f the member r unbrn child. What shuld yu d if yu have a medical emergency If yu have a medical emergency: Get help as fast as pssible. Call 911 r g t the nearest emergency rm r hspital. Call fr an ambulance if yu need it. Yu d nt need t get apprval r a referral first. As sn as pssible, make sure that ur plan has been tld abut yur emergency. We need t fllw up n yur emergency care. Yu r a persn yu chse shuld call t tell us abut yur emergency care, usually within 48 hurs, by calling , seven days a week, frm 8 a.m. t 8 p.m. Fr help with any medical r behaviral health (mental health and/r substance abuse) questins r needs, yu can call seven days a week, frm 8 a.m. t 8 p.m. What is cvered if yu have a medical emergency Yu may get cvered emergency care whenever yu need it, anywhere in the United States r its territries. If yu need an ambulance t get t the emergency rm, ur plan cvers that. T learn mre, see the Benefits Charts in Chapter 4, Sectin D, page 40. Yu dn t need apprval frm yur prvider t get emergency care. Yu can get emergency care 24 hurs a day, seven days a week, within the U.S. and its territries. We will cver emergency-related ambulance transprtatin and pst-stabilizatin care services. A prvider will examine and treat yur If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 31

33 emergency health needs befre sending yu hme r mving yu t anther hspital, if necessary. Hwever, emergency department visits utside f the U.S. and its territries are nt cvered. If yu have an emergency, we will talk with the dctrs wh give yu emergency care. Thse dctrs will tell us when yur medical emergency is ver. After the emergency is ver, yu may need fllw-up care t be sure yu get better; this care is called pst-stabilizatin care services. Pst-stabilizatin care services are cvered services that help yu get better and stay healthy after an emergency health cnditin. Yu can get these services at hspitals and all health care centers that prvide emergency services. Yur fllwup care will be cvered by ur plan. If yu get yur emergency care frm ut-f-netwrk prviders, we will try t get netwrk prviders t take ver yur care as sn as pssible. What shuld yu d if yu have a behaviral health emergency In a behaviral health emergency, yu shuld g t the nearest emergency rm. Yu will be evaluated by a crisis team that will assist in finding yu an apprpriate facility fr care. N prir authrizatin is required fr this type f emergency within the U.S. and its territries. T learn mre, see the Benefits Charts in Chapter 4, Sectin D, page 40. Yu can als cntact the Massachusetts Emergency Service Prgram (ESP) at ESP prvides behaviral health crisis assessment, interventin, and stabilizatin services, 24 hurs a day, seven days per week, and 365 days a year. ESP includes fur services: 1. Mbile Crisis Interventin (MCI) services fr yuth these services are available 24 hurs a day, seven days a week, as fllws: frm 7 a.m. t 8 p.m. at all ESP cmmunity-based lcatins, and frm 8 p.m. t 7 a.m. at residential prgrams and hspital emergency departments. 2. MCI services fr adults these services are available 24 hurs a day, seven days a week, as fllws: frm 7 a.m. t 8 p.m. at all ESP cmmunity-based lcatins, and frm 8 p.m. t 7 a.m. at residential prgrams and hspital emergency departments. 3. ESP cmmunity-based lcatins hurs vary based n lcatin; fr details g t masspartnership.cm/prvider/pdf/mbhpespdirectry070914fin.pdf. 4. Cmmunity crisis stabilizatin (CCS) services fr peple age 18 and lder these services are available 24 hurs a day, seven days a week; fr details g t masspartnership.cm/prvider/pdf/mbhpespdirectry070914fin.pdf. What if it wasn t an emergency after all Smetimes it can be hard t knw if yu have a medical r behaviral health emergency. Yu might g in fr emergency care, but the dctr may say it wasn t really an emergency. As lng as it was reasnable fr yu t think yur health was in serius danger, we will cver yur care. 32

34 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services Hwever, after the dctr says it was nt an emergency, we will cver yur additinal care nly if: Yu g t a netwrk prvider; r The care yu get is cnsidered urgently needed care and yu fllw the rules fr getting this care. (See the next sectin.) Getting urgently needed care What is urgently needed care Urgently needed care is care yu get fr a sudden illness, injury, r cnditin that isn t an emergency but still needs care right away. Fr example, yu might have a flare-up f an existing cnditin and need t have it treated. Getting urgently needed care when yu are in the plan s service area In mst situatins, we will cver urgently needed care nly if: Yu get this care frm a netwrk prvider; and Yu fllw the ther rules described in this chapter. Hwever, if yu can t get t a netwrk prvider, we will cver urgently needed care that yu get frm an ut-f-netwrk prvider. An urgent care situatin is when yu experience a health prblem that needs attentin right away but yu dn t believe yu are having an emergency. Yu may experience a health prblem that is serius but des nt put yur life in danger r risk permanent health damage when, fr example, yu have flu-like symptms that are getting wrse, r when yu have a cugh r cld that is nt getting better. Yur primary care prvider (PCP) r, if applicable, yur behaviral health prvider can usually address these health prblems. In urgent situatins, call yur PCP r behaviral health prvider. Yu can cntact any f yur prviders ffices 24 hurs a day, seven days a week. If apprpriate, make an appintment t visit yur prvider. Yur prvider must see yu within 48 hurs fr urgent care appintments. If yur cnditin gets wrse befre yur PCP r behaviral health prvider sees yu, call 911 r g t the emergency rm. If yu have a behaviral health cncern, yu may als call yur lcal emergency services prgram (ESP) prvider. Getting urgently needed care when yu are utside the plan s service area When yu are utside the service area, yu might nt be able t get care frm a netwrk prvider. In that case, ur plan will cver urgently needed care that yu get frm any prvider. If yu are traveling and need emergency care, g t the nearest emergency rm. If yu need urgent care, call yur PCP s ffice and fllw yur prvider s directin. Fr ther rutine health If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 33

35 care issues, call yur PCP. Fr rutine behaviral health issues, call yur behaviral health prvider. If yu are utside f Tufts Health Plan Netwrk Health s service area but in the United States r its territries, we ll nly cver emergency care, pst-stabilizatin care services, r urgently needed care. We will nt cver: Nnemergency tests r treatment that yur PCP asked fr but that yu decided t get utside f the service area Rutine r fllw-up care that can wait until yur return t the service area, such as physical exams, flu shts, stitch remval, and behaviral health cunseling Care that yu knew yu were ging t get befre yu left the service area, such as elective surgery Urgently needed care r any ther nnemergency care that yu get utside the U.S. r its territries A prvider may ask yu t pay fr care yu get utside f Tufts Health Plan Netwrk Health s service area at the time f service. If yu pay fr emergency care, pst-stabilizatin care services, r urgent care that yu get utside f ur service area, yu may ask us t reimburse yu. Yu may als call ur member services team at fr help with any bills that yu get frm a prvider. J. What if yu are billed directly fr the full cst f services cvered by ur plan If a prvider sends yu a bill instead f sending it t the plan, yu can ask us t pay the bill. Yu shuld nt pay the bill yurself. If yu d, the plan may nt be able t pay yu back. If yu have paid fr yur cvered services r if yu have gtten a bill fr cvered medical services, see Chapter 7 t learn what t d. Tufts Health Unify cvers all services: That are medically necessary; and That are listed in the plan s Benefits Charts (see Chapter 4); and That yu get by fllwing the plan s rules. If yu get services that aren t cvered by ur plan, yu will have t pay the full cst yurself. If yu want t knw if we will pay fr any medical service r care, yu have the right t ask us. If we say we will nt pay fr yur services, yu have the right t appeal ur decisin. Chapter 9 explains what t d if yu want the plan t pay fr a medical service it desn t usually pay fr. It als tells yu hw t appeal a decisin abut a service. Yu may als call member services at t learn mre abut this. 34

36 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services We will pay fr sme services up t a certain limit. If yu g ver the limit, yu will have t pay the full cst t get mre f that type f service. Call member services t find ut what the limits are and hw clse yu are t reaching them. K. Hw are yur health care services cvered when yu are in a clinical research study What is a clinical research study A clinical research study (als called a clinical trial) is a way fr dctrs t test new types f health care r drugs. They ask fr vlunteers t help with the study. This kind f study helps dctrs decide if a new kind f health care r drug wrks, and if it is safe. If yu vlunteer fr a clinical research study, we will pay any csts if Medicare apprves the study. If yu are part f a study that Medicare has nt apprved, yu will have t pay any csts fr being in the study. Once Medicare apprves a study that yu want t be in, smene wh wrks n the study will cntact yu. That persn will tell yu abut the study and see if yu qualify t be in it. Yu can be in the study as lng as yu meet the required cnditins. Yu must als understand and accept what yu must d fr the study. If yu are in a Medicare-apprved clinical research study, Medicare, nt the One Care plan, pays fr mst f the cvered services yu get. While yu are in the study, yu may stay enrlled in ur plan. That way, yu can cntinue t get care nt related t the study. If yu want t participate in a Medicare-apprved clinical research study, yu d nt need t get apprval frm us r yur PCP. The prviders that give yu care as part f the study d nt need t be netwrk prviders. But yu d need t tell us befre yu start participating in a clinical research study. Here s why: We can tell yu if the clinical research study is Medicare-apprved; and We can tell yu which services yu will get frm clinical research study prviders instead f frm ur plan. If yu plan t be in a clinical research study, yu r yur care manager shuld cntact member services. When yu are in a clinical research study, wh pays fr what Once yu jin a Medicare-apprved clinical research study, yu are cvered fr mst items and services yu get as part f the study. This includes: If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 35

37 Rm and bard fr a hspital stay that Medicare wuld pay fr even if yu weren t in a study An peratin r ther medical prcedure that is part f the research study Treatment f any side effects and cmplicatins f the new care Medicare pays mst f the cst f the cvered services yu get as part f the study. After Medicare pays its share f the cst fr these services, ur plan will als pay fr the rest f the csts. Remember, this nly applies t services that are related t the research study. Other care services yu receive, including rutine care frm yur prviders, must meet the health plan requirements. Learning mre Yu can learn mre abut jining a clinical research study by reading Medicare & Clinical Research Studies n the Medicare website (medicare.gv/publicatins/pubs/pdf/02226.pdf). Yu can als call 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call L. Hw are yur health care services cvered when yu are in a religius nnmedical health care institutin What is a religius nnmedical health care institutin A religius nnmedical health care institutin is a place that prvides care that yu wuld nrmally get in a hspital r skilled nursing facility. If getting care in a hspital r a skilled nursing facility is against yur religius beliefs, we will cver care in a religius nnmedical health care institutin. Yu may chse t get health care at any time, fr any reasn. This benefit is nly fr Medicare Part A inpatient services (nnmedical health care services). Medicare will pay fr nnmedical health care services prvided nly by religius nnmedical health care institutins. What care frm a religius nnmedical health care institutin is cvered by ur plan T get care frm a religius nnmedical health care institutin, yu must sign a legal dcument that says yu are against getting medical treatment that is nnexcepted. Nnexcepted medical treatment is any care that is vluntary and nt required by any federal, state, r lcal law. Excepted medical treatment is any care that is nt vluntary and is required under federal, state, r lcal law. T be cvered by ur plan, the care yu get frm a religius nnmedical health care institutin must meet the fllwing cnditins: 36

38 Tufts Health Unify Member Handbk Chapter 3: Using the plan s cverage fr yur health care and ther cvered services The facility prviding the care must be certified by Medicare. Services are limited t nnreligius aspects f care. Services yu get in yur hme must be services that we wuld nrmally cver. (That is, we wuld cver them if yu gt them frm hme health agencies that are nt religius nnmedical health care institutins.) Medicare cverage limits apply. See the Benefits Charts in Chapter 4, Sectin D, page 40. If yu get services in a facility: The services must be fr a medical cnditin that we wuld cver as inpatient hspital care r skilled nursing facility care; and Yu must get apprval frm ur plan befre yu are admitted t the facility, r yur stay will nt be cvered. M. Rules fr wning durable medical equipment (DME) Will yu wn yur DME DME means certain items rdered by a prvider fr use in yur wn hme. Examples f these items are xygen equipment and supplies, wheelchairs, canes, crutches, walkers, and hspital beds. Yu will always wn certain items, such as prsthetics. In this sectin, we discuss DME yu must rent. In Medicare, peple wh rent certain types f DME wn them after 13 mnths. As a member f Tufts Health Unify, hwever, yu usually will nt wn the rented equipment, n matter hw lng yu rent it. Call member services t find ut abut the requirements yu must meet and the papers yu need t prvide. What happens if yu switch t Medicare Yu will have t make 13 new payments in a rw under Original Medicare t wn the equipment if: Yu did nt becme the wner f the DME item while yu were in ur plan; and Yu leave ur plan and get yur Medicare benefits utside f any health plan in the Original Medicare prgram. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 37

39 If yu made payments fr the DME under Original Medicare befre yu jined ur plan, thse Medicare payments d nt cunt tward the 13 payments. Yu will have t make 13 new payments in a rw under Original Medicare t wn the item. There are n exceptins t this case when yu return t Original Medicare. 38

40 Chapter 4: Benefits Charts Table f cntents A. Understanding yur cvered services B. Our plan des nt allw prviders t charge yu fr services C. Abut the Benefits Charts D. The Benefits Charts E. Benefits nt cvered by the plan A. Understanding yur cvered services This chapter tells yu what services Tufts Health Unify cvers. Yu can als learn abut services that are nt cvered. Infrmatin abut drug benefits is in Chapter 5, and infrmatin abut what yu pay fr drugs is in Chapter 6. This chapter als explains limits n sme services. With Tufts Health Unify, yu pay nthing fr the cvered services in this chapter as lng as yu fllw the plan s rules. See Chapter 3, Sectin B, page 21 fr details abut the plan s rules. This cvered services list is fr yur general infrmatin nly. Please call Tufts Health Unify fr the mst up-t-date infrmatin. MassHealth regulatins are ne f the factrs that cntrl the services and benefits available t yu. T access MassHealth regulatins: G t MassHealth s website at mass.gv/masshealth; r Call MassHealth custmer service at (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled), Mnday thrugh Friday, frm 8 a.m. t 5 p.m. If yu need help understanding what services are cvered, call yur care manager r ur member services at B. Our plan des nt allw prviders t charge yu fr services We d nt allw Tufts Health Unify prviders t bill yu fr services. Yu shuld never get a bill frm a netwrk prvider. If yu d, see Chapter 7, page 87. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 39

41 C. Abut the Benefits Charts The Benefits Charts tell yu which services the plan cvers. The charts list and explain the cvered services. We will pay fr the services listed in the Benefits Charts nly when the fllwing rules are met. Yu d nt pay anything fr the service listed in the Benefits Charts as lng as yu meet the cverage requirements described belw. Yur Medicare and MassHealth cvered services must be prvided accrding t the rules set by Medicare and MassHealth. The services (including medical care, behaviral health care, lng-term services and supprts (LTSS), ther services, supplies, and equipment) must be medically necessary. Medically necessary means yu reasnably need the services t prevent, diagnse, r treat a medical cnditin. It als means there is n ther similar, less expensive service that is suitable fr yu. Yu get yur care frm a netwrk prvider. A netwrk prvider is a prvider wh wrks with Tufts Health Unify. In mst cases, the plan will nt cver care yu get frm an utf-netwrk prvider. Chapter 3, Sectin D, page 24 has mre infrmatin abut using netwrk and ut-f-netwrk prviders. In mst cases, yur primary care prvider (PCP) must give yu apprval befre yu can see ther netwrk prviders. This is called a referral. Chapter 3, Sectin D, page 24 has mre infrmatin abut getting a referral and explains when yu d nt need a referral. Sme f the services listed in the Benefits Charts are cvered nly if yur care team, dctr, r ther netwrk prvider gets apprval frm us first. This is called prir authrizatin (permissin). Cvered services that need apprval first are marked in the Benefits Charts by an asterisk (*). Sme f the services in the Benefits Charts are cvered nly if yu and yur care team decide that they are right fr yu and they are in yur persnal care plan. D. The Benefits Charts General services that ur plan cvers Abdminal artic aneurysm screening The plan cvers ultrasund screening fr peple at risk. Yu must get a referral fr it at yur Welcme t Medicare preventive visit. Abrtin services 40

42 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Adult day health services* The plan cvers services frm adult day health prviders at an rganized prgram. These services may include the fllwing: Nursing services and health versight Therapy Assistance with activities f daily living Nutritinal and dietary services Cunseling services Activities Case management Transprtatin Adult fster care services* The plan cvers services frm adult fster care prviders in a residential setting. These services may include the fllwing: Assistance with activities f daily living, instrumental activities f daily living, and persnal care Supervisin Nursing versight Alchl-misuse screening and cunseling* The plan cvers alchl-misuse screening. If yu screen psitive fr alchl misuse, the plan cvers cunseling sessins with a qualified primary care prvider (PCP) r practitiner in a primary care setting. Ambulance services Cvered ambulance services include fixed-wing, rtary-wing, and grund ambulance services. The ambulance will take yu t the nearest place that can give yu care. Yur cnditin must be serius enugh that ther ways f getting t a place f care culd risk yur life r health. Ambulance services fr ther cases must be apprved by the plan. In cases that are nt emergencies, the plan may pay fr an ambulance. Yur cnditin must be serius enugh that ther ways f getting t a place f care culd risk yur life r health. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 41

43 General services that ur plan cvers Audilgist services The plan cvers audilgist (hearing) exams and evaluatins. Bne-mass measurement* The plan cvers certain prcedures fr members wh qualify (usually smene at risk f lsing bne mass r at risk f steprsis). These prcedures identify bne mass, find bne lss, r find ut bne quality. The plan will als cver a dctr lking at and cmmenting n the results. Prir authrizatin is nt required by netwrk prviders except fr members yunger than 50 r members whse test frequency exceeds ne test every tw years, r mre frequently if they are medically necessary. Breast cancer screening (mammgrams) The plan cvers mammgrams and clinical breast exams. Cardiac (heart) rehabilitatin services* The plan cvers cardiac rehabilitatin services, such as exercise, educatin, and cunseling. Members must meet certain cnditins with a dctr s rder. The plan als cvers intensive cardiac rehabilitatin prgrams, which are mre intense than standard cardiac rehabilitatin prgrams. Cardivascular (heart) disease risk-reductin visit (therapy fr heart disease) The plan cvers visits with yur PCP t help lwer yur risk fr heart disease. During this visit, yur dctr may: Discuss aspirin use Check yur bld pressure Give yu tips t make sure yu are eating well Cardivascular (heart) disease testing The plan cvers bld tests t check fr cardivascular disease nce. These bld tests als check fr defects due t high risk f heart disease. Cervical and vaginal cancer screening The plan cvers Pap tests and pelvic exams. Chirpractic services* The plan cvers adjustments f the spine t crrect alignment, ffice visits, and radilgy services. Prir authrizatin required after 20 visits. 42

44 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Clrectal-cancer screening The plan cvers the fllwing services: Flexible sigmidscpy (r screening barium enema) Fecal ccult bld test Screening clnscpy (r screening barium enema) Cmmunity health center services The plan cvers services frm a cmmunity health center. Examples include the fllwing: Office visits fr PCP and specialists OB/GYN and prenatal care Pediatric services, including early peridic screening, diagnsis, and treatment (EPSDT) Health educatin/wellness prgrams Medical scial services Nutritin services, including diabetes self-management training and medical nutritin therapy Tbacc-cessatin services Vaccines nt cvered by the Massachusetts Department f Public Health (MDPH) Cunseling t stp smking r tbacc use As a preventive service, the plan cvers cunseling n attempts t quit. Tufts Health Unify members can als get medicatins and cunseling t help quit smking frm the Massachusetts Tbacc Cessatin & Preventin Prgram (MTCP) and MassHealth. Fr mre infrmatin abut quitting smking, talk t yur PCP. Day habilitatin services* The plan cvers a prgram f services ffered by day habilitatin prviders if yu qualify because yu have an intellectual r develpmental disability. At this prgram, yu develp a service plan that includes yur gals and bjectives and the activities t help yu meet them. These services may include the fllwing: Nursing services and health care supervisin Develpmental-skills training Therapy services Life skills/adult daily living training If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 43

45 General services that ur plan cvers Dental services* The plan cvers preventive, restrative, and emergency ral health care. We cver tw cleanings per year and ne X-ray panel every tw years. Other dental services, like rthdntic and prsthetic services, are cvered. Yu may need t get prir authrizatin befre we cver sme dental services. Depressin screening The plan cvers depressin screening. The screening must be dne in a primary care setting that can give fllw-up treatment and referrals. Diabetes screening The plan cvers diabetes screening (includes fasting glucse tests). Diabetic self-management training, services, and supplies These services are cvered if medically necessary. The plan cvers the fllwing services fr all peple wh have diabetes r prediabetes (even if they dn t use insulin): Supplies t mnitr yur bld glucse, including the fllwing:» A bld glucse mnitr» Bld glucse test strips» Lancet devices and lancets» Glucse-cntrl slutins fr checking the accuracy f test strips and mnitrs Fr peple with diabetes wh have severe diabetic ft disease, the plan cvers the fllwing:» Therapeutic custm-mlded shes (including inserts), r» Depth shes (including nncustmized remvable inserts) The plan will als cver fitting the therapeutic custm-mlded r depth shes. In sme cases, the plan cvers training t help yu manage yur diabetes, such as educatinal and training services by a physician and ther accredited prvider (registered nurse, physician assistant, nurse practitiner, licensed dietitian) t treat prediabetes r diabetes. 44

46 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Durable medical equipment (DME),* including related supplies, replacement parts, training, mdificatins, and repairs (Fr a definitin f durable medical equipment, see Chapter 3, Sectin M, page 37 r Chapter 12, page 163 f this handbk.) The fllwing items are examples f DME that are cvered: Wheelchairs Crutches Hspital beds Bandages Mnitring equipment Persnal Emergency Respnse Systems (PERS) rentals Special beds Canes Cmmdes Nebulizers Oxygen equipment IV infusin pumps Walkers Other items may be cvered, including envirnmental aids r assistive/adaptive technlgy. The plan may als cver yu learning hw t use, mdify, r repair yur item. Yur care team will wrk with yu t decide if these ther items and services are right fr yu and will be in yur persnal care plan. We cver all medically necessary DME that Medicare and MassHealth usually pay fr. If ur supplier in yur area des nt carry a particular brand r maker, yu may ask them if they can special-rder it fr yu. Prir authrizatin may be required fr sme DME. T find a DME supplier, see ur Prvider and Pharmacy Directry. If yu (r yur prvider) d nt agree with the plan s decisin abut paying fr yur equipment, yu r yur dctr may file an appeal. Yu can als file an appeal if yu d nt agree with yur dctr s decisin abut what prduct r brand is right fr yur medical cnditin. (Fr mre infrmatin abut appeals, see Chapter 9.) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 45

47 General services that ur plan cvers Emergency medical care Emergency care means services that are: Given by a prvider trained t give emergency services; and Needed t treat a medical emergency. A medical emergency is a medical cnditin that anyne with an average knwledge f health and medicine culd expect is s serius that, if it desn t get immediate medical attentin, it wuld result in: Placing the persn s health at serius risk; Serius harm t bdily functins; Serius dysfunctin f any bdily rgan r part; r An active labr in the case f a pregnant wman, meaning labr at a time when either f the fllwing circumstances wuld ccur:» There is nt enugh time t safely transfer the member t anther hspital befre delivery; r» The transfer may pse a threat t the health r safety f the member r unbrn child Emergency care is cvered fr inpatient and utpatient medical and behaviral health (mental health and/r substance abuse) emergency services prvided within the U.S. and its territries. If yu get emergency care at an ut-f-netwrk hspital and need inpatient care after yur emergency is stabilized, yu must return t a netwrk hspital fr yur care t cntinue t be paid fr. Yu can stay in the ut-f-netwrk hspital fr yur inpatient care nly if the plan apprves yur stay. 46

48 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Family-planning services Yu may chse any prvider in Tufts Health Unify s netwrk r a MassHealth prvider t get certain family-planning services. This means that yu can pick any dctr, clinic, hspital, pharmacy, r family-planning ffice. The plan cvers the fllwing services: Family-planning exam and medical treatment Family-planning lab and diagnstic tests Family-planning methds (birth cntrl pills, patch, ring, IUD, injectins, r implants) Family-planning supplies with prescriptin (cndm, spnge, fam, film, diaphragm, r cap) Cunseling and diagnsis f infertility Cunseling and testing fr sexually transmitted infectins (STIs), AIDS, and ther HIVrelated cnditins Treatment fr STIs Vluntary sterilizatin (yu must be 21 r lder, and yu must sign a federal sterilizatincnsent frm; at least 30 days, but nt mre than 180 days, must pass between the date that yu sign the frm and the date f surgery) Genetic cunseling The plan will als pay fr sme ther family-planning services. Hwever, yu must see a prvider in the plan s netwrk fr the fllwing services: Treatment fr medical cnditins f infertility (this service des nt include artificial ways t becme pregnant) Treatment fr AIDS and ther HIV-related cnditins Genetic testing, if medically necessary (yu must see a prvider in the plan s netwrk) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 47

49 General services that ur plan cvers Grup adult fster care* The plan cvers services prvided by grup adult fster care prviders fr members wh qualify. These services are ffered in a grup-supprted husing envirnment and may include the fllwing: Assistance with activities f daily living, instrumental activities f daily living, and persnal care Supervisin Nursing versight Care management Health and wellness educatin prgrams These are prgrams fcused n health cnditins such as high bld pressure, chlesterl, asthma, and special diets. Prgrams designed t enrich the health and lifestyles f members include weight management, fitness, and stress management. Hearing services,* including hearing aids The plan cvers hearing and balance tests dne by yur prvider. These tests tell yu whether yu need medical treatment. They are cvered as utpatient care when yu get them frm a physician, audilgist, r ther qualified prvider. The plan als cvers the fllwing: Prviding and dispensing hearing aids, if medically necessary, batteries, and accessries Instructin in the use, care, and management f hearing aids Ear mlds Ear impressins Lan f a hearing aid, when necessary N prir authrizatin is required fr batteries, accessries, aid, instructin f use/care/ maintenance, and services during the lifetime f the hearing aid. Fr netwrk prviders, prir authrizatin is required fr mnaural (ne ear) mre than $500 r binaural (tw ears) mre than $1,000. Prir authrizatin is required fr all ut-f-netwrk prviders. 48

50 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers HIV screening The plan cvers HIV screening exams and HIV screening tests. Hme health agency care* The plan cvers services prvided by a hme health agency, including: Physical therapy, ccupatinal therapy, and speech therapy Medical and scial services Transprtatin t yur care r services Medical equipment and supplies Hme health aide services * The plan cvers services frm a hme health aide, under the supervisin f a licensed registered nurse (RN) r ther prfessinal, fr members wh qualify. Services may include the fllwing: Simple dressing changes Assistance with medicatins Activities t supprt skilled therapies Rutine care f prsthetic and rthtic devices Part-time r intermittent hme health aide services Part-time r intermittent skilled nursing If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 49

51 General services that ur plan cvers Hspice care* Yu can get care frm any hspice prgram certified by Medicare. Yur hspice dctr can be a netwrk prvider r an ut-f-netwrk prvider. When yu are in a hspice prgram certified by Medicare, yur hspice services and yur Medicare Part A and B services related t yur terminal illness are paid fr by Medicare. Tufts Health Unify may nt bill yu fr the services related t yur terminal illness. The plan cvers the fllwing: Drugs t treat symptms and pain (please see belw fr infrmatin abut cverage f Part D drugs yur hspice benefit desn t cver) Shrt-term respite care Hme care, including:» Nursing» Medical scial services» Physician services» Cunseling, including bereavement, dietary, and spiritual» Physical, ccupatinal, and speech language therapy» Hmemaker/hme health aid» Medical supplies and bilgical supplies Fr hspice services and services cvered by Medicare Part A r B that relate t yur terminal illness: The hspice prvider will bill Medicare fr yur services. Medicare will pay fr hspice services and any Medicare Part A r B services. Yu pay nthing fr these services. Fr services cvered by Medicare Part A r B that are nt related t yur terminal illness (except fr emergency care r urgently needed care): The prvider will bill Medicare fr yur services. Medicare will pay fr the services cvered by Medicare Part A r B. Yu pay nthing fr these services. 50

52 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Hspice care, cntinued Fr services cvered by Tufts Health Unify but nt cvered by Medicare Part A r B: Tufts Health Unify cvers plan-cvered services nt cvered under Medicare Part A r B. The plan will cver the services even if they are nt related t yur terminal illness. Yu pay nthing fr these services. Fr drugs that may be cvered by Tufts Health Unify s Medicare Part D benefit: Drugs are never cvered by bth hspice and ur plan at the same time. Fr mre infrmatin, please see Chapter 5. Nte: If yu need nnhspice care, yu shuld call yur care crdinatr t arrange the services. Nnhspice care is care that is nt related t yur terminal illness. Our plan cvers hspice cnsultatin services (ne time nly) fr a terminally ill persn wh has nt chsen the hspice benefit. Immunizatins The plan cvers certain vaccines, such as: Pneumnia and HPV Flu shts and FluMist, nce a year, in the fall r winter Hepatitis B vaccine if yu are at high r intermediate risk f getting hepatitis B Shingles vaccine fr members ver age 60 Other vaccines if yu are at risk and they meet Medicare Part B cverage rules Other vaccines that meet the MassHealth r Medicare Part D cverage rules (read Chapter 6, Sectin D, page 86 t learn mre) Vaccines and vaccine administratin are cvered if medically necessary r when required fr schl. We d nt cver state-supplied serum unless the state supply is exhausted. Vaccines are nt cvered if required fr travel utside the U.S. and its territries. Independent nursing* The plan cvers care frm a nurse in yur hme. The nurse may either wrk fr a hme health agency r be an independent nurse. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 51

53 General services that ur plan cvers Inpatient behaviral health care* The plan cvers inpatient services, such as: Inpatient mental health services t evaluate and treat an acute psychiatric cnditin Inpatient substance abuse services Observatin/hlding beds Administratively necessary day services Under this plan, there is n lifetime limit n the number f days a member can have in an inpatient mental health care facility. Inpatient hspital care* The plan cvers medically necessary inpatient stays, as fllws: Members receiving medical services nly Members receiving medical and behaviral health services cvered, nt subject t 20-day benefit limitatin Yu must get apprval frm the plan t keep getting inpatient care at an ut-f-netwrk hspital after yur emergency is under cntrl. The plan cvers services including: A semi-private rm (r a private rm if it is medically necessary) Meals, including special diets Regular nursing services Csts f special care units, such as intensive care r crnary care units Drugs and medicatins Lab tests X-rays and ther radilgy services Surgical and medical supplies Appliances, like wheelchairs Operating and recvery rm services Physical, ccupatinal, and speech therapy Inpatient substance abuse services 52

54 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Inpatient hspital care* (cntinued) Transplants, such as crneal, kidney, kidney/pancreatic, heart, liver, lung, heart/lung, bne marrw, stem cell, and intestinal/multivisceral. If yu need a transplant, a Medicareapprved transplant center will review yur case and decide whether yu are a candidate. Transplant prviders may be lcal r utside the service area. If lcal transplant prviders are willing t accept the Medicare rate, yu can get yur transplant services lcally r at a distant lcatin utside the service area. If Tufts Health Unify prvides transplant services at a distant lcatin utside the service area and yu chse t get yur transplant there, we will arrange r pay fr ldging and travel csts fr yu and ne ther persn. Bld, including strage and administratin» The plan cvers whle bld, packed red cells, and all ther parts f bld. Physician services Inpatient services* The plan cvers services yu get while yu are in the hspital r a nursing facility. The plan cvers services including: In-netwrk inpatient behaviral health (mental health and/r substance abuse) Dctr services Diagnstic tests, like lab tests X-ray, radium, and istpe therapy, including technician materials and services Surgical dressings Splints, casts, and ther devices used fr fractures and dislcatins Prsthetics and rthtic devices, ther than dental, including replacement r repairs f such devices. These are devices that:» Replace all r part f an internal bdy rgan (including cntiguus tissue), r» Replace all r part f the functin f an inperative r malfunctining internal bdy rgan. Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes (this includes adjustments, repairs, and replacements needed because f breakage, wear, lss, r a change in the patient s cnditin) Physical therapy, speech therapy, and ccupatinal therapy If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 53

55 General services that ur plan cvers Medical nutritin therapy This benefit is fr peple with diabetes r kidney disease withut dialysis. It is als fr the time after a kidney transplant when referred by yur dctr. The plan will cver ne-n-ne cunseling services. If yur cnditin, treatment, r diagnsis changes, yu may be able t get mre hurs f treatment with a dctr s referral. A dctr must prescribe these services and renew the referral each year if yur treatment is needed in the next calendar year. Medically necessary nnemergency transprtatin* The plan cvers transprtatin yu need fr medical reasns ther than emergencies. Medicare Part B prescriptin drugs These drugs are cvered under Part B f Medicare. Tufts Health Unify will cver the fllwing drugs: Drugs yu dn t usually give yurself and that are injected r infused while yu are getting dctr, hspital utpatient, r ambulatry surgery center services Drugs yu take using DME (such as nebulizers) that were authrized by the plan Cltting factrs yu give yurself by injectin if yu have hemphilia Immunsuppressive drugs, if yu were enrlled in Medicare Part A at the time f the rgan transplant Osteprsis drugs that are injected; these drugs are paid fr if yu are hmebund, have a bne fracture that a dctr certifies was related t pstmenpausal steprsis, and cannt inject the drug yurself Antigens Certain ral anticancer drugs and antinausea drugs Certain drugs fr hme dialysis, including heparin, the antidte fr heparin (when medically needed), tpical anesthetics, and erythrpiesis-stimulating agents (such as Epgen, Prcrit, Epetin alfa, Aranesp, r Darbepetin alfa) IV immune glbulin fr the hme treatment f primary immune-deficiency diseases Chapter 5, page 68 explains the utpatient prescriptin drug benefit. It als explains the rules yu must fllw t have prescriptins cvered. Nursing facility care* The plan cvers nursing facility care if medically necessary and if received in an inpatient setting. Prir authrizatin is required fr in-netwrk and ut-f-netwrk services. 54

56 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Obesity screening and therapy t keep weight dwn The plan cvers cunseling t help yu lse weight. Yu must get the cunseling in a primary care setting. That way, it can be managed with yur full preventin plan. Talk t yur PCP t find ut mre. Orthtic services* The plan cvers braces (nndental) and ther mechanical r mlded devices t supprt r crrect the frm r functin f the human bdy. Outpatient behaviral health (mental health) services* The plan cvers mental health services prvided by the fllwing prviders: A state-licensed psychiatrist r dctr A clinical psychlgist A clinical scial wrker A clinical nurse specialist A nurse practitiner A physician assistant, r Any ther Medicare-qualified mental health care prfessinal as allwed under applicable state laws The plan cvers medically necessary services, including: Clinic services fr the first 12 in-netwrk utpatient mental health visits Day treatment fr the first 12 in-netwrk utpatient mental health visits Psychscial rehabilitatin services fr the first 12 in-netwrk utpatient mental health visits The fllwing mental health services are als cvered if medically necessary, with limitatins as nted: Individual, grup, and cuples/family treatment prir authrizatin required in-netwrk after 12 visits and fr all ut-f-netwrk visits Medicatin visit prir authrizatin required ut-f-netwrk Diagnstic evaluatin prir authrizatin required in-netwrk after 12 visits and fr all utf-netwrk visits Family cnsultatin prir authrizatin required ut-f-netwrk Case cnsultatin prir authrizatin required ut-f-netwrk Dialectical behaviral therapy (DBT)* prir authrizatin required in-netwrk and ut-f-netwrk If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 55

57 General services that ur plan cvers Outpatient behaviral health (mental health) services* (cntinued) Psychiatric cnsultatin n an inpatient medical unit prir authrizatin required ut-f-netwrk Inpatient-utpatient bridge visit prir authrizatin required ut-f-netwrk Psychlgical testing* prir authrizatin required in-netwrk and ut-f-netwrk Acupuncture treatment prir authrizatin required in-netwrk and ut-f-netwrk Opiid replacement therapy prir authrizatin required ut-f-netwrk Ambulatry detxificatin (Level II.d) prir authrizatin required in-netwrk and ut-f-netwrk Outpatient diagnstic tests and therapeutic services and supplies* The plan cvers medically necessary services, including: X-rays, electrcardigrams (EKG), electrencephalgrams (EEG), and ultrasunds Radiatin (radium and istpe) therapy, including technician materials and supplies Surgical supplies, such as dressings Splints, casts, and ther devices used fr fractures and dislcatins Lab tests Bld, beginning with the first pint f bld needed (the plan will pay fr strage and administratin; hwever, prir authrizatin is required) Other utpatient diagnstic prcedures, such as clnscpy, sigmidscpy, gastrscpy, and endscpy Outpatient drugs Please read Chapter 5 fr infrmatin n drug benefits and Chapter 6 fr infrmatin n what yu pay fr drugs. Outpatient hspital services* The plan cvers medically needed services yu get in the utpatient department f a hspital fr diagnsis r treatment f an illness r injury. The plan cvers services including: Services in an emergency department r utpatient clinic, such as bservatin services r utpatient surgery Labs and diagnstic tests billed by the hspital Mental health care, including care in a partial-hspitalizatin prgram, if a dctr certifies that inpatient treatment wuld be needed withut it 56

58 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Outpatient hspital services* (cntinued) X-rays and ther radilgy services billed by the hspital Medical supplies, such as splints and casts Sme screenings and preventive services Sme drugs that yu can t give yurself Outpatient rehabilitatin services* The plan cvers physical therapy, ccupatinal therapy, and speech therapy. Yu can get utpatient rehabilitatin services frm hspital utpatient departments, independent therapist ffices, cmprehensive utpatient rehabilitatin facilities (CORFs), and ther facilities. Outpatient substance abuse services* When medically necessary, the fllwing are cvered: Clinic and day treatment services fr the first 12 in-netwrk utpatient substance abuse service visits The fllwing substance abuse services are als cvered if medically necessary, with limitatins as nted: Acupuncture treatment prir authrizatin required in-netwrk and ut-f-netwrk Opiid replacement therapy prir authrizatin required ut-f-netwrk Ambulatry detxificatin (Level II.d) prir authrizatin required in-netwrk and ut-f-netwrk Outpatient surgery The plan cvers utpatient surgery and services at hspital utpatient facilities and ambulatry surgical centers. Oxygen and respiratry therapy equipment The plan cvers services such as xygen systems, refills, and xygen therapy equipment rental if yu meet criteria fr hme xygen therapy. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 57

59 General services that ur plan cvers Persnal care attendant services* The plan cvers persnal care attendant services t assist yu with activities f daily living and instrumental activities f daily living if yu qualify. These include, fr example: Bathing Feeding Dressing Medicatin management Laundry Husekeeping Yu can hire a wrker yurself r use an agency t hire ne fr yu. A wrker can help yu with hands-n tasks. The plan may als pay fr a wrker t help yu, even if yu d nt need hands-n help. Yur care team will wrk with yu t decide if that service is right fr yu and will be in yur persnal care plan. Physician/prvider services,* including dctr s ffice visits The plan cvers the fllwing services: Medically necessary health care r surgery services given in places such as:» A physician s ffice» A certified ambulatry surgical center» A hspital utpatient department Cnsultatin, diagnsis, and treatment by a specialist Basic hearing and balance exams given by yur PCP r specialist, if yur dctr rders them t see whether yu need treatment Sme telehealth services, including cnsultatin, diagnsis, and treatment by a physician r practitiner fr patients in rural areas r ther places apprved by Medicare Secnd pinin by anther netwrk prvider befre a medical prcedure; we must give prir authrizatin when yur prvider wants yu t get a secnd pinin frm a prvider wh is nt part f ur prvider netwrk Nnrutine dental care cvered services are limited t the fllwing:» Surgery f the jaw r related structures» Setting fractures f the jaw r facial bnes» Pulling teeth befre radiatin treatments f neplastic cancer, r» Services that wuld be cvered when prvided by a physician 58

60 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Physician, nurse practitiner, and nurse midwife services The plan cvers physician, nurse practitiner, and nurse midwife services. These include, fr example: Office visits fr primary care and specialists OB/GYN and prenatal care Diabetes self-management training Medical nutritinal therapy Tbacc-cessatin services Pdiatry services* Cvered fr all medical cnditins. Prir authrizatin is required fr in-netwrk, nndiabetic care, and fr any ut-f-netwrk care. The plan cvers the fllwing services: Diagnsis and medical r surgical treatment f injuries and diseases f the ft (such as hammer te r heel spurs) Rutine ft care fr members with cnditins affecting the legs, such as diabetes Radilgical and labratry care Prstate-cancer screening exams The plan cvers the fllwing services: A digital rectal exam A prstate specific antigen (PSA) test Prsthetic devices and related supplies* Prsthetic services and devices replace all r part f a bdy part r functin. The plan cvers services including: Clstmy bags and supplies related t clstmy care Pacemakers Braces Prsthetic shes Artificial arms and legs Breast prstheses (including a surgical brassiere after a mastectmy) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 59

61 General services that ur plan cvers Prsthetic devices and related supplies* (cntinued) In additin, the plan cvers evaluatin, fabricatin, and fitting f sme supplies related t prsthetic devices. The plan als cvers repairing r replacing prsthetic devices. Certain limitatins apply and prir authrizatin may be required. The plan ffers sme cverage after cataract remval r cataract surgery. See Visin care later in this sectin n page 62 fr details. The plan will nt cver prsthetic dental devices. Pulmnary-rehabilitatin services* With prir authrizatin, the plan cvers pulmnary-rehabilitatin prgrams fr members wh have mderate t very severe chrnic bstructive pulmnary disease (COPD). The member must have a referral fr pulmnary rehabilitatin frm the dctr r prvider treating the COPD. Renal (kidney) disease services and supplies* The plan cvers the fllwing services: Kidney disease educatin services t teach kidney care and help members make gd decisins abut their care yu must have stage IV chrnic kidney disease, and yur dctr must refer yu; the plan will cver up t six sessins f kidney disease educatin services Outpatient dialysis treatments, including dialysis treatments when temprarily ut f the service area, as explained in Chapter 3, Sectin B, page 21 Inpatient dialysis treatments if yu are admitted as an inpatient t a hspital fr special care Self-dialysis training, including training fr yu and anyne helping yu with yur hme dialysis treatments Hme dialysis equipment and supplies Certain hme supprt services, such as necessary visits by trained dialysis wrkers t check n yur hme dialysis, t help in emergencies, and t check yur dialysis equipment and water supply Yur Medicare Part B drug benefit cvers sme drugs fr dialysis. Fr infrmatin, please see Medicare Part B prescriptin drugs abve. Sexually transmitted infectins (STIs) screening and cunseling The plan cvers screenings fr chlamydia, gnrrhea, syphilis, and hepatitis B. A PCP must rder the tests. The plan als cvers face-t-face, high-intensity behaviral cunseling sessins. The plan cvers these cunseling sessins as a preventive service nly if they are given by a PCP. The sessins must be in a primary care setting, such as a dctr s ffice. 60

62 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts General services that ur plan cvers Skilled nursing facility care* This is cvered if medically necessary and received in an inpatient setting. Prir authrizatin is required fr in-netwrk and ut-f-netwrk services. The plan cvers services including: A semi-private rm r a private rm if it is medically necessary Meals, including special diets Nursing services Physical therapy, ccupatinal therapy, and speech therapy Drugs yu get as part f yur plan f care, including substances that are naturally in the bdy, such as bld-cltting factrs Bld, including strage and administratin:» The plan will pay fr whle bld and packed red cells.» The plan will pay fr all ther parts f bld, beginning with the first pint used. Medical and surgical supplies given by nursing facilities Lab tests given by nursing facilities X-rays and ther radilgy services given by nursing facilities Appliances, such as wheelchairs, usually given by nursing facilities Physician/prvider services Skilled nursing facility care* (cntinued) Yu will usually get yur care frm netwrk facilities. Hwever, yu may be able t get yur care frm a facility nt in ur netwrk. Yu can get care frm the fllwing places if they accept ur plan s amunts fr payment: A nursing hme r cntinuing-care retirement cmmunity where yu lived befre yu went t the hspital (as lng as it prvides nursing facility care) A nursing facility where yur spuse lives at the time yu leave the hspital If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 61

63 General services that ur plan cvers Urgently needed care Urgently needed care is care given t treat the fllwing: A nnemergency (des nt include rutine primary care services) A sudden medical illness An injury A cnditin that needs care right away If yu require urgently needed care, yu shuld first try t get it frm a netwrk prvider. Hwever, yu can use ut-f-netwrk prviders when yu cannt get t a netwrk prvider. Urgently needed care is cvered fr inpatient and utpatient medical and behaviral health (mental health and/r substance abuse) emergency services prvided within the U.S. and its territries. Visin care The plan will pay fr the fllwing: Cmprehensive eye exams, frm participating prviders, nce every 12 mnths Visin training Eye glasses, ne pair every 24 mnths Cntact lenses and ther visual aids The plan cvers utpatient dctr services fr the diagnsis and treatment f diseases and injuries f the eye. This includes treatment fr age-related macular degeneratin. Fr peple at high risk f glaucma, the plan cvers glaucma screenings. The plan cvers glasses r cntact lenses after cataract surgery when the dctr inserts an intracular lens. Welcme t Medicare preventive visit The plan cvers the ne-time Welcme t Medicare preventive visit. The visit includes: A review f yur health Educatin and cunseling abut the preventive services yu need (including screenings and shts) Referrals fr ther care if yu need it Imprtant: We cver the Welcme t Medicare preventive visit nly during the first 12 mnths that yu have Medicare Part B. When yu make yur appintment, tell yur dctr s ffice yu want t schedule yur Welcme t Medicare preventive visit. Wellness visit The plan cvers wellness checkups. This is t make r update a preventin plan. 62

64 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts In additin t these general services, ur plan als cvers cmmunity-based behaviral health care services. These are smetimes called diversinary behaviral health services. These are services that yu may be able t use instead f ging t the hspital r a facility fr sme behaviral health needs. Yur care team will wrk with yu t decide if these services are right fr yu and will be in yur care plan. Cmmunity-based (diversinary) behaviral health care services* that ur plan cvers These services include the fllwing: Cmmunity crisis stabilizatin prir authrizatin required in-netwrk and ut-f-netwrk Cmmunity Supprt Prgram (CSP) prir authrizatin required in-netwrk and ut-f-netwrk Partial hspitalizatin» Partial hspitalizatin is a structured prgram f active psychiatric treatment. It is ffered in a hspital utpatient setting r by a cmmunity mental health center. It is mre intense than the care yu get in yur dctr s r therapist s ffice. It can help keep yu frm having t stay in the hspital. Acute treatment services fr substance abuse prir authrizatin required in-netwrk and ut-f-netwrk Clinical supprt services fr substance abuse prir authrizatin required in-netwrk and ut-f-netwrk Psychiatric day treatment Intensive utpatient prgram Structured utpatient addictin prgram Prgram f Assertive Cmmunity Treatment (PACT) prir authrizatin required in-netwrk and ut-f-netwrk Emergency Services Prgram (ESP) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 63

65 Our plan als cvers cmmunity-based services t prmte wellness, recvery, self-management f chrnic cnditins, and independent living. These services may als help yu stay ut f the hspital r nursing facility. Yur care team will wrk with yu t decide if these services are right fr yu and will be in yur care plan. Cmmunity-based services that ur plan cvers Care transitins assistance* The plan cvers services t help with transitins between care settings fr members wh qualify. These services may include the fllwing: Crdinatin f infrmatin between yur prviders Fllw-up after yur inpatient r facility stay Educatin abut yur health cnditin Referrals Cmmunity health wrkers* The plan cvers services prvided by cmmunity health wrkers, which may include the fllwing: Health educatin in yur hme r cmmunity Getting yu the services yu need Cunseling, supprt, and screenings Services frm a cmmunity health wrker means that yu ll be getting help frm smene wh will advcate fr yu and wh understands yur culture, needs, and preferences. Day services* The plan cvers structured day activities at a prgram t help yu learn skills that yu need t live as independently as pssible in the cmmunity. Skills are designed t meet yur needs and may include the fllwing: Daily living skills Cmmunicatin training Prevcatinal skills Scializatin skills 64

66 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts Cmmunity-based services that ur plan cvers Hme care services* The plan cvers hme care services prvided in yur hme r cmmunity if yu qualify. These services may include the fllwing: A wrker t help yu with husehld tasks A wrker t help yu with yur everyday tasks and persnal care. Assistance can be hands-n, prmpting r supervising these tasks. Training r activities t imprve yur cmmunity living skills and help yu advcate fr yurself Hme mdificatins* The plan cvers mdificatins t yur hme if yu qualify. The mdificatins must be designed t ensure yur health, welfare, and safety r make yu mre independent in yur hme. Mdificatins may include the fllwing: Ramps Grab-bars Widening f drways Special systems fr medical equipment Medicatin management* The plan cvers medicatin management services frm a supprt wrker if yu qualify. The supprt wrker will help yu take yur prescriptin and ver-the-cunter medicatins. The service may include the fllwing: Reminding yu t take yur medicatin Checking the medicatin package Watching yu take yur medicatin Writing dwn when yu take yur medicatin Opening medicatins and reading the labels fr yu Nnmedical transprtatin* The plan cvers transprtatin t cmmunity services and activities that help yu stay independent and active in yur cmmunity. Peer supprt/cunseling/navigatin* The plan cvers training, instructin, and mentring services if yu qualify. These services will help yu t advcate fr yurself and participate in yur cmmunity. Yu may get these services frm a peer r in small grups. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 65

67 Cmmunity-based services that ur plan cvers Respite care* The plan cvers respite-care services if yur primary caregiver needs relief r is ging t be unavailable fr a shrt-term basis. These services can be prvided in an emergency r planned in advance. If planned in advance, services might be in yur hme r, during a shrtterm placement, in adult fster care, adult day health, a nursing facility, assisted living, a rest hme, r a hspital. E. Benefits nt cvered by the plan This sectin tells yu what kinds f benefits are excluded by the plan. Excluded means that the plan des nt pay fr these benefits. The list belw describes sme services and items that are nt cvered by the plan under any cnditins and sme that are excluded by the plan nly in sme cases. The plan will nt cver the excluded medical benefits listed in this sectin (r anywhere else in this Member Handbk). Medicare and Medicaid will nt pay fr them either. If yu think that we shuld pay fr a service that is nt cvered, yu can file an appeal. Fr infrmatin abut filing an appeal, see Chapter 9, Sectin 5.3, page 114. In additin t any exclusins r limitatins described in the Benefits Charts, r anywhere else in this Member Handbk, the fllwing items and services are nt cvered by ur plan: Services that are nt medically necessary accrding t the standards f Medicare and MassHealth Experimental medical and surgical treatments, items, and drugs, unless cvered by Medicare r under a Medicare-apprved clinical research study r by ur plan. See Chapter 3, Sectin K, page 35 fr mre infrmatin n clinical research studies. Experimental treatment and items are thse that are nt generally accepted by the medical cmmunity Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, antiaging, and mental perfrmance), except when medically needed Csmetic surgery r ther csmetic wrk, unless it is needed because f an accidental injury r t imprve a part f the bdy that is malfrmed; hwever, the plan will pay fr recnstructin f a breast after a mastectmy and fr treating the ther breast t match it Orthpedic shes, unless the shes are part f a leg brace and are included in the cst f the brace, r the shes are fr a persn with diabetic ft disease Supprtive devices fr the feet, except fr rthpedic r therapeutic shes fr peple with diabetic ft disease Radial kerattmy, LASIK surgery, visin therapy, and ther lw-visin aids Reversal f sterilizatin prcedures and nnprescriptin cntraceptive supplies 66

68 Tufts Health Unify Member Handbk Chapter 4: Benefits Charts Naturpath services (the use f natural r alternative treatments) Acupuncture, except t treat substance use, if medically necessary; see this chapter, Sectin D fr additinal details If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 67

69 Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan Table f cntents Intrductin Rules fr the plan s utpatient drug cverage A. Getting yur prescriptins filled Fill yur prescriptin at a netwrk pharmacy Shw yur plan ID card when yu fill a prescriptin What if yu want t change t a different netwrk pharmacy What if the pharmacy yu use leaves the netwrk What if yu need a specialized pharmacy Can yu use mail-rder services t get yur drugs Can yu get a lng-term supply f drugs Can yu use a pharmacy that is nt in the plan s netwrk B. The plan s Drug List What is n the Drug List Hw can yu find ut if a drug is n the Drug List What is nt n the Drug List C. Limits n cverage fr sme drugs Why d sme drugs have limits What kinds f rules are there D any f these rules apply t yur drugs D. Why yur drug might nt be cvered Yu can get a temprary supply E. Changes in cverage fr yur drugs If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 68

70 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan F. Drug cverage in special cases If yu are in a hspital r a skilled nursing facility fr a stay that is cvered by the plan If yu are in a lng-term care facility If yu are in a Medicare-certified hspice prgram G. Prgrams n drug safety and managing drugs Prgrams t help members use drugs safely Prgrams t help members manage their drugs Intrductin This chapter explains rules fr getting yur utpatient prescriptin drugs. These are drugs that yur prvider rders fr yu that yu get frm a pharmacy r by mail rder. They include drugs cvered under Medicare Part D and MassHealth. Tufts Health Unify als cvers the fllwing drugs, but they will nt be discussed in this chapter: Drugs cvered by Medicare Part A. These include sme drugs given t yu while yu are in a hspital r nursing facility. Drugs cvered by Medicare Part B. These include sme chemtherapy drugs; sme drug injectins yu get during an ffice visit with a dctr r ther prvider, and drugs yu get at a dialysis clinic. T learn mre abut which Medicare Part B drugs are cvered, see the Benefits Charts in Chapter 4, Sectin D, page 40. Rules fr the plan s utpatient drug cverage The plan will usually cver yur drugs as lng as yu fllw the rules in this sectin: 1. A dctr r ther prvider must write yur prescriptin. This persn ften is yur primary care prvider (PCP). It culd als be anther netwrk prvider if yur primary care prvider has referred yu t that prvider fr care. 2. Yu generally must use a netwrk pharmacy t fill yur prescriptin. 3. Yur prescribed drug generally must be n the plan s List f Cvered Drugs. We call it the Drug List fr shrt. If it is nt n the Drug List, we may be able t cver it by giving yu an exceptin. See Chapter 9, Sectin 6.2, page 123 t learn abut asking fr an exceptin. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 69

71 4. Yur drug must be used fr a medically accepted indicatin. This means that the use f the drug is apprved by the Fd and Drug Administratin r supprted by certain apprved reference bks. A. Getting yur prescriptins filled Fill yur prescriptin at a netwrk pharmacy In mst cases, the plan will pay fr prescriptins nly if they are filled at the plan s netwrk pharmacies. A netwrk pharmacy is a drugstre that has agreed t fill prescriptins fr ur plan members. Yu may g t any f ur netwrk pharmacies. T find a netwrk pharmacy, yu can: Lk in the Prvider and Pharmacy Directry Visit ur website at TuftsHealthUnify.rg, r Cntact member services at Shw yur plan ID card when yu fill a prescriptin T fill yur prescriptin, shw yur plan ID card at yur netwrk pharmacy. The netwrk pharmacy will bill the plan fr yur cvered prescriptin drug. If yu d nt have yur plan ID card with yu when yu fill yur prescriptin, ask the pharmacy t call the plan t get the necessary infrmatin. If the pharmacy is nt able t get the necessary infrmatin, r the pharmacy asks yu t pay fr the drug, cntact member services right away. We will d what we can t help. What if yu want t change t a different netwrk pharmacy If yu change pharmacies and need a refill f a prescriptin, yu can ask yur pharmacy t transfer the prescriptin t the new pharmacy. If yu need help changing yur netwrk pharmacy, yu can cntact member services at What if the pharmacy yu use leaves the netwrk If the pharmacy yu use leaves the plan s netwrk, yu will have t find a new netwrk pharmacy s that the plan cntinues t pay fr yur prescriptins. T find a new netwrk pharmacy, yu can lk in the Prvider and Pharmacy Directry, visit ur website at TuftsHealthUnify.rg, r cntact member services at What if yu need a specialized pharmacy Smetimes prescriptins must be filled at a specialized pharmacy. Specialized pharmacies include: 70

72 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan Pharmacies that supply drugs fr hme infusin therapy. Our plan will cver hme infusin therapy if: Yur prescriptin drug is n ur Drug List r an exceptin has been granted fr yur prescriptin Yur prescriptin drug is nt therwise cvered under ur plan s medical benefit Our plan has apprved yur prescriptin fr hme-infusin therapy Yur prescriptin is written by an authrized prescriber Pharmacies that supply drugs fr residents f a lng-term care facility, such as a nursing facility. Usually, lng-term care facilities have their wn pharmacies. Residents may get prescriptin drugs thrugh a facility s pharmacy as lng as it is part f ur netwrk. If yur lng-term care facility s pharmacy is nt in ur netwrk, please cntact member services. Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health Prgram. Except in emergencies, nly Native Americans r Alaska Natives may use these pharmacies. Pharmacies that supply drugs that require special handling and instructins n their use. T find a specialized pharmacy, yu can lk in the Prvider and Pharmacy Directry, visit ur website, r cntact member services at Can yu use mail-rder services t get yur drugs Fr certain kinds f drugs, yu can use the plan s netwrk mail-rder services. Generally, the drugs available thrugh mail rder are drugs that yu take n a regular basis fr a chrnic r lng-term medical cnditin. Our plan s mail-rder service requires yu t rder at least a 30-day supply f the drug and n mre than a 90-day supply. Hw d I fill my prescriptins by mail T get infrmatin abut filling yur prescriptins by mail, g ur website at TuftsHealthUnify.rg r call ur member services at Usually, a mail-rder prescriptin will get t yu within 14 days. Hwever, smetimes yur mail rder may be delayed. If yur rder is delayed, please call member services, seven days a week, frm 8 a.m. t 8 p.m., and we will allw yu t fill a partial supply f the medicatin at a netwrk retail pharmacy. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 71

73 Hw will the mail-rder service prcess my prescriptin The mail-rder service has different prcedures fr new prescriptins it gets frm yu, new prescriptins it gets directly frm yur prvider s ffice, and refills n yur mail-rder prescriptins: 1. New prescriptins the mail-rder pharmacy gets frm yu The pharmacy will autmatically fill and deliver new prescriptins it receives frm yu. 2. New prescriptins the mail-rder pharmacy gets directly frm yur prvider s ffice After the pharmacy receives a prescriptin frm a health care prvider, it will cntact yu t see if yu want the medicatin filled immediately r at a later time. This will give yu an pprtunity t make sure the pharmacy is delivering the crrect drug (including strength, amunt, and frm) and, if needed, allw yu t stp r delay the rder befre it is shipped. It is imprtant that yu respnd each time yu are cntacted by the pharmacy, t let them knw what t d with the new prescriptin and t prevent any delays in shipping. 3. Refills n mail-rder prescriptins Fr refills, please cntact yur pharmacy 25 days befre yu think the drugs yu have n hand will run ut t make sure yur next rder is shipped t yu in time. S the pharmacy can reach yu t cnfirm yur rder befre shipping, please make sure t let the pharmacy knw the best ways t cntact yu. Call CVS/caremark custmer care tll-free at (TTY: ), seven days a week, 7 a.m. t 12 a.m., t prvide yur preferred phne number. Can yu get a lng-term supply f drugs Yu can get a lng-term supply f maintenance drugs n ur plan s Drug List. Maintenance drugs are drugs that yu take n a regular basis fr a chrnic r lng-term medical cnditin. Sme netwrk pharmacies allw yu t get a lng-term supply f maintenance drugs. The Prvider and Pharmacy Directry tells yu which pharmacies can give yu a lng-term supply f maintenance drugs. Yu can als call member services fr mre infrmatin. Yu can use the plan s netwrk mail-rder services t get a lng-term supply f maintenance drugs. See the sectin abve n this page t learn abut mail-rder services. Can yu use a pharmacy that is nt in the plan s netwrk Yu shuld always use a pharmacy in Tufts Health Unify s netwrk if yu can. If yu think yu are nt able t use a pharmacy in ur netwrk, call member services first. We usually pay fr drugs filled at an ut-f-netwrk pharmacy nly when yu are nt able t use a netwrk pharmacy. We will pay fr prescriptins filled at an ut-f-netwrk pharmacy in the fllwing cases: Medical emergencies we will cver prescriptins that are filled at an ut-f-netwrk pharmacy if the prescriptins are related t care fr a medical emergency r urgently needed 72

74 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan care. In this situatin, yu will generally have t pay the full cst when yu fill the prescriptin. Yu can ask us t reimburse yu fr the cst by submitting yur request in writing with yur prescriptin receipts t: CVS/caremark P.O. Bx Phenix, AZ When yu travel r are away frm the plan s service area if yu take a prescriptin drug n a regular basis and yu are ging n a trip, be sure t check yur supply f the drug befre yu leave. When pssible, take alng all the medicatin yu will need. Yu may be able t rder yur prescriptin drugs ahead f time thrugh ur netwrk mail-rder pharmacy service r thrugh a retail netwrk pharmacy. If yu are traveling within the U.S. but utside f ur service area and yu becme ill, r if yu lse r run ut f yur prescriptin drugs, we will cver prescriptins that are filled at an ut-fnetwrk pharmacy if yu fllw all ther cverage rules identified within this dcument and a netwrk pharmacy is nt available. In this situatin, yu generally will have t pay the full cst when yu fill the prescriptin. Yu can ask us t reimburse yu fr the pharmacy cst by submitting yur receipts t CVS/caremark. T learn mre, see Chapter 7, Sectin B, page 89. Prir t filling yur prescriptins at an ut-f-netwrk pharmacy, call member services t find ut if there is a netwrk pharmacy in the area where yu are traveling. Our pharmacy netwrk is natinwide. If there are n netwrk pharmacies in that area, member services may be able t make arrangements fr yu t get yur prescriptins frm an ut-f-netwrk pharmacy. Other times yu can get yur prescriptin cvered if yu g t an ut-f-netwrk pharmacy we will cver yur prescriptin at an ut-f-netwrk pharmacy if at least ne f the fllwing applies: If yu are unable t get a cvered drug in a timely manner within ur service area because there are n netwrk pharmacies within a reasnable driving distance that prvide 24-hur service If yu are trying t fill a cvered drug that is nt regularly stcked at an eligible netwrk retail r mail-rder pharmacy (these drugs include rphan drugs r ther specialty drugs). Befre yu fill yur prescriptin in either f these situatins, call member services t see if there is a netwrk pharmacy in yur area where yu can fill yur prescriptin. If yu d g t an ut-f-netwrk pharmacy fr the reasns listed abve, yu generally will have t pay the full cst when yu fill yur prescriptin. Yu can ask us t reimburse yu fr the cst by submitting yur request in writing alng with yur prescriptin receipts. In these cases, please check first with member services t see if there is a netwrk pharmacy nearby. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 73

75 If yu use an ut-f-netwrk pharmacy fr sme ther reasn, the pharmacy may ask yu t pay fr the full cst f yur prescriptin. If this happens, call member services first. If yu pay the full cst when yu get yur prescriptin, yu can ask us t pay yu back. T learn mre abut this, see Chapter 7, Sectin B, page 89. B. The plan s Drug List The plan has a List f Cvered Drugs. We call it the Drug List fr shrt. The drugs n the Drug List are selected by the plan with the help f a team f dctrs and pharmacists. The Drug List als tells yu if there are any rules yu need t fllw t get yur drugs. We will usually cver a drug n the plan s Drug List as lng as yu fllw the rules explained in this chapter. What is n the Drug List The Drug List includes the drugs cvered under Medicare Part D and sme prescriptin and ver-thecunter drugs cvered under yur MassHealth benefits. The Drug List includes bth brand-name and generic drugs. Generic drugs have the same ingredients as brand-name drugs. They wrk just as well as brand-name drugs and usually cst less. Generic drugs are apprved by the Fd and Drug Administratin (FDA). We will usually cver drugs n the plan s Drug List as lng as yu fllw the rules explained in this chapter. Our plan als cvers certain ver-the-cunter drugs and prducts. Sme ver-the-cunter drugs cst less than prescriptin drugs and wrk just as well. Fr mre infrmatin, call member services. Hw can yu find ut if a drug is n the Drug List T find ut if a drug yu are taking is n the Drug List, yu can: Check the mst recent Drug List that we sent t yu in the mail; Visit the plan s website at TuftsHealthUnify.rg (the Drug List n the website is always the mst current ne); Yu may als call member services and ask fr a cpy f the list. What is nt n the Drug List The plan des nt cver all prescriptin drugs. Sme drugs are nt n the Drug List because the law des nt allw the plan t cver thse drugs. In ther cases, we have decided nt t include a drug n the Drug List. Tufts Health Unify will nt pay fr the drugs listed in this sectin. These are called excluded drugs. If yu get a prescriptin fr an excluded drug, yu must pay fr it yurself. If yu think we shuld pay fr 74

76 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan an excluded drug in yur case, yu can file an appeal. (T learn hw t file an appeal, see Chapter 9, Sectin 5.3.) Here are three general rules fr excluded drugs: Our plan s utpatient drug cverage cannt cver a drug that wuld already be cvered under Medicare Part A r Part B. Drugs cvered under Medicare Part A r Part B are cvered by Tufts Health Unify fr free, but they are nt cnsidered t be part f yur utpatient prescriptin drug benefits. Our plan cannt cver a drug purchased utside the United States and its territries. The use f the drug must be apprved by the Fd and Drug Administratin (FDA) r supprted by certain apprved reference bks as a treatment fr yur cnditin. Yur dctr might prescribe a certain drug t treat yur cnditin, even thugh the drug was nt apprved t treat that cnditin. This is called ff-label use. Our plan usually des nt cver drugs when they are prescribed fr ff-label use. By law, the types f drugs listed belw are als nt cvered by Medicare r Medicaid: Drugs used t prmte fertility Drugs used fr csmetic purpses r t prmte hair grwth Drugs used fr the treatment f sexual r erectile dysfunctin, such as Viagra, Cialis, Levitra, and Caverject Drugs used fr treatment f anrexia, weight lss, r weight gain Outpatient drugs when the cmpany that makes the drugs says that yu have t have tests r services dne nly by them What are tiers Every drug n the plan s Drug List is in ne f three tiers. Tier 1 drugs have n c-pay. They are generic drugs. Tier 2 drugs have n c-pay. They are brand-name drugs. Tier 3 drugs have n c-pay. They are ver-the-cunter drugs. T find ut which tier yur drug is in, lk fr the drug in the plan s Drug List. C. Limits n cverage fr sme drugs Why d sme drugs have limits There are special rules that limit hw and when the plan cvers certain prescriptin drugs. In general, ur rules encurage yu t get a drug that wrks fr yur medical cnditin and is safe and effective. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 75

77 When a safe, lwer-cst drug will wrk just as well as a higher-cst drug, the plan expects yur prvider t use the lwer-cst drug. If there is a special rule fr yur drug, it usually means that yu r yur prvider will have t take extra steps fr us t cver the drug. Fr example, yur prvider may have t tell us yur diagnsis r prvide results f bld tests first. If yu r yur prvider thinks ur rule shuld nt apply t yur situatin, yu shuld ask us t make an exceptin. After review, we may agree t let yu use the drug withut taking the extra steps. T learn mre abut asking fr exceptins, see Chapter 9, Sectin 6.2, page 123. What kinds f rules are there 1. Limiting use f a brand-name drug when a generic versin is available Generally, a generic drug wrks the same as a brand-name drug and usually csts less. In mst cases, if there is a generic versin f a brand-name drug, ur netwrk pharmacies will give yu the generic versin. We usually will nt pay fr the brand-name drug when there is a generic versin. Hwever, if yur prvider has tld us the medical reasn that the generic drug will nt wrk fr yu, then we will cver the brand-name drug. 2. Getting plan apprval in advance Fr sme drugs, yu r yur dctr must get apprval frm Tufts Health Unify befre yu fill yur prescriptin. This is called prir apprval (r prir authrizatin). If yu dn t get apprval, Tufts Health Unify may nt cver the drug. 3. Trying a different drug first (step therapy) In general, the plan wants yu t try lwer-cst drugs (that ften are just as effective) befre the plan cvers drugs that cst mre. Fr example, if Drug A and Drug B treat the same medical cnditin, and Drug A csts less than Drug B, the plan may require yu t try Drug A first. If Drug A des nt wrk fr yu, then the plan will cver Drug B. This is called step therapy. 4. Quantity limits Fr sme drugs, we limit the amunt f the drug yu can have. Fr example, the plan might limit: Hw many refills yu can get; r Hw much f a drug yu can get each time yu fill yur prescriptin. D any f these rules apply t yur drugs T find ut if any f the rules abve apply t a drug yu take r want t take, check the Drug List. Fr the mst up-t-date infrmatin, call member services at r check ur website at TuftsHealthUnify.rg. 76

78 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan D. Why yur drug might nt be cvered We try t make yur drug cverage wrk well fr yu. But smetimes a drug might nt be cvered in the way that yu wuld like it t be. Fr example: The drug yu want t take is nt cvered by the plan. The drug might nt be n the Drug List. A generic versin f the drug might be cvered, but the brand-name versin yu want t take is nt. A drug might be new and we have nt yet reviewed it fr safety and effectiveness. The drug is cvered, but there are extra rules r limits n cverage fr that drug. As explained in the sectin abve, sme f the drugs cvered by the plan have rules that limit their use. In sme cases, yu may want us t ignre the rule fr yu. There are things yu can d if yur drug is nt cvered in the way that yu wuld like it t be. Yu can get a temprary supply In sme cases, the plan can give yu a temprary supply f a drug when the drug is nt n the Drug List r when it is limited in sme way. This gives yu time t talk with yur prvider abut getting a different drug r t ask the plan t cver the drug. Tufts Health Unify determines which drugs are Part D drugs. We may decide that sme lder drugs r drugs withut prven clinical utcmes d nt qualify as Part D drugs. If yu are taking a drug that Tufts Health Unify des nt cnsider t be a Part D drug, yu have the right t get a ne-time, 72-hur supply f the drug. If the pharmacy is nt able t bill Tufts Health Unify fr this ne-time supply, MassHealth will pay fr it. This is required by Massachusetts law. Als, yu may be able t get a lnger temprary supply f a Part D drug r f a nn-part D drug that MassHealth wuld cver. T find ut hw lng Tufts Health Unify will prvide a temprary supply f a drug, call member services at T get a temprary supply f a drug, yu must meet the tw rules belw: 1. The drug yu have been taking: Is n lnger n the plan s Drug List; r Was never n the plan s Drug List; r Is nw limited in sme way. 2. Yu must be in ne f these situatins: Fr Medicare Part D drugs: Yu were in the plan last year and d nt live in a lng-term care facility. We will cver a temprary supply f yur drug during the first 90 days f the calendar year. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 77

79 This temprary supply will be fr up t 30 days. If yur prescriptin is written fr fewer days, we will allw multiple fills t prvide up t a maximum f a 30-day supply f medicatin. Yu must fill the prescriptin at a netwrk pharmacy. Yu are new t the plan and d nt live in a lng-term care facility. We will cver a temprary supply f yur Medicare Part D drug during the first 90 days f yur membership in the plan. This temprary supply will be fr up t a 30-day supply. If yur prescriptin is written fr fewer days, we will allw multiple fills t prvide up t a maximum f a 30-day f medicatin. Yu must fill the prescriptin at a netwrk pharmacy. Yu were in the plan last year and live in a lng-term care facility. We will cver a temprary supply f yur drug during the first 90 days f yur membership in the plan. The ttal supply will be fr a maximum f a 91-day supply. If yur prescriptin is written fr fewer days, we will allw multiple fills t prvide up t a maximum f a 91-day supply f medicatin. (Please nte that the lng-term care pharmacy may prvide the drug in smaller amunts at a time t prevent waste.) Yu are new t the plan and live in a lng-term care facility. We will cver a temprary supply f yur Medicare Part D drug during the first 90 days f yur membership in the plan. The ttal supply will be fr up t 91 days. If yur prescriptin is written fr fewer days, we will allw multiple fills t prvide up t a maximum f 91-day supply f medicatin. (Nte that the lng-term care pharmacy may prvide the drug in smaller amunts at a time t prevent waste.) Yu have been in the plan fr mre than 90 days and live in a lng-term care facility and need a supply right away. We will cver ne 31-day supply f yur Medicare Part D drug, r less if yur prescriptin is written fr fewer days. This is in additin t the abve lng-term care transitin supply. Yu are in a lng-term facility and yu experience an unplanned drug change. If yu experience an unplanned drug change due t a change in level f care, yu can request that we apprve a ne-time, temprary fill f the nncvered medicatin t allw yu time t discuss a transitin plan with yur physician. Yur physician can als request an exceptin t cverage fr the nncvered drug based n review fr medical necessity fllwing the standard exceptin prcess utlined previusly. The temprary first fill will generally be up t a 31-day supply, but it may be extended t allw yu and yur physician time t manage the cmplexities f multiple medicatins r when special circumstances warrant. Yu can request a temprary prescriptin fill by calling member services at Nte: Our transitin plicy applies nly t thse drugs that are Part D drugs and bught at a netwrk pharmacy. The transitin plicy can t be used t buy nn-part D drugs r a drug at an ut-f-netwrk pharmacy, unless yu qualify fr ut-f-netwrk access. 78

80 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan Fr MassHealth drugs: Yu are new t the plan. We will cver a supply f yur MassHealth drug fr 90 days r until yur assessment and care plan are cmplete, r less if yur prescriptin is written fr fewer days. T ask fr a temprary supply f a drug, call member services at When yu get a temprary supply f a drug, yu shuld talk with yur prvider t decide what t d when yur supply runs ut. Here are yur chices: Yu can change t anther drug. There may be a different drug cvered by the plan that wrks fr yu. Yu can call member services t ask fr a list f cvered drugs that treat the same medical cnditin. The list can help yur prvider find a cvered drug that might wrk fr yu. OR Yu can ask fr an exceptin. Yu and yur prvider can ask the plan t make an exceptin. Fr example, yu can ask the plan t cver a drug even thugh it is nt n the Drug List. Or yu can ask the plan t cver the drug withut limits. If yur prvider says yu have a gd medical reasn fr an exceptin, he r she can help yu ask fr an exceptin. T learn mre abut asking fr an exceptin, see Chapter 9. If yu need help asking fr an exceptin, yu can cntact Member Services. E. Changes in cverage fr yur drugs Mst changes in drug cverage happen n January 1. Hwever, the plan might make changes t the Drug List during the year. Sme f the things that the plan might d include: Add drugs because new drugs, including generic drugs, became available, r the gvernment apprved a new use fr an existing drug Remve drugs because they were recalled r because cheaper drugs wrk just as well Add r remve a limit n cverage fr a drug Replace a brand-name drug with a generic drug If any f the fllwing changes affect a drug yu are taking, the change will nt affect yu until January 1 f the next year: If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 79

81 We put a new limit n yur use f the drug. We remve yur drug frm the Drug List, but nt because f a recall r because a new generic drug has replaced it. Befre January 1 f the next year, yu usually will nt have added limits t yur use f the drug. Thse changes will nt affect yu until January 1 f the next year. In the fllwing cases, yu will be affected by the cverage change befre January 1: If a brand-name drug yu are taking is replaced by a new generic drug, the plan must give yu at least 60 days ntice abut the change. The plan may give yu a 60-day refill f yur brand-name drug at a netwrk pharmacy. Yu shuld wrk with yur prvider during thse 60 days t change t the generic drug r t a different drug that the plan cvers. Yu and yur prvider can ask the plan t cntinue cvering the brand-name drug fr yu. T learn hw, see Chapter 9, Sectin 6.1, page 122. If a drug is recalled because it is fund t be unsafe r fr ther reasns, the plan will remve the drug frm the Drug List. We will tell yu abut this change right away. Yur prvider will als knw abut this change. He r she can wrk with yu t find anther drug fr yur cnditin. If there is a change t cverage fr a drug yu are taking, the plan will send yu a ntice. Nrmally, the plan will let yu knw at least 60 days befre the change. F. Drug cverage in special cases If yu are in a hspital r a skilled nursing facility fr a stay that is cvered by the plan If yu are admitted t a hspital r skilled nursing facility fr a stay cvered by the plan, we will generally cver the cst f yur prescriptin drugs during yur stay. Yu will nt have t pay a cpayment. Once yu leave the hspital r skilled nursing facility, the plan will cntinue t cver yur drugs as lng as the drugs meet all f ur rules fr cverage. If yu are in a lng-term care facility Usually, a lng-term care facility, such as a nursing facility, has its wn pharmacy r a pharmacy that supplies drugs fr all f its residents. If yu are living in a lng-term care facility, yu may get yur prescriptin drugs thrugh the facility s pharmacy if it is part f ur netwrk. Check yur Prvider and Pharmacy Directry t find ut if yur lng-term care facility s pharmacy is part f ur netwrk. If it is nt, r if yu need mre infrmatin, please cntact member services. 80

82 Tufts Health Unify Member Handbk Chapter 5: Getting yur utpatient prescriptin drugs thrugh the plan If yu are in a Medicare-certified hspice prgram Drugs are never cvered by bth hspice and ur plan. If yu are enrlled in a Medicare hspice and require a drug nt cvered by yur hspice because it is unrelated t yur terminal illness and related cnditins, ur plan must receive ntificatin frm either the prescriber r yur hspice prvider that the drug is unrelated befre ur plan can cver the drug. T prevent delays in receiving any unrelated drugs that shuld be cvered by ur plan, yu can ask yur hspice prvider r prescriber t make sure we have the ntificatin that the drug is unrelated befre yu ask a pharmacy t fill yur prescriptin. If yu leave hspice, ur plan shuld cver all f yur drugs. T prevent any delays at a pharmacy when yur Medicare hspice benefit ends, yu shuld bring dcumentatin t the pharmacy t verify that yu have left hspice. See the previus parts f this chapter that describe the rules fr getting drug cverage under Part D. T learn mre abut the hspice benefit, see Chapter 4, Sectin D, page 40. G. Prgrams n drug safety and managing drugs Prgrams t help members use drugs safely Each time yu fill a prescriptin, we lk fr pssible prblems, such as: Drug errrs Drugs that may nt be needed because yu are taking anther drug that des the same thing Drugs that may nt be safe fr yur age r gender Drugs that culd harm yu if yu take them at the same time Drugs that are made f things that yu are allergic t If we see a pssible prblem in yur use f prescriptin drugs, we will wrk with yur prvider t fix the prblem. Prgrams t help members manage their drugs If yu take medicatins fr different medical cnditins, yu may be eligible t get services, at n cst t yu, thrugh a medicatin therapy management (MTM) prgram. This prgram helps yu and yur prvider make sure that yur medicatins are wrking t imprve yur health. A pharmacist r ther health prfessinal will give yu a cmprehensive review f all yur medicatins and talk with yu abut: Hw t get the mst benefit frm the drugs yu take Any cncerns yu have, like medicatin csts and drug reactins Hw best t take yur medicatins If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 81

83 Any questins r prblems yu have abut yur prescriptin and ver-the-cunter medicatin Yu ll get a written summary f this discussin. The summary has a medicatin actin plan that recmmends what yu can d t make the best use f yur medicatins. Yu ll als get a persnal medicatin list that will include all the medicatins yu re taking and why yu take them. It s a gd idea t schedule yur medicatin review befre yur yearly Wellness visit, s yu can talk t yur dctr abut yur actin plan and medicatin list. Bring yur actin plan and medicatin list with yu t yur visit r anytime yu talk with yur dctrs, pharmacists, and ther health care prviders. Als, take yur medicatin list with yu if yu g t the hspital r emergency rm. MTM prgrams are vluntary and free t members that qualify. If we have a prgram that fits yur needs, we will enrll yu in the prgram and send yu infrmatin. If yu d nt want t be in the prgram, please let us knw and we will take yu ut f the prgram. If yu have any questins abut these prgrams, please cntact member services. 82

84 Chapter 6: What yu pay fr yur utpatient prescriptin drugs Table f cntents Intrductin A. The Part D explanatin f benefits (EOB) B. Keeping track f yur drug csts Use yur plan ID card Make sure we have the infrmatin we need Check the reprts we send yu C. What yu pay fr a ne-mnth supply f drugs The plan s tiers Yur pharmacy chices Getting a lng-term supply f a drug D. Vaccinatins Befre yu get a vaccinatin Intrductin T learn mre abut prescriptin drugs that Tufts Health Unify cvers, yu can lk in these places: The plan s List f Cvered Drugs. We call this the Drug List. It tells yu: Which drugs the plan pays fr; Which f the three tiers each drug is in; and Whether there are any limits n the drugs. If yu need a cpy f the Drug List, call member services at Yu can als find the Drug List n ur website at TuftsHealthUnify.rg. The Drug List n the website is always the mst current. Chapter 5 f this Member Handbk. Chapter 5, page 68 tells hw t get yur utpatient prescriptin drugs thrugh the plan. It includes rules yu need t fllw. It als tells which types f prescriptin drugs are nt cvered by ur plan. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 83

85 Tufts Health Unify Member Handbk Chapter 6: What yu pay fr yur utpatient prescriptin drugs The plan s Prvider and Pharmacy Directry. In mst cases, yu must use a netwrk pharmacy t get yur cvered drugs. Netwrk pharmacies are pharmacies that have agreed t wrk with ur plan. The Prvider and Pharmacy Directry has a list f netwrk pharmacies. Yu can read mre abut netwrk pharmacies in Chapter 5, Sectin A, page 70. A. The Part D explanatin f benefits (EOB) Our plan keeps track f yur prescriptin drugs. We keep track f tw types f csts: 1. Yur ut-f-pcket csts. This is the amunt f mney yu, r thers paying fr yu, pay fr yur prescriptins. With Tufts Health Unify, yu d nt have t pay anything fr yur prescriptins as lng as yu fllw the rules in Chapter 5. Yur ut-f-pcket csts will be zer. 2. Yur ttal drug csts. This is the amunt f mney yu, r thers paying fr yu, pay fr yur prescriptins, plus the amunt the plan pays. When yu get prescriptin drugs thrugh the plan, we send yu a reprt called the explanatin f benefits. We call it the EOB fr shrt. The EOB includes: Infrmatin fr the mnth. The reprt tells what Part D prescriptin drugs yu gt. It shws the ttal Part D drug csts, what the plan paid, and what yu and thers paid fr yur drugs. Year-t-date infrmatin. This is yur ttal drug csts and the ttal payments made this year. We ffer cverage f drugs nt cvered under Medicare. Payments made fr these drugs will nt cunt tward yur ttal ut-f-pcket csts. T find ut which drugs ur plan cvers, see the Drug List. B. Keeping track f yur drug csts T keep track f yur drug csts, we use recrds we get frm yu and frm yur pharmacy. Here is hw yu can help us: 1. Use yur plan ID card. Shw yur plan ID card every time yu get a prescriptin filled. This will help us knw what prescriptins yu fill and what yu pay fr them. 2. Make sure we have the infrmatin we need. Give us cpies f receipts fr drugs that yu have paid fr. Yu shuld always fllw the rules in Chapter 5 fr getting drugs. If yu fllw the rules, yu will pay nthing fr drugs cvered by Tufts Health Unify. If yu ever pay the full cst f yur drug, yu shuld keep the receipt and yu can ask us t pay yu back fr the drug. Here are sme times when yu shuld give us cpies f yur receipts: When yu buy a cvered drug at a netwrk pharmacy at a special price r using a discunt card that is nt part f ur plan s benefit 84

86 When yu pay a c-pay fr drugs that yu get under a drug-maker s patient-assistance prgram When yu buy cvered drugs at an ut-f-netwrk pharmacy When yu pay the full price fr a cvered drug T learn hw t ask us t pay yu back fr the drug, see Chapter 7, Sectin A, page Check the reprts we send yu. When yu get an EOB in the mail, please make sure it is cmplete and crrect. If yu think smething is wrng r missing frm the reprt, r if yu have any questins, please call member services. Be sure t keep these reprts. They are an imprtant recrd f yur drug expenses. C. What yu pay fr a ne-mnth supply f drugs The plan s tiers Cst-sharing tiers are grups f drugs with the same c-pay. Every drug in the plan s Drug List is in ne f three tiers. T find yur drugs, yu can lk in the Drug List. Tier 1 drugs have n c-pay. They are generic drugs. Tier 2 drugs have n c-pay. They are brand-name drugs. Tier 3 drugs have n c-pay. They are ver-the-cunter drugs. Yur pharmacy chices In limited cases, we cver prescriptins filled at ut-f-netwrk pharmacies. See Chapter 5 t find ut when we will d that. T learn mre abut pharmacy chices, see Chapter 5 in this handbk and the plan s Prvider and Pharmacy Directry. Getting a lng-term supply f a drug Fr sme drugs, yu can get a lng-term supply (als called an extended supply ) when yu fill yur prescriptin. A lng-term supply is up t a 90-day supply. There is n cst t yu fr a lng-term supply. Fr details n where and hw t get a lng-term supply f a drug, see Chapter 5 r the Prvider and Pharmacy Directry. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 85

87 Tufts Health Unify Member Handbk Chapter 6: What yu pay fr yur utpatient prescriptin drugs D. Vaccinatins Our plan cvers Medicare Part D vaccines. There are tw parts t ur cverage f Medicare Part D vaccinatins: 1. The first part f cverage is fr the cst f the vaccine itself. The vaccine is a prescriptin drug. 2. The secnd part f cverage is fr the cst f giving yu the sht. Befre yu get a vaccinatin We recmmend that yu call us first at member services whenever yu are planning t get a vaccinatin. We can tell yu abut hw yur vaccinatin is cvered by ur plan. We can tell yu nw t keep yur csts dwn by using netwrk pharmacies and prviders. Netwrk pharmacies are pharmacies that have agreed t wrk with ur plan. A netwrk prvider is a prvider wh wrks with the health plan. A netwrk prvider shuld wrk with Tufts Health Plan Netwrk Health t ensure that yu dn t nt have any upfrnt csts fr Part D vaccine. If yu are nt able t use a netwrk prvider and pharmacy, yu may have t pay the entire cst fr bth the vaccine itself and fr getting the sht. If yu are in this situatin, we recmmend that yu call us first at member services. Yu can als ask the prvider t call Tufts Health Unify befre yu get yur vaccine. If yu pay the full cst f the vaccine at a prvider s ffice, we can tell yu hw t ask us t pay yu back. T learn hw t ask us t pay yu back, see Chapter 7, Sectin A, page

88 Chapter 7: Asking us t pay fr services Table f cntents A. Asking us t pay B. Hw and where t send us yur request fr payment C. We will make a cverage decisin D. Yu can make an appeal A. Asking us t pay With One Care, there are sme rules fr getting services. One f the rules is that the service must be cvered by Tufts Health Unify. Anther rule is that yu must get the service frm ne f the prviders that Tufts Health Unify wrks with. G t Chapter 3 t read all the rules. If yu fllw all the rules, then the plan will pay fr yur services autmatically and yu d nt have t ask us t pay. In thse cases, yu shuld nt pay anything t yur prviders r get any bills. If yu are nt sure if the plan will pay fr a service yu want t get r a prvider yu want t see, ask ur member services team. D this befre yu get the service. Our member services team will tell yu if Tufts Health Unify will pay, r if yu need t ask Tufts Health Unify fr a cverage decisin. Read Chapter 9 t learn mre abut cverage decisins. If yu chse t get a service that may nt be cvered by Tufts Health Unify, r if yu get a service frm a prvider wh des nt wrk with Tufts Health Unify, then Tufts Health Unify will nt autmatically pay fr the service. Here are sme different situatins and infrmatin abut payment fr yur services. 1. If yu get emergency r urgently needed health care frm an ut-f-netwrk prvider Yu shuld ask the prvider t bill the plan. Call member services r yur care manager if yu need help. If yu pay the full amunt when yu get the care, ask us t make sure yu get paid back. Send us the bill and prf f any payment yu made. If yu get a bill frm the prvider asking fr payment that yu think yu d nt we, send us the bill and prf f any payment yu made. If the prvider shuld be paid, we will pay the prvider directly. If yu have already paid fr the service, we will make sure yu get paid back. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 87

89 Tufts Health Unify Member Handbk Chapter 7: Asking us t pay fr services 2. If a prvider in Tufts Health Unify s netwrk sends yu a bill Netwrk prviders must always bill the plan. They are nt allwed t bill yu. If yu ever get a bill frm a netwrk prvider, d nt pay the bill. Send us the bill. We will cntact the prvider directly and take care f the prblem. If yu have already paid a bill frm a netwrk prvider, send us the bill and prf f any payment yu made. We will help yu get paid back fr yur cvered services. 3. If yu use an ut-f-netwrk pharmacy t get a prescriptin filled If yu g t a pharmacy that is nt in Tufts Health Unify s netwrk, yu may have t pay the full cst f yur prescriptin. In nly a few cases, we will cver prescriptins filled at ut-f-netwrk pharmacies. Send us a cpy f yur receipt when yu ask us t pay yu back. Please see Chapter 5, Sectin A, page 70 t learn mre abut ut-f-netwrk pharmacies. 4. If yu pay the full cst fr a prescriptin because yu d nt have yur Tufts Health Unify ID card with yu If yu d nt have yur plan ID card with yu, ask the pharmacy t call the plan r t lk up yur plan enrllment infrmatin. If the pharmacy cannt get the infrmatin they need right away, yu may have t pay the full cst f the prescriptin yurself. Send us a cpy f yur receipt when yu ask us t pay yu back. 5. If yu pay the full cst fr a prescriptin fr a drug that is nt cvered Yu may pay the full cst f the prescriptin because the drug is nt cvered. The drug may nt be n the plan s List f Cvered Drugs (Drug List), r it culd have a requirement r restrictin that yu did nt knw abut r d nt think shuld apply t yu. If yu decide t get the drug, yu may need t pay the full cst fr it. If yu d pay fr the drug but think it shuld be cvered, yu can ask fr a cverage decisin (see Chapter 9, Sectin 5.2, page 112). If yu and yur dctr think yu need the drug right away, yu can ask fr a fast cverage decisin (see Chapter 9, Sectin 5.2, page 112). Send us a cpy f yur receipt when yu ask us t pay yu back. In sme situatins, we may need t get mre infrmatin frm yur dctr in rder t pay yu back fr the drug. When yu send us a request fr payment, we will review yur request and decide whether the service r drug shuld be cvered. This is called making a cverage decisin. If we decide it shuld be cvered, we will pay fr the service r drug. If we deny yur request fr payment, yu can appeal ur decisin. T learn hw t make an appeal, see Chapter 9. 88

90 B. Hw and where t send us yur request fr payment Send us yur bill and prf f any payment yu have made. Prf f payment can be a cpy f the check yu wrte r a receipt frm the prvider. It is a gd idea t make a cpy f yur bill and receipts fr yur recrds. Yu can ask yur care manager fr help. T make sure yu are giving us all the infrmatin we need t make a decisin, call member services at and ask what infrmatin yu will need t prvide t make a payment request. Fr any nn-pharmacy-related payments, mail yur request alng with any bills r receipts t: Tufts Health Plan Netwrk Health Attn: Member Services 101 Statin Landing, Furth Flr Medfrd, MA Fr pharmacy-related payments, mail yur request alng with any bills r receipts t: CVS/caremark P.O. Bx Phenix, AZ See Chapter 5, Sectin A, page 70 f this handbk fr details n which pharmacy expenses may be reimbursed. Yu must submit yur claim t us within 365 days f the date yu gt the service, item, r drug. C. We will make a cverage decisin When we get yur request fr payment, we will make a cverage decisin. This means that we will decide whether yur service r drug is cvered by the plan. We will als decide the amunt, if any, yu have t pay fr the service r prescriptin. We will let yu knw if we need mre infrmatin frm yu. If we decide that the service r drug is cvered and yu fllwed all the rules fr getting it, we will pay fr it. If yu have already paid fr the service r drug, we will mail yu a check fr what yu paid. If yu have nt paid fr the service r drug yet, we will pay the prvider directly. Chapter 3, Sectin B, page 21 explains the rules fr getting yur services cvered. Chapter 5, page 68 explains the rules fr getting yur prescriptin drugs cvered. If we decide nt t pay fr the service r drug, we will send yu a letter explaining why nt. The letter will als explain yur rights t make an appeal. T learn mre abut cverage decisins, see Chapter 9, Sectin 5.2, page 112. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 89

91 Tufts Health Unify Member Handbk Chapter 7: Asking us t pay fr services D. Yu can make an appeal If yu think we made a mistake in turning dwn yur request fr payment, yu can ask us t change ur decisin. This is called making an appeal. Yu can als make an appeal if yu d nt agree with the amunt we pay. The appeals prcess is a frmal prcess with detailed prcedures and imprtant deadlines. T learn mre abut appeals, see Chapter 9, Sectin 5.3, page 114. If yu want t make an appeal abut getting paid back fr a health care service, g t Chapter 9, Sectin 5.3, page 114. If yu want t make an appeal abut getting paid back fr a drug, g t Chapter 9, Sectin 6.5, page

92 Chapter 8: Yur rights and respnsibilities Table f cntents Intrductin A. Yu have a right t get infrmatin in a way that meets yur needs B. We must treat yu with respect, fairness, and dignity at all times C. We must make sure that yu get timely access t cvered services and drugs D. We must prtect yur privacy and persnal health infrmatin Hw we prtect yur health infrmatin Yu have a right t see yur medical recrds E. We must give yu infrmatin abut the plan, its netwrk prviders, and yur cvered services F. Netwrk prviders cannt bill yu directly G. Yu have a right t leave ur plan H. Yu have a right t make decisins abut yur health care Yu have the right t knw yur treatment ptins and make decisins abut yur health care Yu have the right t say what yu want t happen if yu are unable t make health care decisins fr yurself What t d if yur instructins are nt fllwed I. Yu have the right t make cmplaints and t ask us t recnsider decisins we have made What t d if yu believe yu are being treated unfairly r yur rights are nt being respected Hw t get mre infrmatin abut yur rights J. Yu als have respnsibilities as a member f the plan If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 91

93 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities Intrductin In this chapter, yu will find yur rights and respnsibilities as a member f the plan. We must hnr yur rights. A. Yu have a right t get infrmatin in a way that meets yur needs We must tell yu abut the plan s benefits, yur health and treatment ptins, and yur rights in a way that yu can understand. We must tell yu abut yur rights each year that yu are in ur plan. T get infrmatin in a way that yu can understand, call member services. Our plan has peple wh can answer questins in different languages. We can prvide written materials t yu in Spanish fr free. We can als give yu infrmatin fr free in Braille, large print, and auditape. If yu are having truble getting infrmatin frm ur plan because f language prblems r a disability and yu want t file a cmplaint, call Medicare at 800-MEDICARE ( ). Yu can call 24 hurs a day, seven days a week. TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call Yu can als call the MassHealth custmer service center at , Mnday thrugh Friday, frm 8 a.m. t 5 p.m. (TTY: ). Tenems la bligación de avisarle sbre ls beneficis del plan, su salud y sus pcines de tratamient y sus derechs de una manera que usted pueda entenderl. Tenems la bligación de avisarle sus derechs cada añ que usted esté en nuestr plan. Para btener infrmación de una manera que pueda entender, llame a servicis para miembrs. Nuestr plan tiene persnas que pueden respnder a preguntas en idimas diferentes. Pdems prveerle materiales pr escrit en españl gratuitamente. También pdems darle infrmación gratis en Braille, letras grandes, y cinta de audi. Si tiene prblemas para btener infrmación de su plan pr prblemas de idima alguna discapacidad y quiere presentar una queja, llame a Medicare al 800-MEDICARE ( ). Puede llamar 24 hras al día, siete días a la semana. Ls usuaris de TTY (persnas srdas, cn dificultades para ír hablar) deberán llamar al También puede llamar al centr de servicis al cliente de MassHealth al , de lunes a viernes, de 8 a.m. a 5 p.m. (TTY: ). 92

94 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities B. We must treat yu with respect, fairness, and dignity at all times Our plan must bey laws that prtect yu frm discriminatin r unfair treatment. We d nt discriminate against members fr any f the fllwing reasns: Race Ethnicity Natinal rigin Religin Sex Sexual rientatin Age Mental ability Behavir Mental r physical disability Health status Receipt f health care Use f services Claims experience Appeals Medical histry Genetic infrmatin Evidence f insurability r ther surce f payment Gegraphic lcatin within the service area Yu have the right t have yur questins and cncerns answered cmpletely and curteusly. Yu have the right t be treated with respect and with cnsideratin fr yur dignity. Under the rules f the plan, yu have the right t be free frm any kind f physical restraint r seclusin that wuld be used as a means f cercin, frce, discipline, cnvenience, r retaliatin. (In ther wrds, yu shuld be free frm being physically cntrlled r kept alne as a way t frce yu t d smething, t punish yu, r t make things easier fr thers.) Yu have the right t make recmmendatins regarding yur rights and respnsibilities. We cannt deny services t yu r punish yu fr exercising yur rights. Fr mre infrmatin, r if yu think that yu might have a cmplaint abut discriminatin r that yu gt unfair treatment, call the Department f Health and Human Services Office fr Civil Rights at (TTY fr peple wh are deaf, hard f hearing, r speech disabled: ). Yu can als call yur lcal Office fr Civil Rights at (TTY: ). If yu have a disability and need help getting care r reaching a prvider, call member services. If yu have a cmplaint, such as a prblem with wheelchair access, member services can help. If yu have questins, call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 93

95 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities C. We must make sure that yu get timely access t cvered services and drugs If yu cannt get services within a reasnable amunt f time, we have t pay fr ut-f-netwrk care. As a member f ur plan, these are yur rights: Yu have the right t chse a primary care prvider (PCP) in the plan s netwrk. A netwrk prvider is a prvider wh wrks with the health plan. Call member services r lk in the Prvider and Pharmacy Directry t learn which dctrs are accepting new patients. Yu have the right t g t a gyneclgist r anther wmen s health specialist withut getting a referral. A referral is apprval frm yur PCP t see anther prvider. Yu have the right t get cvered services frm netwrk prviders within a reasnable amunt f time. This includes the right t get timely services frm specialists. Yu have the right t get emergency services r urgent care withut first getting apprval (prir authrizatin) in an emergency. Yu have the right t get yur prescriptins filled withut lng delays at any f ur netwrk pharmacies. Yu have the right t knw when yu can see an ut-f-netwrk prvider. T learn abut ut-f-netwrk prviders, see Chapter 3, Sectin D, page 24. Chapter 9, page 104 tells yu what yu can d if yu think yu are nt getting yur services r drugs within a reasnable amunt f time. Chapter 9 als tells yu what yu can d if we have denied cverage fr yur services r drugs and yu d nt agree with ur decisin. D. We must prtect yur privacy and persnal health infrmatin Yu have the right t have privacy during treatment and t expect cnfidentiality f all recrds and cmmunicatins. We prtect yur persnal health infrmatin as required by federal and state laws. Yur persnal health infrmatin includes the infrmatin yu gave us when yu enrlled in this plan. It als includes yur medical recrds and ther medical and health infrmatin. Yu have the right t get infrmatin and t cntrl hw yur health infrmatin is used. We will give yu a written ntice that tells abut these rights. The ntice is called the Ntice f Privacy Practices. The ntice als explains hw we prtect the privacy f yur health infrmatin. 94

96 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities Hw we prtect yur health infrmatin We will make sure that unauthrized peple d nt see r change yur recrds. In mst situatins, we d nt give yur health infrmatin t anyne wh is nt prviding yur care r paying fr yur care. If we d, we are required t get written permissin frm yu first. Written permissin can be given by yu r by smene wh has the legal pwer t make decisins fr yu. There are certain cases when we d nt have t get yur written permissin first. These exceptins are allwed r required by law: We must release health infrmatin t gvernment agencies that are checking n ur quality f care. We must give Medicare and MassHealth yur health and drug infrmatin. If Medicare releases yur infrmatin fr research r ther uses, it will be dne accrding t federal laws. If MassHealth releases yur infrmatin fr research r ther uses, it will be dne accrding t federal and state laws. Yu have a right t see yur medical recrds Yu have the right t lk at yur medical recrds and t get a cpy f yur recrds. We are allwed t charge yu a fee fr making a cpy f yur medical recrds. Yu have the right t ask us t update r crrect yur medical recrds. If yu ask us t d this, we will wrk with yur health care prvider t decide whether the changes shuld be made. Yu have the right t knw if and hw yur health infrmatin has been shared with thers. Yu have the right t ask us in writing t restrict the use r disclsure f yur persnal health infrmatin. We may nt be able t cmply with all requests. Yu have the right t ask us in writing t cmmunicate yur persnal health infrmatin t yu in the way r at the lcatin f yur chice. We must cmply with any reasnable request. Yu have the right t request changes, crrectins, r deletins t yur persnal health infrmatin that yu believe is incrrect r incmplete. We may nt be able t cmply with all requests. Yu have the right t request further infrmatin r file a cmplaint by cntacting ur Tufts Health Plan Netwrk Health privacy fficer. Yu may als file a written cmplaint regarding yur privacy rights with the directr f the Office fr Civil Rights f the U.S. Department f Health and Human Services. Our privacy fficer will prvide yu with the crrect address fr the directr. Tufts Health Plan Netwrk Health will nt retaliate against yu if yu file a cmplaint with us r the Office f Civil Rights. If yu have questins, call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 95

97 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities If yu have questins r cncerns abut the privacy f yur persnal health infrmatin, call member services. Fr details r t find ut hw t exercise yur rights, visit TuftsHealthUnify.rg, call us at , seven days a week, frm 8 a.m. t 8 p.m., r cntact ur privacy fficer: Tufts Health Plan Netwrk Health Attn: Privacy Officer 101 Statin Landing, Furth Flr Medfrd, MA Phne: [email protected] Ntice f Privacy Practices We are cmmitted t prtecting yur rights and privacy. Our Ntice f Privacy Practices describes hw we may use and disclse yur persnal health infrmatin, and hw yu can access this infrmatin. Yu can read the Ntice f Privacy Practices by ging t Chapter 11, Sectin D, page 155, r yu can get a cpy by calling us at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. E. We must give yu infrmatin abut the plan, its netwrk prviders, and yur cvered services As a member f Tufts Health Unify, yu have the right t get timely infrmatin and updates abut yur plan frm us. If yu d nt speak English, we must give yu the infrmatin in a language yu understand free f charge. We have written materials available in Spanish free f charge. We can als give yu infrmatin free f charge in Braille, large print, and auditape. If yu want t knw abut any f the fllwing, call member services: Infrmatin abut ur plan, including: What financial infrmatin is available, Hw the plan has been rated by plan members, Hw many appeals ur members have made, and Hw t leave the plan Infrmatin abut ur netwrk prviders and ur netwrk pharmacies, including: Hw t chse r change primary care prviders, What the qualificatins are f ur netwrk prviders and pharmacies, and Hw we pay the prviders in ur netwrk Fr a list f prviders and pharmacies in the plan s netwrk, see the Prvider and Pharmacy Directry. Fr mre detailed infrmatin abut ur prviders r pharmacies, call member services r visit ur website at TuftsHealthUnify.rg. 96

98 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities Infrmatin abut cvered services and drugs and abut rules yu must fllw, including: Services and drugs cvered by the plan, Limits t yur cverage and drugs, and Rules yu must fllw t get cvered services and drugs Infrmatin abut why a drug r service is nt cvered and what yu can d abut it, including: Asking us t put in writing why the drug r service is nt cvered, Asking us t change a decisin we made, and Asking us t pay fr a bill yu gt F. Netwrk prviders cannt bill yu directly Dctrs, hspitals, and ther prviders in ur netwrk cannt make yu pay fr cvered services. They als cannt charge yu if we pay them less than they charged us. T learn what t d if a prvider tries t charge yu fr cvered services, see Chapter 7, page 87. G. Yu have a right t leave ur plan Yu have the right t leave the plan. N ne can make yu stay in ur plan if yu d nt want t. Yu can cntact the MassHealth custmer service center at (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled) and request t leave the plan at any time. Yu can als call 800-MEDICARE t enrll in a Medicare Advantage r prescriptin drug plan and leave ur plan. Please see Chapter 10 fr mre infrmatin n leaving ur plan. If yu chse t leave ur plan, yur services will stay in place until the end f that mnth. Fr example, if yu leave ur plan n September 5, yu will be cvered by ur plan until the end f September. If yu leave ur plan, yu will still be in the Medicare and MassHealth prgrams. Yu have the right t get mst f yur health care services thrugh Original Medicare r a Medicare Advantage plan. Yu als have a right t get yur MassHealth benefits directly frm the MassHealth Medicaid prgram. Yu can get yur Medicare Part D prescriptin drug benefits frm a prescriptin drug plan r frm a Medicare Advantage plan. If yu have questins, call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 97

99 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities H. Yu have a right t make decisins abut yur health care Yu have the right t knw yur treatment ptins and make decisins abut yur health care Yu have the right t get full infrmatin frm yur dctrs and ther health care prviders when yu get services. Yu als have the right t have access t dctrs and ther prviders wh can meet yur needs. This includes prviders wh can meet yur health care needs, cmmunicate with yu, and prvide yu with services in lcatins that yu can physically access. Yur prviders must explain yur cnditin and yur treatment chices in a way that yu can understand. Yu may als chse t have a family member r caregiver invlved in yur services and treatment discussins. Knw yur chices. Yu have the right t have yur medical needs explained t yu, and t be tld abut all the kinds f treatment available t yu, regardless f cst r benefit cverage. Knw the risks. Yu have the right t be tld abut any risks invlved in yur services r treatments. Yu must be tld in advance if any f yur services r treatments are part f a research experiment. Yu have the right t refuse experimental treatments. Yu can get a secnd pinin. Yu have the right t see anther dctr befre yu decide n a treatment. Yu can say n. Yu have the right t refuse any treatment. This includes the right t leave a hspital r ther medical facility, even if yur dctr advises yu nt t. Yu als have the right t stp taking a drug. If yu refuse treatment r stp taking a drug, yu will nt be drpped frm the plan. Hwever, if yu refuse treatment r stp taking a drug, yu accept full respnsibility fr what happens t yu. Yu can ask us t explain why a prvider denied care. Yu have the right t get an explanatin frm us if a prvider has denied care that yu believe yu shuld get. Yu can ask us t cver a service r drug that was denied r that is usually nt cvered. Chapter 9, Sectin 5.2, page 112 tells yu hw t ask the plan fr a cverage decisin. Yu can change yur prviders. Yu have the right t change yur prviders. Yu have the right t say what yu want t happen if yu are unable t make health care decisins fr yurself Smetimes peple are unable t make health care decisins fr themselves. Befre that happens t yu, yu can: Fill ut a written frm t give smene the right t make health care decisins fr yu; and Give yur dctrs written instructins abut hw yu want them t handle yur health care if yu becme unable t make decisins fr yurself. 98

100 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities The legal dcument that yu can use t give yur directins is called an advance directive. There are different types f advance directives and different names fr them. Examples are a living will and a pwer f attrney fr health care. In Massachusetts, if yu are at least 18 years ld and f sund mind, yu can make decisins fr yurself. Yu may als chse smene as yur health care agent r health care prxy. Yur health care agent r prxy can make health care decisins fr yu in the event that yur prviders determine yu are unable t make yur wn decisins. As a Tufts Health Unify member, yu have certain rights that relate t an advance directive. T chse a health care agent r prxy, yu must fill ut a health care prxy frm, available frm yur prvider r Tufts Health Unify. With advance directives, yu als have the right t: Make decisins abut yur medical care Get the same level f care and be free frm any frm f discriminatin Get written infrmatin abut yur prvider s advance directive plicies Have yur advance directive in yur medical recrd Our netwrk prviders will cmply with state law cncerning advance directives. Advance directives are recgnized under Massachusetts law. We als educate staff and peple they interact with in the cmmunity abut advance directives. Yu d nt have t use an advance directive, but yu can if yu want t. Here is what t d: Get the frm. Yu can get a frm frm yur dctr, a lawyer, a legal services agency, r a scial wrker. Organizatins that give peple infrmatin abut Medicare r MassHealth, such as the Massachusetts Executive Office f Elder Affairs may als have advance directive frms. Yu can als request an advance directive frm frm the Executive Office f Elder Affairs by sending a self-addressed and stamped envelpe t: Cmmnwealth f Massachusetts Executive Office f Elder Affairs 1 Ashburtn Place, Rm 517 Bstn, MA Fill it ut and sign the frm. The frm is a legal dcument. Yu shuld cnsider having a lawyer help yu fill it ut. Give cpies t peple wh need t knw abut it. Yu shuld give a cpy f the frm t yur dctr. Yu shuld als give a cpy t the persn yu name as the ne wh will make decisins fr yu. Yu may als want t give cpies t clse friends r family members. Be sure t keep a cpy at hme. If yu are ging t be hspitalized and yu have signed an advance directive, take a cpy f it t the hspital. If yu have questins, call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 99

101 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities The hspital will ask yu whether yu have signed an advance directive frm and whether yu have it with yu. If yu have nt signed an advance directive frm, the hspital has frms available and will ask if yu want t sign ne. Remember, it is yur chice t fill ut an advance directive. What t d if yur instructins are nt fllwed If yu have signed an advance directive and yu believe that a dctr r hspital did nt fllw the instructins in it, yu may file a cmplaint with the One Care Ombudsman (OCO) in the fllwing ways: By telephne: , Mnday thrugh Friday, 8:30 a.m. t 4:30 p.m. Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. Visit the OCO nline at OneCareOmbuds.rg Write t r visit the OCO ffice at: One Care Ombudsman 11 Dartmuth Street, Suite 301 Malden, MA I. Yu have the right t make cmplaints and t ask us t recnsider decisins we have made Chapter 9, page 104 tells yu what yu can d if yu have any prblems r cncerns abut yur cvered services r care. Fr example, yu culd ask us t make a cverage decisin, make an appeal t us t change a cverage decisin, r make a cmplaint. Yu have the right t get infrmatin abut appeals and cmplaints that ther members have filed against ur plan. T get this infrmatin, call member services. What t d if yu believe yu are being treated unfairly r yur rights are nt being respected If yu believe yu have been treated unfairly and it is nt abut discriminatin fr the reasns listed n page 93 yu can get help in these ways: Yu can call ur member services at Yu can call the State Health Insurance Assistance Prgram called SHIP. Fr details abut this rganizatin and hw t cntact it, see Chapter 2, Sectin E, page 16. Yu can call Medicare at 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call

102 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities Yu can call MassHealth at , Mnday thrugh Friday, frm 8 a.m. t 5 p.m. TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call Yu can call the One Care Ombudsman (OCO) at (Tll Free), Mnday thrugh Friday frm 8:30 a.m. t 4:30 p.m. Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. Yu can als the OCO at [email protected]. The OCO is an independent prgram that can help yu address cncerns r cnflicts with yur enrllment in One Care r yur access t One Care benefits and services. Hw t get mre infrmatin abut yur rights There are a few ways t get mre infrmatin abut yur rights: Yu can call member services. Yu can call SHINE. Fr details abut this rganizatin and hw t cntact it, see Chapter 2, Sectin E, page 16. Yu can cntact Medicare. Yu can visit the Medicare website t read r dwnlad Medicare Rights & Prtectins. (G t medicare.gv/publicatins/pubs/pdf/11534.pdf.) Or yu can call 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call Yu can call MassHealth at , Mnday thrugh Friday, frm 8 a.m. t 5 p.m. (TTY: ). Yu can call the One Care Ombudsman (OCO) at (tll free), Mnday thrugh Friday, frm 8:30 a.m. t 4:30 p.m. Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. Yu can als the OCO at [email protected]. The OCO is an independent prgram that can help yu address cncerns r cnflicts with yur enrllment in One Care r yur access t One Care benefits and services. J. Yu als have respnsibilities as a member f the plan As a member f the plan, yu have a respnsibility t d the things that are listed belw. If yu have any questins, call member services. Read the Member Handbk t learn what is cvered and what rules yu need t fllw t get cvered services and drugs. If yu have questins, call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 101

103 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities Fr details abut yur cvered services, see Chapter 3, page 20 and Chapter 4, page 39. Thse chapters tell yu what is cvered, what is nt cvered, what rules yu need t fllw, and what yu pay. Fr details abut yur cvered drugs, see Chapter 5, page 68 and Chapter 6, page 83. Tell us abut any ther health r prescriptin drug cverage yu have. Please call member services t let us knw. We are required t make sure that yu are using all f yur cverage ptins when yu receive health care. This is called crdinatin f benefits. Fr mre infrmatin abut crdinatin f benefits, see Chapter 1, page 1. Tell yur dctr and ther health care prviders that yu are enrlled in ur plan. Shw yur plan ID card every time yu get services r drugs. Help yur dctrs and ther health care prviders give yu the best care. Chse a netwrk primary care prvider. Call yur primary care prvider, care manager, r ther apprpriate individual per the plan s care mdel when yu need health care r within 48 hurs f any emergency r ut-f-netwrk treatment. Give them the infrmatin they need abut yu and yur health that is cmplete and accurate. Learn as much as yu can abut yur health prblems. Fllw the treatment plans and instructins that yu and yur prviders agree n. Make sure yur dctrs and ther prviders knw abut all f the drugs yu are taking. This includes prescriptin drugs, ver-the-cunter drugs, vitamins, and supplements. Make sure yu ask any questins that yu have. Yur dctrs and ther prviders must explain things in a way yu can understand. If yu ask a questin and yu d nt understand the answer, ask again. Understand the rle f yur primary care prvider, yur care manager, and yur care team in prviding yur care and arranging ther health care services that yu may need. Fllw the care plan yu and yur care team agree t. Understand yur benefits and what is cvered and knw what is nt cvered. Be cnsiderate. We expect all ur members t respect the rights f ther patients. We als expect yu t act with respect in yur dctr s ffice, hspitals, and ther prviders ffices, and in yur hme when prviders are visiting yu. Pay what yu we. As a plan member, yu are respnsible fr these payments: If yu get any services r drugs that are nt cvered by ur plan, yu must pay the full cst. 102

104 Tufts Health Unify Member Handbk Chapter 8: Yur rights and respnsibilities If yu disagree with ur decisin nt t cver a service r drug, yu can make an appeal. Please see Chapter 9, Sectin 5.3, page 114 t learn hw t make an appeal. Tell us if yu mve. If yu are ging t mve, it is imprtant t tell us right away. Call member services. If yu mve utside f ur plan service area, yu cannt still be a member f ur plan. Chapter 1, Sectin D, page 4 tells yu abut ur service area. We can help yu figure ut whether yu are mving utside ur service area. We can let yu knw if we have a plan in yur new area. Als, be sure t let Medicare and MassHealth knw yur new address when yu mve. See Chapter 2, pages 17 and 18 fr phne numbers fr Medicare and MassHealth. If yu mve but stay in ur service area, we still need t knw. We need t keep yur recrd up t date and knw hw t cntact yu. Tell us if yur persnal infrmatin changes. It is imprtant t tell us right away if yu have a change in persnal infrmatin, such as yur telephne number, marriage, additins t the family, eligibility, r ther health insurance cverage. Tell us if yu have access t any ther insurance. Tell us if yu suspect ptential fraud and/r abuse. Vice yur cncerns and cmplaints clearly. Keep yur appintments, be n time, r call if yu ll be late r need t cancel an appintment. Call member services at fr help if yu have questins r cncerns. If yu have questins, call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 103

105 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) What s in this chapter This chapter has infrmatin abut yur rights. Read this chapter t find ut what t d if yu think any f the fllwing applies t yu: Yu have a prblem with r a cmplaint abut Tufts Health Unify r yur care. Yu need a service r medicatin that Tufts Health Unify has said it will nt pay fr. Yu disagree with a decisin that Tufts Health Unify has made abut yur care, including reducing services. Yu think Tufts Health Unify shuld prvide r arrange a service faster. Yu think that yu were asked t leave the hspital t sn. This chapter is brken int different sectins t help yu easily find infrmatin abut what t d fr yur prblem r cncern. If yu are facing a prblem with yur services Yu shuld receive the medical services, behaviral health services, drugs, and lng-term services and supprts (LTSS) that are necessary fr yur care as a part f yur care plan. This chapter will explain the ptins yu have fr different prblems and cmplaints. Yu can als call the One Care Ombudsman t help yu with yur prblem. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 104

106 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Table f cntents What s in this chapter If yu are facing a prblem with yur services Sectin 1: Intrductin Sectin 1.1: What t d if yu have a prblem Sectin 1.2: What abut the legal terms Sectin 2: Where t call fr help Sectin 2.1: Where t get mre infrmatin and help Sectin 3: Which sectins t read in this chapter t help with yur prblem Sectin 4: Cverage decisins and appeals Sectin 4.1: Overview Sectin 4.2: Getting help Sectin 4.3: Which sectin f this chapter will help yu Sectin 5: Prblems abut services and drugs (nt Part D drugs) Sectin 5.1: When t use this sectin Sectin 5.2: Asking fr a cverage decisin Sectin 5.3: Level 1 appeal fr services and drugs (nt Part D drugs) Sectin 5.4: Level 2 appeal fr services and drugs (nt Part D drugs) Sectin 5.5: Payment prblems Sectin 6: Part D drugs Sectin 6.1: What t d if yu have prblems getting a Part D drug r yu want us t pay yu back fr a Part D drug Sectin 6.2: What is an exceptin Sectin 6.3: Imprtant things t knw when asking fr exceptins Sectin 6.4: Asking fr a cverage decisin abut a Part D drug r reimbursement fr a Part D drug, including an exceptin If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 105

107 Sectin 6.5: Level 1 appeal fr Part D drugs Sectin 6.6: Level 2 appeal fr Part D drugs Sectin 7: Asking us t cver a lnger hspital stay Sectin 7.1: Yur Medicare rights if yu are admitted t the hspital Sectin 7.2: Level 1 appeal t change yur hspital discharge date Sectin 7.3: Level 2 appeal t change yur hspital discharge date Sectin 7.4: What happens if I miss an appeal deadline Sectin 8: What t d if yu think yur hme health care, skilled nursing care, r cmprehensive utpatient rehabilitatin facility (CORF) services are ending t sn Sectin 8.1: We will tell yu in advance when yur cverage will be ending Sectin 8.2: Level 1 appeal t cntinue yur care Sectin 8.3: Level 2 appeal t cntinue yur care Sectin 8.4: What if yu miss the deadline fr making yur level 1 appeal Sectin 9: Taking yur appeal beynd level Sectin 9.1: Next steps fr Medicare services Sectin 9.2: Next steps fr MassHealth services Sectin 10: Hw t make a cmplaint What kinds f prblems shuld be cmplaints Sectin 10.1: Details and deadlines Sectin 10.2: Yu can file cmplaints with the Office f Civil Rights Sectin 10.3: Yu can make cmplaints abut quality f care t the quality imprvement rganizatin Sectin 10.4: Yu can tell Medicare abut yur cmplaint Sectin 10.5: Cmplaints abut mental health parity

108 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 1: Intrductin Sectin 1.1: What t d if yu have a prblem This chapter will tell yu what t d if yu have a prblem with Tufts Health Unify r with yur services. These prcesses have been apprved by Medicare and MassHealth. Each prcess has a set f rules, prcedures, and deadlines that must be fllwed. This is a summary f yur rights. Sectin 1.2: What abut the legal terms There are legal terms fr sme f the rules and deadlines in this chapter. Sme f these terms may be hard t understand, s we have used simpler wrds in place f certain legal terms. We use abbreviatins as little as pssible. Fr example, we will say: Making a cmplaint rather than filing a grievance Cverage decisin rather than rganizatin determinatin r cverage determinatin Fast cverage decisin rather than expedited determinatin Understanding and knwing the meaning f the prper legal terms can help yu cmmunicate mre clearly, s we prvide thse t. Sectin 2: Where t call fr help Sectin 2.1: Where t get mre infrmatin and help Smetimes it can be cnfusing t start r fllw thrugh the prcess fr dealing with a prblem. This can be especially true if yu d nt feel well r have limited energy. Other times, yu may nt knw hw t take the next step. Yu can get help frm the One Care Ombudsman (OCO) The One Care Ombudsman (OCO) is an independent prgram that can help yu if yu have questins, cncerns, r prblems related t One Care. Yu can cntact the OCO t get infrmatin r assistance. The OCO s services are free. The OCO can answer yur questins r refer yu t the right place t find what yu need. The OCO can help yu address a prblem r cncern with One Care r yur One Care plan, Tufts Health Unify. The OCO will listen, investigate the issue, and discuss ptins with yu t help slve the prblem. The OCO helps with appeals. An appeal is a frmal way f asking yur One Care plan, MassHealth, r Medicare t review a decisin abut yur services. The OCO can talk with yu abut hw t make an appeal and what t expect during the appeal prcess. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 107

109 Yu can call, write, r visit the OCO at its ffice. Call , Mnday thrugh Friday, frm 8:30 a.m. t 4:30 p.m. Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. [email protected] Write t r visit the OCO ffice at: 11 Dartmuth Street, Suite 301, Malden, MA Visit the OCO nline at OneCareOmbuds.rg Yu can get help frm the State Health Insurance Assistance Prgram (SHIP) Yu can als call yur State Health Insurance Assistance Prgram (SHIP). In Massachusetts, this prgram is called SHINE (Serving the Health Insurance Needs f Everyne). SHINE cunselrs can answer yur questins and help yu understand what t d t take care f yur prblem. SHINE is nt cnnected with us r with any insurance cmpany r health plan. SHINE has trained cunselrs in Massachusetts, and services are free. The SHINE phne number is (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled; Massachusetts nly). Getting help frm Medicare Yu can call Medicare directly fr help with prblems. Here are tw ways t get help frm Medicare: Call 800-MEDICARE ( ), 24 hurs a day, seven days a week (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled). The call is free. Visit the Medicare website at medicare.gv. Getting help frm MassHealth Yu can call MassHealth custmer service directly fr help with prblems. Call (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled). 108

110 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 3: Which sectins t read in this chapter t help with yur prblem The chart belw will help yu find the right sectin f this chapter t read fr yur prblem r cmplaint. Is yur prblem r cncern abut yur benefits r cverage (This includes prblems abut whether particular medical care, behaviral health care, lng-term services and supprts (LTSS), r prescriptin drugs are cvered and paid fr by Tufts Health Unify.) Yes. My prblem is abut benefits r cverage. G n t Sectin 4 f this chapter, Cverage decisins and appeals. N. My prblem is nt abut benefits r cverage. Skip ahead t Sectin 10 at the end f this chapter, Hw t make a cmplaint abut quality f care, waiting times, custmer service, r ther cncerns. Sectin 4: Cverage decisins and appeals Sectin 4.1: Overview When yu ask fr infrmatin n cverage decisins and making appeals, it means that yu re dealing with prblems related t yur benefits and cverage. This als includes prblems with payment. What is a cverage decisin A cverage decisin is a decisin we make abut what services we will cver fr yu. Fr example, yur plan netwrk dctr makes a (favrable) cverage decisin fr yu whenever yu receive medical care frm him r her r if yur netwrk dctr refers yu t a medical specialist. If yu r yur dctr is nt sure if a service is cvered by Tufts Health Unify, either f yu can ask fr a cverage decisin befre the dctr gives the service. In ther wrds, if yu want t knw if we will cver a medical service befre yu receive it, yu can ask us t make a cverage decisin fr yu. What is an appeal An appeal is a frmal way f asking us t review ur cverage decisin. Fr example, we might decide that a service r drug that yu want is nt cvered r is nt medically necessary fr yu. If If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 109

111 yu disagree with ur decisin, yu can appeal this decisin. If yu want, yur prvider can file an appeal fr yu. Sectin 4.2: Getting help Wh can I call fr help with asking fr cverage decisins r making an appeal There are a few different ways that yu can ask fr help. Yu can call us at member services at Yu can call, write, r visit the One Care Ombudsman (OCO).» Call , Mnday thrugh Friday, frm 8:30 a.m. t 4:30 p.m. Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay.» [email protected].» Write t r visit the OCO ffice at: 11 Dartmuth Street, Suite 301, Malden, MA » Visit the OCO nline at OneCareOmbuds.rg. Call the State Health Insurance Assistance Prgram (SHIP) fr free help. In Massachusetts, the SHIP is called SHINE. SHINE is an independent rganizatin. It is nt cnnected with this plan. The SHINE phne number is (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled; Massachusetts nly). Talk t yur dctr r ther prvider. Yur dctr r ther prvider can ask fr a cverage decisin r appeal n yur behalf and act as yur representative. Talk t a friend r family member and ask him r her t act fr yu. Yu can name anther persn t act fr yu as yur representative and t ask fr a cverage decisin r make an appeal.» If yu want a friend, relative, r ther persn beside yur prvider t be yur representative, call member services and ask fr the Appintment f Representative frm. Yu can als get the frm n the Medicare website at cms.hhs.gv/cmsfrms/dwnlads/cms1696.pdf r n ur website at TuftsHealthUnify.rg. The frm will give the persn permissin t act fr yu. Yu must give us a cpy f the signed frm. Yur designated representative will have the same rights as yu d in asking fr a cverage decisin r making an appeal. Yu d nt need t prvide this frm fr yur dctr r ther health care prvider t act as yur representative. Yu als have the right t ask a lawyer t act fr yu. Yu may call yur wn lawyer r get the name f a lawyer frm the lcal bar assciatin r ther referral service. Tufts Health Unify will nt pay fr yu t have a lawyer. Sme legal grups will give yu free legal services if yu qualify. If yu want a lawyer t represent yu, yu will need t fill ut the Appintment f Representative frm. Hwever, yu d nt have t have a lawyer t ask fr any kind f cverage decisin r t make an appeal. 110

112 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 4.3: Which sectin f this chapter will help yu There are fur different types f situatins that invlve cverage decisins and appeals. Each situatin has different rules and deadlines. We separate this chapter int different sectins t help yu find the rules yu need t fllw. Sectin 5 gives yu infrmatin if yu have prblems abut services and sme drugs (nt Part D drugs). Fr example, use this sectin if: Yu are nt getting a service yu want and yu believe that this service is cvered by ur plan. We did nt apprve services r drugs that yur dctr wants t give yu and yu believe this care shuld be cvered and is medically necessary. NOTE: Use Sectin 5 nly if these are drugs nt cvered by Part D. Drugs in the List f Cvered Drugs with an asterisk (*) are nt cvered by Part D. Fr drugs with the asterisk symbl, use Sectin 5 fr appeals. See Sectin 6 fr Part D drug appeals. Yu gt and paid fr medical services yu thught were cvered, and yu want t ask us t pay yu back. NOTE: Fr mre infrmatin abut the rules t fllw fr Tufts Health Unify t pay fr yur health care and services, see Chapter 3. We have ntified yu that cverage fr care yu have been getting will be reduced r stpped, and yu disagree with ur decisin. NOTE: If the cverage that will be stpped is fr hspital care, hme health care, skilled nursing facility care, r cmprehensive utpatient rehabilitatin facility (CORF) services, yu need t read a separate sectin f this chapter; special rules apply t these types f services. See Sectins 7 and 8. Sectin 6 gives yu infrmatin abut Part D drugs. Fr example, use this sectin if: Yu want t ask us t make an exceptin t cver a Part D drug that is nt n the plan s List f Cvered Drugs (Drug List). Yu want t ask us t waive limits n the amunt f the drug yu can get. Yu want t ask us t cver a drug that requires prir apprval. We did nt apprve yur request r exceptin, and yu r yur dctr r ther prescriber thinks that we shuld have. Yu want t ask us t pay fr a prescriptin drug yu already bught. (This is asking fr a cverage decisin abut payment.) If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 111

113 Sectin 7 gives yu infrmatin n hw t ask us t cver a lnger inpatient hspital stay. Use this sectin if yu were in the hspital and think that the dctr asked yu t leave the hspital t sn. Sectin 8 gives yu infrmatin if yu think yur hme health care, skilled nursing facility care, and CORF services are ending t sn. If yu re nt sure which sectin yu shuld be using, please call member services at Yu can als get help r infrmatin frm the One Care Ombudsman by calling (MassRelay: 711) r ing [email protected]. Sectin 5: Prblems abut services and drugs (nt Part D drugs) Sectin 5.1: When t use this sectin This sectin is abut what t d if yu have prblems with yur benefits fr yur medical care, behaviral health care, and lng-term services and supprts (LTSS). Yu can als use this sectin fr prblems with drugs that are nt cvered by Part D. Drugs in the List f Cvered Drugs with an asterisk (*) are nt cvered by Part D. Use Sectin 6 fr Part D drug appeals. This sectin tells yu what yu can d if: 1. Yu think the plan cvers a medical, behaviral health, r LTSS service that yu need but that yu were tld yu cannt get. What yu can d: Yu can ask the plan t make a cverage decisin. G t Sectin 5.2 belw fr infrmatin n asking fr a cverage decisin. 2. The plan did nt apprve care that yur dctr r prvider wants t give yu, and yu think it shuld have. Or, yur cverage fr a certain service is being reduced r stpped, and yu d nt agree with this decisin. What yu can d: Yu can appeal the plan s decisin. G t Sectin 5.3, page 114 fr infrmatin n making an appeal. NOTE: If the cverage that will be stpped is fr hspital care, hme health care, skilled nursing facility care, r CORF services, special rules apply. Read Sectins 7 r 8 t find ut mre. 3. If yu have a prblem with payment, g t Sectin 5.5. Sectin 5.2: Asking fr a cverage decisin T ask fr a cverage decisin, call, write, r fax us, r ask yur representative r dctr t ask us fr a decisin. Yu can reach us at (TTY: ) Yu can fax us at

114 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Yu can write t us at: Tufts Health Plan Netwrk Health Attn: Member Services 101 Statin Landing, Furth Flr Medfrd, MA Hw lng des it take t get a cverage decisin It usually takes up t 14 days after yu ask. If we dn t give yu ur decisin within 14 days, yu can appeal. Smetimes we need mre time, and we will send yu a letter telling yu that we will take up t 14 mre days. Can I get a cverage decisin faster Yes. If yu need a respnse faster because f yur health, yu shuld ask us t make a fast cverage decisin. If we apprve the request, we will ntify yu f ur decisin within 72 hurs. Hwever, smetimes we need mre time. If that happens, we will send yu a letter telling yu that we will take up t 14 mre days. The legal term fr fast cverage decisin is expedited determinatin. T ask fr a fast cverage decisin: Start by calling, writing, r faxing ur plan t ask us t cver the care yu want. Yu can call us at Fr the details n hw t cntact us, g t Chapter 2, Sectin A, page 11. Yu can als have yur prvider r yur representative call us. What are the rules fr asking fr a fast cverage decisin Yu can get a fast cverage decisin nly if: Yu are asking abut care yu have nt yet received. (Yu cannt get a fast cverage decisin if yur request is abut care yu have already received.) The usual 14-day deadline culd cause serius harm t yur health r hurt yur ability t functin. If yur prvider says that yu need a fast cverage decisin, we will autmatically give yu ne. If yu ask fr a fast cverage decisin, withut yur prvider s supprt, we will decide if yu get a fast cverage decisin. If we decide nt t give yu a fast cverage decisin, we will use the standard 14-day deadline instead. We will als send yu a letter. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 113

115 This letter will tell yu that if yur prvider asks fr the fast cverage decisin, we will autmatically give yu ne. The letter will als tell yu hw yu can file a fast cmplaint abut ur decisin t give yu a standard cverage decisin instead f the fast cverage decisin yu asked fr. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) Hw will I find ut the plan s answer abut my cverage decisin The plan will send yu a letter telling yu whether r nt we apprved cverage. If the cverage decisin is yes, when will I be able t get the service Yu will be authrized t get the service within 14 days (fr a standard cverage decisin) r 72 hurs (fr a fast cverage decisin) frm the time yu asked us. If we extended the time needed t make ur cverage decisin, we will prvide the cverage by the end f that extended perid. What if the cverage decisin is n If the answer is n, the letter we send yu will tell yu ur reasns fr saying n. If we say n, yu have the right t ask us t recnsider and change this decisin by making an appeal. Making an appeal means asking us t review ur decisin t deny cverage. If yu decide t appeal the cverage decisin, it means yu are ging n t level 1 f the appeals prcess (see Sectin 5.3 belw). Sectin 5.3: Level 1 appeal fr services and drugs (nt Part D drugs) What is an appeal An appeal is a frmal way f asking us t review a cverage decisin, r any adverse actin that the plan has taken. If yu r yur dctr disagrees with ur decisin, yu can appeal. Yu must start yur appeal at level 1 and appeal t Tufts Health Unify. What is an adverse actin An adverse actin is an actin, r lack f actin, by Tufts Health Unify that yu can appeal. This includes: Tufts Health Unify denied r apprved a limited service yur dctr requested; Tufts Health Unify reduced, suspended, r ended cverage that we had already apprved; Tufts Health Unify did nt pay fr an item r service that yu think is a cvered service; Tufts Health Unify did nt reslve yur service authrizatin request within the required time frames; Yu culd nt get a cvered service frm a prvider in Tufts Health Unify s netwrk within a reasnable amunt f time; and 114

116 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Tufts Health Unify did nt act within the time frames fr reviewing a cverage decisin and giving yu a decisin. What is a level 1 appeal A level 1 appeal is the first appeal t Tufts Health Unify. We will review ur cverage decisin t see if it is crrect. The reviewer will be smene wh did nt make the riginal cverage decisin. Yu can ask us fr a standard appeal r a fast appeal. When we cmplete the review, we will give yu ur decisin. The legal term fr fast appeal is expedited recnsideratin. Hw d I make a level 1 appeal T start yur appeal, yu, yur dctr, r yur representative must cntact us. Yu can call us at Fr additinal details n hw t reach us fr appeals, see Chapter 2, Sectin A, page 11. If yu are asking fr a standard appeal, yu can make yur appeal in writing r verbally. Yu can submit a request t the fllwing address: Tufts Health Plan Netwrk Health Attn: Member Services 101 Statin Landing, Furth Flr Medfrd, MA Or, yu can call member services at If yu are asking fr a fast appeal, make yur appeal in writing r call us. Yu can call us at Or write t us at the address abve. Can smene else make the level 1 appeal fr me Yes. Yur prvider can request the appeal n yur behalf. If yu want smene besides yur prvider t make the appeal fr yu, yu must first cmplete an Appintment f Representative frm. The frm gives the ther persn permissin t act fr yu. T get an Appintment f Representative frm, call member services and ask fr ne, r visit the Medicare website at cms.hhs.gv/cmsfrms/dwnlads/cms1696.pdf r ur website at TuftsHealthUnify.rg. We must receive the cmpleted Appintment f Representative frm befre we can review yur request, if the appeal cmes frm smene besides yu r yur prvider. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 115

117 Hw much time d I have t make a level 1 appeal Yu must ask fr an appeal within 60 days frm the date n the letter we sent yu t tell yu ur cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Examples f a gd reasn include: yu had a serius illness, r we gave yu the wrng infrmatin abut the deadline fr requesting an appeal. Can I get a cpy f my case file Yes. Ask us fr a cpy. Can my prvider give yu mre infrmatin t supprt my level 1 appeal Yes. Bth yu and yur prvider may give us mre infrmatin t supprt yur appeal. Hw will the plan make the level 1 appeal decisin We take a careful lk at all f the infrmatin abut yur request fr cverage f medical care. Then we check t see if we were fllwing all the rules when we said n t yur request. The reviewer will be smene wh did nt make the riginal decisin. If we need mre infrmatin, we may ask yu r yur prvider fr it. When and hw will I hear abut the level 1 appeal decisin We must give yu ur answer within 30 calendar days after we get yur appeal. This rule applies if yu sent yur appeal befre getting medical services. We will give yu ur decisin sner if yur health cnditin requires us t. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin, we can take up t 14 mre calendar days. If we decide t take extra days t make a decisin, we will tell yu by letter. If we d nt give yu an answer within 30 calendar days r by the end f the extra days (if we tk them), yur case will autmatically g t level 2 f the appeals prcess if the service is usually cvered by Medicare r Medicare and MassHealth. Yu will be ntified if this happens. We will send yu a letter giving yu ur answer abut yur appeal. If ur answer is yes t part r all f what yu asked fr, we must apprve r give that cverage. If ur answer is n t part r all f what yu asked fr, we will send yu a letter. If the service is traditinally paid fr by Medicare r Medicare and MassHealth, the letter we send will tell yu that we have sent yur case t the independent review entity fr a level 2 appeal. If the service is traditinally paid fr by MassHealth, the letter will als tell yu that yu can ask fr a level 2 appeal frm the MassHealth Bard f Hearings. 116

118 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) What happens if I get a fast appeal When and hw will I hear abut the appeal decisin If yu get a fast appeal, we will give yu yur answer within 72 hurs after we get yur appeal. We will give yu ur answer within 72 hurs if yur health requires us t d s. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin, we can take up t 14 mre calendar days. If we decide t take extra days t make the decisin, we will tell yu by letter. If we d nt give yu an answer within 72 hurs r by the end f the extra days (if we tk them), yur case will g t level 2 f the appeals prcess. We will send yu a letter giving yu ur answer abut yur appeal. If ur answer is yes t part r all f what yu asked fr, we must apprve r give that cverage. If ur answer is n t part r all f what yu asked fr, we will send yu a letter. If the service is traditinally paid fr by Medicare r Medicare and MassHealth, the letter we send will tell yu that we have sent yur case t the independent review entity fr a level 2 appeal. If the service is traditinally paid fr by MassHealth, the letter will als tell yu that yu can ask fr a level 2 appeal frm the MassHealth Bard f Hearings. Will my benefits cntinue during a level 1 appeal If yu are appealing because Tufts Health Unify decided t reduce r stp a service yu were already getting, yu have a right t keep getting that service frm Tufts Health Unify during yur appeal. If yu are appealing t get a new service frm Tufts Health Unify, then yu will nt get that service unless yur appeal is finished and ur decisin is that the service is cvered. Sectin 5.4: Level 2 appeal fr services and drugs (nt Part D drugs) If the plan says n at level 1, what happens next If we say n t yur appeal at level 1, we will send yu a letter. This letter will tell yu if yur appeal is fr a service cvered by Medicare, by bth Medicare and MassHealth, r just by MassHealth. This letter will tell yu hw t make a level 2 appeal and will describe the level 2 appeals prcess. What is a level 2 appeal A level 2 appeal is the secnd appeal, which is dne by an independent rganizatin that is nt cnnected t the plan. Medicare s level 2 appeal rganizatin is called the independent review entity (IRE). MassHealth s level 2 appeal rganizatin is called the MassHealth Bard f Hearings. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 117

119 Yu have appeal rights with bth Medicare and MassHealth. Sme f the services that yu can get with Tufts Health Unify are cvered by bth Medicare and MassHealth. Other services are cvered just by MassHealth. When a service is cvered by bth Medicare and MassHealth, yu will autmatically get a Medicare level 2 appeal frm the IRE if the answer t yur level 1 appeal was n. Yu can als ask fr a level 2 appeal frm the MassHealth Bard f Hearings. When a service is cvered nly by MassHealth, then yu must ask fr a level 2 appeal frm the MassHealth Bard f Hearings if the answer t yur level 1 appeal was n and yu want t appeal again. T make sure that level 2 appeals are fair and d nt take t lng, there are sme rules, prcedures, and deadlines that must be fllwed by us and by yu. What are the rules fr asking fr a level 2 appeal frm the MassHealth Bard f Hearings Yu must ask fr a level 2 appeal frm the MassHealth Bard f Hearings within 30 calendar days frm the date f ur letter telling yu abut ur level 1 appeal decisin. The letter will tell yu hw t ask fr a level 2 appeal frm the Bard f Hearings: The MassHealth Bard f Hearings is nt cnnected with Tufts Health Unify. Yu may ask fr a cpy f yur file. T ask fr a level 2 appeal frm the Bard f Hearings, yu must cmplete a Fair Hearing Request frm. Yu can get the frm: Online at mass.gv/ehhs/dcs/masshealth/memlibrary/fhr-1.pdf By calling MassHealth custmer service at (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled) The Bard f Hearings must give yu an answer t yur level 2 appeal within 30 calendar days f when it gets yur appeal. If the Bard f Hearings needs t gather mre infrmatin that may help yu, it can take up t 14 mre calendar days. If yu had a fast appeal at level 1, yu will autmatically have a fast appeal at level 2. The Bard f Hearings must give yu an answer within 72 hurs f when it gets yur appeal. If the Bard f Hearings needs t gather mre infrmatin, it can take up t 14 mre calendar days. What are the rules fr getting an appeal frm the Medicare independent review entity If we say n t yur appeal at level 1 and the service is traditinally cvered by Medicare r Medicare and MassHealth, yu will autmatically get a level 2 Appeal frm the independent review entity (IRE). The IRE will d a careful review f the level 1 decisin and decide whether it shuld be changed. Tufts Health Unify will send yur case t the IRE autmatically. Yu will be ntified if this happens. Yu d nt need t request the level 2 appeal fr services cvered by Medicare. 118

120 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) The IRE is hired by Medicare and is nt cnnected with this plan. Yu may ask fr a cpy f yur file. The IRE must give yu an answer t yur level 2 appeal within 30 calendar days f when it gets yur appeal. This rule applies if yu sent yur appeal befre getting medical services. If the IRE needs t gather mre infrmatin that may help yu, it can take up t 14 mre calendar days. If the IRE decides t take extra days t make a decisin, it will tell yu by letter. If yu had fast appeal at level 1, yu will autmatically have a fast appeal at level 2. The review rganizatin must give yu an answer within 72 hurs f when it gets yur appeal. If the IRE needs t gather mre infrmatin, it can take up t 14 mre calendar days. If the IRE decides t take extra days t make a decisin, it will tell yu by letter. Will my benefits cntinue during the level 2 appeal Yu have a right t get the service that yur appeal is abut while yu are appealing if: Yu are appealing because Tufts Health Unify decided t reduce r stp a service yu were already getting, AND Yu ask fr a level 2 appeal frm the MassHealth Bard f Hearings. T get a service while yu are appealing: Within 10 days f getting a letter frm Tufts Health Unify abut ur level 1 appeal decisin, yu must ask fr the MassHealth Bard f Hearings t review yur appeal. Yu must tell the MassHealth Bard f Hearings that yu want Tufts Health Unify t keep giving yu the service while yu are appealing. If yu cntinue t receive services during the Bard f Hearings appeal prcess and the decisin isn t in yur favr, yu may have t pay fr the cst f thse services. If yu d nt ask fr the MassHealth Bard f Hearings t review yur appeal, yu will nt get the service during yur appeal. If yu are appealing t get a new service, yu will nt get that service while yu are appealing, even if yu ask fr an appeal by the MassHealth Bard f Hearings. Hw will I find ut abut the decisin If yur level 2 appeal went t the MassHealth Bard f Hearings, the Bard f Hearings will send yu a letter explaining its decisin. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 119

121 If the Bard f Hearings says yes t part r all f what yu asked fr, we must apprve the service fr yu within 72 hurs. If the Bard f Hearings says n t part r all f what yu asked fr, it means the Bard f Hearings agrees with the level 1 appeal decisin. This is called uphlding the decisin. It is als called turning dwn yur appeal. If yur appeal went t the IRE, the IRE will send yu a letter explaining its decisin. If the IRE says yes t part r all f what yu asked fr, we must authrize the medical care cverage within 72 hurs frm the date we receive the IRE s ntice. If the IRE says n t part r all f what yu asked fr, it means the IRE agrees with the level 1 decisin. This is called uphlding the decisin. It is als called turning dwn yur appeal. What if I appealed t bth the IRE and the Bard f Hearings and they have different decisins If either the Bard f Hearings r the IRE decides yes fr all r part f what yu asked fr, we will give yu the apprved services that are clsest t what yu asked fr in yur appeal. If the decisin is n fr all r part f what I asked fr, can I make anther appeal Yes. The letter yu get frm the IRE will explain additinal appeal rights yu may have. Yu can appeal again nly if the dllar value f the service yu want meets a certain minimum amunt. Yu can appeal a decisin f the MassHealth Bard f Hearings t the Cmmnwealth f Massachusetts Superir Curt. Sectin 5.5: Payment prblems With One Care, there are sme rules fr getting services. One f the rules is that the service must be cvered by Tufts Health Unify. Anther rule is that yu must get the service frm ne f the prviders that Tufts Health Unify wrks with. G t Chapter 3 t read all the rules. If yu fllw all the rules, then the plan will pay fr yur services. If yu are nt sure if Tufts Health Unify will pay fr a service yu want t get r a prvider yu want t see, ask ur member services befre yu get the service. Our member services will tell yu if the plan will pay r if yu need t ask the plan fr a cverage decisin. If yu chse t get a service that may nt be cvered by Tufts Health Unify, r if yu get a service frm a prvider that des nt wrk with Tufts Health Unify, then Tufts Health Unify will nt autmatically pay fr the service. In that case, yu may have t pay fr the service yurself. If that happens and yu want t ask us t pay yu back fr the service, start by reading Chapter 7 f this bklet, Asking us t pay fr services. Chapter 7 describes the situatins in which yu may need t ask fr Tufts Health Unify t pay yu back r t pay a bill yu have received frm a prvider. It als tells yu hw t send us the paperwrk that asks us fr payment. 120

122 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Hw d I ask the plan t pay me back fr services I paid fr If yu are asking t be paid back, yu are asking fr a cverage decisin. We will decide if the service yu paid fr is a cvered service and we will check t see if yu fllwed all the rules fr using yur cverage. If the medical care yu paid fr is cvered and yu fllwed all the rules, we will send yu the payment fr yur medical care within 60 calendar days after we get yur request. Or, if yu haven t paid fr the services yet, we will send the payment directly t the prvider. When we send the payment, it s the same as saying yes t yur request fr a cverage decisin. If the care is nt cvered r yu did nt fllw all the rules, we will send yu a letter telling yu that we will nt pay fr the service and explaining why. What if the plan says they will nt pay If yu d nt agree with ur decisin, yu can make an appeal. If yu make an appeal t be paid back, we must give yu ur answer within 60 calendar days after we get yur appeal. If yu are asking us t pay yu back fr care that yu have already received and paid fr yurself, yu are nt allwed t ask fr a fast appeal. If we answer n t yur appeal and the service is cvered by Medicare, we will autmatically send yur case t the IRE. We will ntify yu by letter if this happens. Yu cannt appeal t the MassHealth Bard f Hearings fr appeals abut payment. If the IRE reverses ur decisin and says that we shuld pay yu, we must send the payment t yu r t the prvider within 30 calendar days. If the answer t yur appeal is yes at any stage f the appeals prcess after level 2, we must send the payment yu asked fr t yu r t the prvider within 60 calendar days. What if the IRE says n t yur appeal If the IRE says n t yur appeal, it means the IRE agrees with ur decisin nt t apprve yur request. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) T cntinue and make anther appeal at level 3, the dllar value f the service yu are requesting must meet a minimum amunt. If the dllar value f the cverage yu are requesting is t lw, yu cannt make anther appeal and the decisin at level 2 is final. The ntice yu get frm the independent review rganizatin will tell yu the dllar value that must be in dispute t cntinue with the appeals prcess. If the dllar value f the cverage yu are requesting meets the requirement, yu may chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after level 2 (fr a ttal f five levels f appeal). If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 121

123 If yur level 2 appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t level 3 and make a third appeal. If yu decide t make a third appeal, the details n hw t d this are in the written ntice yu gt after yur secnd appeal. The level 3 appeal is handled by an administrative law judge. Sectin 9 in this chapter tells mre abut levels 3, 4, and 5 f the appeals prcess. Sectin 6: Part D drugs Sectin 6.1: What t d if yu have prblems getting a Part D drug r yu want us t pay yu back fr a Part D drug Yur benefits as a member f ur plan include cverage fr many prescriptin drugs. Mst f these drugs are Part D drugs. There are a few drugs that Medicare Part D des nt cver but that MassHealth may cver. This sectin applies nly t Part D drug appeals. The List f Cvered Drugs (Drug List), includes sme drugs with an asterisk (*). These drugs are nt Part D drugs. Appeals r cverage decisins abut drugs with an asterisk (*) symbl fllw the prcess in Sectin 5. The legal term fr a cverage decisin abut yur Part D drugs is cverage determinatin. Can I ask fr a cverage decisin r make an appeal abut Part D prescriptin drugs Yes. Here are examples f cverage decisins yu can ask us t make abut yur Part D drugs: Yu ask us t make an exceptin, such as:» Asking us t cver a Part D drug that is nt n the plan s List f Cvered Drugs (Drug List); r» Asking us t waive a restrictin n the plan s cverage fr a drug (such as limits n the amunt f the drug yu can get). Yu ask us if a drug is cvered fr yu (fr example, when yur drug is n the plan s Drug List but we require yu t get apprval frm us befre we will cver it fr yu).» Please nte: If yur pharmacy tells yu that yur prescriptin cannt be filled, yu will get a ntice explaining hw t cntact us t ask fr a cverage decisin. Yu ask us t pay fr a prescriptin drug yu already bught. This is asking fr a cverage decisin abut payment. If yu disagree with a cverage decisin we have made, yu can appeal ur decisin. This sectin tells yu hw t ask fr cverage decisins and hw t request an appeal. Use the chart belw t find ut which part f this sectin has infrmatin fr yur situatin. 122

124 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Which f these situatins are yu in D yu need a drug that isn t n ur Drug List r need us t waive a rule r restrictin n a drug we cver D yu want us t cver a drug n ur Drug List, and yu believe yu meet any plan rules r restrictins (such as getting apprval in advance) fr the drug yu need D yu want t ask us t pay yu back fr a drug yu have already received and paid fr Have we already tld yu that we will nt cver r pay fr a drug in the way that yu want it t be cvered r paid fr Yu can ask us t make an exceptin. (This is a type f cverage decisin.) Start with Sectin 6.2 f this chapter. Als see Sectins 6.3 and 6.4. Yu can ask us fr a cverage decisin. Skip ahead t Sectin 6.4 f this chapter. Yu can ask us t pay yu back. (This is a type f cverage decisin.) Skip ahead t Sectin 6.4 f this chapter. Yu can make an appeal. (This means yu are asking us t recnsider.) Skip ahead t Sectin 6.5 f this chapter. Sectin 6.2: What is an exceptin An exceptin is permissin t get cverage fr a drug that is nt nrmally cvered n ur Drug List, r t use the drug withut certain rules and limitatins. If a drug is nt n ur List f Cvered Drugs, r is nt cvered in the way yu wuld like, yu can ask us t make an exceptin. When yu ask fr an exceptin, yur dctr r ther prescriber will need t explain the medical reasns why yu need the exceptin. Here are examples f exceptins that yu r yur dctr r anther prescriber can ask us t make. 1. Cvering a Part D drug that is nt n ur List f Cvered Drugs (Drug List). 2. Remving a restrictin n ur cverage. There are extra rules r restrictins that apply t certain drugs n ur Drug List (fr mre infrmatin, g t Chapter 5, page 68). The extra rules and restrictins n cverage fr certain drugs include:» Being required t use the generic versin f a drug instead f the brand-name drug. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 123

125 » Getting plan apprval befre we will agree t cver the drug fr yu. (This is smetimes called prir authrizatin.) We must prvide the medical necessity criteria t get plan apprval fr cvering a drug r service if yu, yur prvider, r MassHealth asks us fr it.» Being required t try a different drug first befre we will agree t cver the drug yu are asking fr. (This is smetimes called step therapy.)» Having quantity limits. Fr sme drugs, the plan limits the amunt f the drug yu can have. The legal term fr asking fr remval f a restrictin n cverage fr a drug is smetimes called asking fr a frmulary exceptin. Sectin 6.3: Imprtant things t knw when asking fr exceptins Yur dctr r ther prescriber must tell us the medical reasns. Yur dctr r ther prescriber must give us a statement explaining the medical reasns fr requesting an exceptin. Our decisin abut the exceptin will be faster if yu include this infrmatin frm yur dctr r ther prescriber when yu ask fr the exceptin. Typically, ur Drug List includes mre than ne drug fr treating a particular cnditin. These different pssibilities are called alternative drugs. If an alternative drug wuld be just as effective as the drug yu are asking fr, and wuld nt cause mre side effects r ther health prblems, we will generally nt apprve yur request fr an exceptin. We will say yes r n t yur request fr an exceptin. If we say yes t yur request fr an exceptin, the exceptin usually lasts until the end f the calendar year. This is true as lng as yur dctr cntinues t prescribe the drug fr yu, and that drug cntinues t be safe and effective fr treating yur cnditin. If we say n t yur request fr an exceptin, yu can ask fr a review f ur decisin by making an appeal. Sectin 5.4, page 117 tells yu hw t make an appeal if we say n. The next sectin tells yu hw t ask fr a cverage decisin, including an exceptin. 124

126 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 6.4: Asking fr a cverage decisin abut a Part D drug r reimbursement fr a Part D drug, including an exceptin What t d Ask fr the type f cverage decisin yu want. Call, write, r fax us t make yur request. Yu, yur representative, r yur dctr (r ther prescriber) can d this. Yu can call us at Yu r yur dctr (r ther prescriber) r smene else wh is acting n yur behalf can ask fr a cverage decisin. Yu can als have a lawyer act n yur behalf. Read Sectin 4, page 109 t find ut hw t give permissin t smene else t act as yur representative. Yu d nt need t give yur dctr r ther prescriber written permissin t ask us fr a cverage decisin n yur behalf. If yu want t ask us t pay yu back fr a drug, read Chapter 7, page 87 f this handbk. Chapter 7 describes the times when yu may need t ask At a glance: Hw t ask fr a cverage decisin abut a drug r payment Call, write, r fax us t ask, r ask yur representative r dctr r ther prescriber t ask. We will give yu an answer n a standard cverage decisin within 72 hurs. We will give yu an answer n reimbursing yu fr a Part D drug yu already paid fr in 14 days. If yu are asking fr an exceptin, include the supprting statement frm yur dctr r ther prescriber. Yu r yur dctr r ther prescriber may ask fr a fast decisin. (Fast decisins usually cme within 24 hurs.) Read this chapter t make sure yu qualify fr a fast decisin! Read it als t find infrmatin abut decisin deadlines. fr reimbursement. It als tells yu hw t send us the paperwrk asking us t pay yu back fr ur share f the cst f a drug that yu have paid fr. If yu are requesting an exceptin, prvide the supprting statement. Yur dctr r ther prescriber must give us the medical reasns fr the drug exceptin. We call this the supprting statement. Yur dctr r ther prescriber can fax r mail the statement t us. Yur dctr r ther prescriber can als tell us n the phne and then, fax r mail a statement. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 125

127 If yur health requires it, ask us t give yu a fast cverage decisin We will use the standard deadlines unless we have agreed t use the fast deadlines. A standard cverage decisin means we will give yu an answer within 72 hurs after we get yur dctr s statement. A fast cverage decisin means we will give yu an answer within 24 hurs.» Yu can get a fast cverage decisin nly if yu are asking fr a drug yu have nt yet received. (Yu cannt get a fast cverage decisin if yu are asking us t pay yu back fr a drug yu have already bught.)» Yu can get a fast cverage decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin.» If yur dctr r ther prescriber tells us that yur health requires a fast cverage decisin, we will autmatically agree t give yu a fast cverage decisin, and the letter will tell yu that.» If yu ask fr a fast cverage decisin n yur wn (withut yur dctr s r ther prescriber s supprt), we will decide whether yu get a fast cverage decisin.» If we decide t give yu a standard decisin, we will send yu a letter telling yu that. The letter will tell yu hw t make a cmplaint abut ur decisin t give yu a standard decisin. Yu can file a fast cmplaint and get a decisin within 24 hurs.» If we decide that yur medical cnditin des nt meet the requirements fr a fast cverage decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). The legal term fr fast cverage decisin is expedited cverage determinatin. Deadlines fr a fast cverage decisin If we are using the fast deadlines, we must give yu ur answer within 24 hurs after we get yur request. Or, if yu are asking fr an exceptin, we must give yu ur answer 24 hurs after we get yur dctr s r prescriber s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we will send yur request n t level 2 f the appeals prcess. At level 2, an utside independent rganizatin will review yur request and ur decisin. If ur answer is yes t part r all f what yu asked fr, we must give yu the cverage within 24 hurs after we get yur request r yur dctr s r prescriber s statement supprting yur request. If ur answer is n t part r all f what yu asked fr, we will send yu a letter that explains why we said n. The letter will als explain hw yu can appeal ur decisin. 126

128 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Deadlines fr a standard cverage decisin abut a drug yu have nt yet received If we are using the standard deadlines, we must give yu ur answer within 72 hurs after we get yur request r, if yu are asking fr an exceptin, after we get yur dctr s r prescriber s supprting statement. We will give yu ur answer sner if yur health requires it. If we d nt meet this deadline, we will send yur request n t level 2 f the appeals prcess. At level 2, an Independent Review Entity (IRE) will review the decisin. If ur answer is yes t part r all f what yu asked fr, we must apprve r give the cverage within 72 hurs after we get yur request r, if yu are asking fr an exceptin, yur dctr s r prescriber s supprting statement. If ur answer is n t part r all f what yu asked fr, we will send yu a letter that explains why we said n. The letter will als explain hw yu can appeal ur decisin. Deadlines fr a standard cverage decisin abut payment fr a drug yu have already bught We must give yu ur answer within 14 calendar days after we get yur request. If we d nt meet this deadline, we will send yur request n t level 2 f the appeals prcess. At level 2, the IRE will review the decisin. If ur answer is yes t part r all f what yu asked fr, we will make payment t yu within 30 calendar days. If ur answer is n t part r all f what yu asked fr, we will send yu a letter that explains why we said n. This statement will als explain hw yu can appeal ur decisin. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 127

129 Sectin 6.5: Level 1 appeal fr Part D drugs T start yur appeal, yu, yur dctr r ther prescriber, r yur representative must cntact us. If yu are asking fr a standard appeal, yu can make yur appeal by sending a request in writing. Yu may als ask fr an appeal by calling us at If yu want a fast appeal, yu may make yur appeal in writing r yu may call us. Make yur appeal request within 60 calendar days frm the date n the ntice that we sent t yu with ur decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Examples f a gd reasn include: yu had a serius illness, r we gave yu the wrng infrmatin abut the deadline fr requesting an appeal. At a glance: Hw t make a level 1 appeal Yu, yur dctr r prescriber, r yur representative may put yur request in writing and mail r fax it t us. Yu may als ask fr an appeal by calling us at Ask within 60 days f the decisin yu are appealing. If yu miss the deadline fr a gd reasn, yu may still appeal. Yu, yur dctr r prescriber, r yur representative can call us t ask fr a fast appeal. Read this chapter t make sure yu qualify fr a fast decisin! Read it als t find infrmatin abut decisin deadlines. Yu can ask fr a cpy f the infrmatin in yur appeal and add mre infrmatin. Yu have the right t ask us fr a cpy f the infrmatin abut yur appeal.» If yu wish, yu and yur dctr r ther prescriber may give us additinal infrmatin t supprt yur appeal. The legal term fr an appeal t the plan abut a Part D drug cverage decisin is plan redeterminatin. If yur health requires it, ask fr a fast appeal If yu are appealing a decisin ur plan made abut a drug yu have nt yet received, yu and yur dctr r ther prescriber will need t decide if yu need a fast appeal. The requirements fr getting a fast appeal are the same as thse fr getting a fast cverage decisin in Sectin 5.2, page 112 f this chapter. 128

130 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) The legal term fr fast appeal is expedited recnsideratin. Our plan will review yur appeal and give yu ur decisin We take anther careful lk at all f the infrmatin abut yur cverage request. We check t see if we were fllwing all the rules when we said n t yur request. We may cntact yu r yur dctr r ther prescriber t get mre infrmatin. Deadlines fr a fast appeal If we are using the fast deadlines, we will give yu ur answer within 72 hurs after we get yur appeal, r sner if yur health requires it. If we d nt give yu an answer within 72 hurs, we will send yur request n t Level 2 f the appeals prcess. At Level 2, the IRE will review ur decisin. If ur answer is yes t part r all f what yu asked fr, we must give the cverage within 72 hurs after we get yur appeal. If ur answer is n t part r all f what yu asked fr, we will send yu a letter that explains why we said n. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within seven calendar days after we get yur appeal, r sner if yur health requires it. If yu think yur health requires it, yu shuld ask fr a fast appeal. If we d nt give yu a decisin within seven calendar days, we will send yur request n t Level 2 f the appeals prcess. At Level 2, the IRE will review ur decisin. If ur answer is yes t part r all f what yu asked fr:» If we apprve a request fr cverage, we must give yu the cverage as quickly as yur health requires, but n later than seven calendar days after we get yur appeal.» If we apprve a request t pay yu back fr a drug yu already bught, we will send payment t yu within 30 calendar days after we get yur appeal request. If ur answer is n t part r all f what yu asked fr, we will send yu a letter that explains why we said n, and tells yu hw t appeal ur decisin. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 129

131 Sectin 6.6: Level 2 appeal fr Part D drugs If we say n t yur appeal, yu then chse whether t accept this decisin, r cntinue by making anther appeal. If yu decide t g n t a level 2 appeal, the IRE will review ur decisin. If yu want the IRE t review yur case, yur appeal request must be in writing. The letter we send abut ur decisin in the level 1 appeal will explain hw t request the level 2 appeal. When yu make an appeal t the IRE, we will send them yur case file. Yu have the right t ask us fr a cpy f yur case file. Yu have a right t give the IRE ther infrmatin t supprt yur appeal. The IRE is an independent rganizatin that is hired by Medicare. It is nt cnnected with this plan and it is nt a gvernment agency. Reviewers at the IRE will take a careful lk at all f the infrmatin related t yur appeal. The rganizatin will send yu a letter explaining its decisin. Deadlines fr fast appeal at level 2 If yur health requires it, ask the IRE fr a fast appeal. If the review rganizatin agrees t give yu a fast appeal, it must answer yur level 2 appeal within 72 hurs after getting yur appeal request. If the IRE says yes t part r all f what yu asked fr, we must apprve r give yu the drug cverage within 24 hurs after we get the decisin. Deadlines fr standard appeal at level 2 At a glance: Hw t make a level 2 appeal If yu want the Independent Review Organizatin (IRE) t review yur case, yur appeal request must be in writing. Ask within 60 days f the decisin yu are appealing. If yu miss the deadline fr a gd reasn, yu may still appeal. Yu, yur dctr r ther prescriber, r yur representative can request the level 2 appeal. Read this chapter t make sure yu qualify fr a fast decisin! Read it als t find infrmatin abut decisin deadlines. If yu have a standard appeal at level 2, the IRE must answer yur level 2 appeal within seven calendar days after it gets yur appeal.» If the IRE says yes t part r all f what yu asked fr, we must apprve r give yu the drug cverage within 72 hurs after we get the decisin.» If the IRE apprves a request t pay yu back fr a drug yu already bught, we will send payment t yu within 30 calendar days after we get the decisin. 130

132 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) What if the IRE says n t yur level 2 appeal N means that the IRE agrees with ur decisin nt t apprve yur request. This is called uphlding the decisin. It is als called, turning dwn yur appeal. If the dllar value f the drug cverage yu want meets a certain minimum amunt, yu can make anther appeal at level 3. The letter yu get frm the IRE will tell yu the minimum dllar amunt needed t cntinue with the appeals prcess. The level 3 appeal is handled by an administrative law judge. Sectin 7: Asking us t cver a lnger hspital stay When yu are admitted t a hspital, yu have the right t get all hspital services that we cver that are necessary t diagnse and treat yur illness r injury. During yur hspital stay, yur dctr, yur care manager, and the hspital staff will be wrking with yu t prepare fr the day when yu will leave the hspital. They will als help arrange fr any care yu may need after yu leave. The day yu leave the hspital is called yur discharge date. Our plan s cverage f yur hspital stay ends n this date. Yur dctr r the hspital staff will tell yu what yur discharge date is. If yu think yu are being asked t leave the hspital t sn, yu can ask fr a lnger hspital stay. This sectin tells yu hw t ask. Sectin 7.1: Yur Medicare rights if yu are admitted t the hspital Within tw days after yu are admitted t the hspital, a casewrker r nurse will give yu a ntice called An Imprtant Message frm Medicare abut Yur Rights. If yu d nt get this ntice, ask any hspital emplyee fr it. If yu need help, please call member services (phne numbers are printed n the back cver f this bklet). Yu can als call 800-MEDICARE ( ), 24 hurs a day, seven days a week. Peple wh are deaf, hard f hearing, r speech disabled shuld call the TTY number, Read this ntice carefully and ask questins if yu dn t understand. The Imprtant Message tells yu abut yur rights as a hspital patient, including the fllwing: Yur right t get Medicare-cvered services during and after yur hspital stay. Yu have the right t knw what these services are, wh will pay fr them, and where yu can get them. Yur right t be a part f any decisins abut the length f yur hspital stay. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 131

133 Yur right t knw where t reprt any cncerns yu have abut the quality f yur hspital care. Yur right t appeal if yu think yu are being discharged frm the hspital t sn. Yu shuld sign the Medicare ntice t shw that yu gt it and that yu understand yur rights. Signing the ntice des nt mean that yu agree t the discharge date tld t yu by yur dctr r hspital staff. Keep yur cpy f the signed ntice s yu will have the infrmatin if yu need it. T lk at a cpy f this ntice in advance, yu can call member services at Yu can als call 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (fr peple wh are deaf, hard f hearing, r speech disabled) shuld call The call is free. Yu can als see the ntice nline at cms.gv/bni/12_hspitaldischargeappealntices.asp. If yu need help, please call member services at Yu can als call 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (fr peple wh are deaf, hard f hearing, r speech disabled) shuld call The call is free. Sectin 7.2: Level 1 appeal t change yur hspital discharge date If yu want us t cver yur inpatient hspital services fr a lnger time, yu must request an appeal. A quality imprvement rganizatin will d the level 1 appeal review t see if yur planned discharge date is medically apprpriate fr yu. T make an appeal t change yur discharge date call the quality imprvement rganizatin at Call right away! Call the quality imprvement rganizatin befre yu leave the hspital and n later than yur planned discharge date. An Imprtant Message frm Medicare abut Yur Rights cntains infrmatin n hw t reach the quality imprvement rganizatin. If yu call befre yu leave, yu are allwed t stay in the hspital after yur discharge date withut paying fr it while yu wait t get the decisin n yur appeal frm the quality imprvement rganizatin. If yu d nt call t appeal, and yu decide t stay in the hspital after yur planned discharge date, yu may have t pay all f the csts fr hspital care yu get after yur planned discharge date. At a glance: Hw t make a level 1 appeal t change yur discharge date Call the quality imprvement rganizatin in yur state at and ask fr a fast review. Call befre yu leave the hspital and befre yur planned discharge date. 132

134 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) If yu miss the deadline fr cntacting the quality imprvement rganizatin abut yur appeal, yu can make yur appeal directly t ur plan instead. Fr details, see Sectin 5.2, page 112. We want t make sure yu understand what yu need t d and what the deadlines are. Ask fr help if yu need it. If yu have questins r need help at any time, please call member services at Yu can als call the State Health Insurance Assistance Prgram (SHIP), which is called SHINE in Massachusetts, at Or, yu can get help frm the One Care Ombudsman by calling (MassRelay: 711) r ing [email protected]. What is a quality imprvement rganizatin It is a grup f dctrs and ther health care prfessinals wh are paid by the federal gvernment. These experts are nt part f ur plan. They are paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. Ask fr a fast review Yu must ask the quality imprvement rganizatin fr a fast review f yur discharge. The legal term fr fast review is immediate review. What happens during the review The reviewers at the quality imprvement rganizatin will ask yu r yur representative why yu think cverage shuld cntinue after the planned discharge date. Yu dn t have t prepare anything in writing, but yu may d s if yu wish. The reviewers will lk at yur medical recrd, talk with yur dctr, and review all f the infrmatin related t yur hspital stay. By nn f the day after the reviewers tell us abut yur appeal, yu will get a letter that gives yur planned discharge date. The letter explains the reasns why yur dctr, the hspital, and we think it is right fr yu t be discharged n that date. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 133

135 The legal term fr this written explanatin is called the Detailed Ntice f Discharge. Yu can get a sample by calling member services at Yu can als call 800-MEDICARE ( ), 24 hurs a day, seven days a week. (TTY users peple wh are deaf, hard f hearing, r speech disabled shuld call ) Or yu can see a sample ntice nline at cms.hhs.gv/bni/. What if the answer is yes If the review rganizatin says yes t yur appeal, we must keep cvering yur hspital services fr as lng as they are medically necessary. What if the answer is n If the review rganizatin says n t yur appeal, they are saying that yur planned discharge date is medically apprpriate. If this happens, ur cverage fr yur inpatient hspital services will end at nn n the day after the quality imprvement rganizatin gives yu its answer. If the review rganizatin says n and yu decide t stay in the hspital, then yu may have t pay the full cst f hspital care yu get after nn n the day after the quality imprvement rganizatin gives yu its answer. If the quality imprvement rganizatin turns dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make a Level 2 Appeal. Sectin 7.3: Level 2 Appeal t change yur hspital discharge date If the quality imprvement rganizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make a Level 2 Appeal. Yu will need t cntact the quality imprvement rganizatin again and ask fr anther review. Ask fr the Level 2 review within 60 calendar days after the day when the quality imprvement rganizatin said n t yur Level 1 Appeal. Yu can ask fr this review nly if yu stayed in the hspital after the date that yur cverage fr the care ended. Yu can reach the quality imprvement rganizatin at At a glance: Hw t make a level 2 appeal t change yur discharge date Call the quality imprvement rganizatin in yur state and ask fr anther review. Reviewers at the quality imprvement rganizatin will take anther careful lk at all f the infrmatin related t yur appeal. 134

136 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Within 14 calendar days, the quality imprvement rganizatin reviewers will make a decisin. What happens if the answer is yes We must pay yu back fr ur share f the csts f hspital care yu have received since nn n the day after the date f yur first appeal decisin. We must cntinue prviding cverage fr yur inpatient hspital care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts, and cverage limitatins may apply. What happens if the answer is n It means the quality review rganizatin agrees with the level 1 decisin and will nt change it. The letter yu get will tell yu what yu can d if yu wish t cntinue with the appeal prcess. If the QIO turns dwn yur level 2 appeal, yu may have t pay the full cst fr yur stay after yur planned discharge date. Sectin 7.4: What happens if I miss an appeal deadline If yu miss an appeal deadline, there is anther way t make level 1 and level 2 appeals called alternate appeals. Level 1 alternate appeal t change yur hspital discharge date If yu miss the deadline fr cntacting the quality imprvement rganizatin, yu can make an appeal t Tufts Health Unify, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. During this review, we take a lk at all f the infrmatin abut yur hspital stay. We check t see if the decisin abut when yu shuld leave the hspital was fair and fllwed all the rules. We will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. We will give yu ur decisin within 72 hurs after yu ask fr a fast review. At a glance: Hw t make a level 1 alternate appeal Call ur member services number and ask fr a fast review f yur hspital discharge date. We will give yu ur decisin within 72 hurs. If we say yes t yur fast review, it means we agree that yu still need t be in the hspital after the discharge date. We will keep cvering hspital services fr as lng as it is medically necessary. It als means that we agree t pay yu back fr ur share f the csts f care that yu have received since the date when we said yur cverage wuld end. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 135

137 If we say n t yur fast review, we are saying that yur planned discharge date was medically apprpriate. Our cverage fr yur inpatient hspital services ends n the day we said cverage wuld end.» If yu stayed in the hspital after yur planned discharge date, then yu may have t pay the full cst f hspital care yu gt after the planned discharge date. The legal term fr fast review r fast appeal is expedited appeal. T make sure we were fllwing all the rules when we said n t yur fast appeal, we will send yur appeal t the IRE. When we d this, it means that yur case is autmatically ging t level 2 f the appeals prcess. Level 2 alternate appeal t change yur hspital discharge date We will send the infrmatin fr yur level 2 appeal t the independent review entity (IRE) within 24 hurs f when we give yu ur level 1 decisin. The letter will als tell yu that yu can ask fr a level 2 appeal frm the MassHealth Bard f Hearings (BOH). Sectin 5 f this chapter tells yu hw t appeal t the Bard f Hearings. If yu think we are nt meeting this deadline r ther deadlines, yu can make a cmplaint. Sectin 10, page 143 f this chapter tells yu hw t make a cmplaint. During the level 2 appeal, the IRE reviews ur decisin when we said n t yur fast review. This rganizatin decides whether the decisin we made shuld be changed. The IRE des a fast review f yur appeal. The reviewers give yu an answer within 72 hurs. The IRE is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. Reviewers at the IRE will take a careful lk at all f the infrmatin related t yur appeal f yur hspital discharge. If the IRE says yes t yur appeal, then we must pay yu back fr ur share f the csts f hspital care that yu have received since the date f yur planned discharge. We must als cntinue the plan s cverage f yur hspital services fr as lng as it is medically necessary. If this rganizatin says n t yur appeal, it means that they agree with us that yur planned hspital discharge date was medically apprpriate. The letter yu get frm the IRE will tell yu what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a level 3 appeal, which is handled by a judge. 136

138 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 8: What t d if yu think yur hme health care, skilled nursing care, r cmprehensive utpatient rehabilitatin facility (CORF) services are ending t sn This sectin is abut the fllwing types f care nly: Hme health care services Skilled nursing care in a skilled nursing facility Rehabilitatin care yu are getting as an utpatient at a Medicare-apprved cmprehensive utpatient rehabilitatin facility (CORF). Usually, this means yu are getting treatment fr an illness r accident, r yu are recvering frm a majr peratin With any f these three types f care, yu have the right t keep getting cvered services fr as lng as the dctr says yu need it. When we decide t stp cvering any f these, we must tell yu befre yur services end. When yur cverage fr that care ends, we will stp paying fr yur care. If yu think we are ending the cverage f yur care t sn, yu can appeal ur decisin. This sectin tells yu hw t ask fr an appeal. Sectin 8.1: We will tell yu in advance when yur cverage will be ending The agency r facility that is prviding yur care will give yu a ntice at least tw days befre we stp paying fr yur care. The written ntice tells yu the date when we will stp cvering yur care. The written ntice als tells yu hw t appeal this decisin. Yu r yur representative shuld sign the written ntice t shw that yu gt it. Signing it des nt mean yu agree with the plan s decisin that it is time fr yu t stp getting the care. When yur cverage ends, we will stp paying. Sectin 8.2: Level 1 appeal t cntinue yur care If yu think we are ending the cverage f yur care t sn, yu can appeal ur decisin. This sectin tells yu hw t ask fr an appeal. Befre yu start, understand what yu need t d and what the deadlines are. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 137

139 Meet the deadlines. The deadlines are imprtant. Be sure that yu understand and fllw the deadlines that apply t things yu must d. There are als deadlines ur plan must fllw. (If yu think we are nt meeting ur deadlines, yu can file a cmplaint. Sectin 10 f this chapter tells yu hw t file a cmplaint.) Ask fr help if yu need it. If yu have questins r need help at any time, please call member services at Or, call yur State Health Insurance Assistance Prgram (SHIP) at During a level 1 appeal, the quality imprvement rganizatin will review yur appeal and decide whether t change the decisin we made. Yu can find ut hw t call them by reading the Ntice f Medicare Nn-Cverage. What is a quality imprvement rganizatin It is a grup f dctrs and ther health care prfessinals wh are paid by the federal gvernment. These experts are nt part f ur plan. They are paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. What shuld yu ask fr Ask them fr an independent review f whether it is medically apprpriate fr us t end cverage fr yur services. What is yur deadline fr cntacting this rganizatin At a glance: Hw t make a level 1 appeal t ask the plan t cntinue yur care Call the quality imprvement rganizatin in yur state and ask fr anther review. Yu can reach the quality imprvement rganizatin at Call befre yu leave the agency r facility that is prviding yur care and befre yur planned discharge date. Yu must cntact the quality imprvement rganizatin n later than nn f the day after yu gt the written ntice telling yu when we will stp cvering yur care. If yu miss the deadline fr cntacting the quality imprvement rganizatin abut yur appeal, yu can make yur appeal directly t us instead. Fr details abut this ther way t make yur appeal, see Sectin 5.3, page 114. The legal term fr the written ntice is Ntice f Medicare Nn-Cverage. T get a sample cpy, call member services at r 800-MEDICARE ( ), 24 hurs a day, seven days a week. (TTY users peple wh are deaf, hard f hearing, r speech disabled shuld call ) Or yu can see a sample ntice nline at cms.hhs.gv/bni/. What happens during the quality imprvement rganizatin s review The reviewers at the quality imprvement rganizatin will ask yu r yur representative why yu think cverage fr the services shuld cntinue. Yu dn t have t prepare anything in writing, but yu may d s if yu wish. 138

140 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) When yu ask fr an appeal, the plan must write a letter explaining why yur services shuld end. The reviewers will als lk at yur medical recrds, talk with yur dctr, and review infrmatin that ur plan has given t them. Within ne full day after the reviewers have all the infrmatin they need, they will tell yu their decisin. Yu will get a letter frm us explaining the decisin. The legal term fr the letter explaining why yur services shuld end is Detailed Explanatin f Nn-Cverage. What happens if the reviewers say yes If the QIO reviewers say yes t yur appeal, then we must keep prviding yur cvered services fr as lng as they are medically necessary. What happens if the reviewers say n If the QIO reviewers say n t yur appeal, then yur cverage will end n the date we tld yu. We will stp paying ur share f the csts f this care. If yu decide t keep getting the hme health care, skilled nursing facility care, r CORF services after the date yur cverage ends, then yu may have t pay the full cst f this care yurself. Sectin 8.3: Level 2 appeal t cntinue yur care If the quality imprvement rganizatin said n t the appeal and yu chse t cntinue getting care after yur cverage fr the care has ended, yu can make a level 2 appeal. Yu can ask the quality imprvement rganizatin t take anther lk at the decisin they made at level 1. If they say they agree with the level 1 decisin, yu may have t pay the full cst fr yur hme health care, skilled nursing facility care, r CORF services after the date when we said yur cverage wuld end. The quality imprvement rganizatin will review yur appeal and decide whether t change the decisin we made. Yu can find ut hw t call them by reading the Ntice f Medicare Nn-Cverage. At a glance: Hw t make a level 2 appeal t require that the plan cver yur care fr lnger Call the quality imprvement rganizatin in yur state and ask fr anther review. Make the call befre yu leave the agency r facility that is prviding yur care and befre yur planned discharge date. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 139

141 Ask fr the level 2 review within 60 days after the day when the quality imprvement rganizatin said n t yur level 1 Appeal. Yu can ask fr this review nly if yu cntinued getting care after the date that yur cverage fr the care ended. Reviewers at the quality imprvement rganizatin will take anther careful lk at all f the infrmatin related t yur appeal. The quality imprvement rganizatin will make its decisin within 14 days. What happens if the review rganizatin says yes We must pay yu back fr ur share f the csts f the care that yu have received since the date when we said yur cverage wuld end. We must cntinue prviding cverage fr the care fr as lng as it is medically necessary. What happens if the review rganizatin says n It means that they agree with the decisin they made n the level 1 appeal and will nt change it. The letter yu get will tell yu what t d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t the next level f appeal, which is handled by a judge. Sectin 8.4: What if yu miss the deadline fr making yur level 1 appeal If yu miss appeal deadlines, there is anther way t make level 1 and level 2 appeals called alternate appeals. Level 1 alternate appeal t cntinue yur care fr lnger If yu miss the deadline fr cntacting the quality imprvement rganizatin, yu can make an appeal t us, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. During this review, we take a lk at all f the infrmatin abut yur hspital stay. We check t see if the decisin abut when yur services shuld end was fair and fllwed all the rules. We will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. We will give yu ur decisin within 72 hurs after yu ask fr a fast review. At a glance: Hw t make a level 1 alternate appeal Call ur member services number and ask fr a fast review. We will give yu ur decisin within 72 hurs. If we say yes t yur fast review, it means we agree that we will keep cvering yur services fr as lng as it is medically necessary. It als means that we agree t pay yu back fr ur share f the csts f the care that yu have received since the date when we said yur cverage wuld end. 140

142 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) If we say n t yur fast review, we are saying that stpping yur services was medically apprpriate. Our cverage ends as f the day we said cverage wuld end.» If yu cntinue getting services after the day we said they wuld stp, yu may have t pay the full cst f the services. T make sure we were fllwing all the rules when we said n t yur fast appeal, we will send yur appeal t the IRE. When we d this, it means that yur case is autmatically ging t level 2 f the appeals prcess. The legal term fr fast review r r fast fast appeal is expedited is appeal. Level 2 alternate appeal t cntinue yur care fr lnger We will send the infrmatin fr yur level 2 appeal t the independent review entity (IRE) within 24 hurs f when we give yu ur level 1 decisin. The letter will als tell yu that yu can ask fr a level 2 appeal frm the MassHealth Bard f Hearings. Sectin 5 f this chapter tells yu hw t appeal t the Bard f Hearings. During the level 2 appeal, the IRE reviews the decisin we made when we said n t yur fast review. This rganizatin decides whether the decisin we made shuld be changed. The IRE des a fast review f yur appeal. The reviewers will give yu an answer within 72 hurs. The IRE is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan, and it is nt a gvernment agency. At a glance: Hw t make a level 2 appeal t require that the plan cntinue yur care Yu d nt have t d anything. The plan will autmatically send yur Appeal t the Independent Review Organizatin (IRE). Reviewers at the IRE will take a careful lk at all f the infrmatin related t yur appeal. If this rganizatin says yes t yur appeal, then we must pay yu back fr ur share f the csts f care. We must als cntinue the plan s cverage f yur services fr as lng as it is medically necessary. If this rganizatin says n t yur appeal, it means they agree with us that stpping cverage f services was medically apprpriate. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 141

143 The letter yu get frm the IRE will tell yu what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a level 3 appeal, which is handled by a judge. The frmal name fr independent review rganizatin is independent review entity. It is smetimes called the IRE. Sectin 9: Taking yur appeal beynd level 2 Sectin 9.1: Next steps fr Medicare services If yu made a level 1 appeal and a level 2 appeal fr Medicare services, and bth yur appeals have been turned dwn, yu may have the right t additinal levels f appeal. The letter yu get frm the independent review entity will tell yu what t d if yu wish t cntinue the appeals prcess. Level 3 f the appeals prcess is an administrative law judge (ALJ) hearing. If yu want an ALJ t review yur case, the item r medical service yu are requesting will have t meet a minimum dllar amunt. If the dllar value is less than the minimum level, yu cannt appeal any further. If the dllar value is high enugh, yu can ask the ALJ t hear yur appeal. If yu d nt agree with the ALJ s decisin, yu can g t the Medicare Appeals Cuncil. After that, yu may have the right t ask a federal curt t lk at yur appeal. If yu need assistance at any stage f the appeals prcess, yu can cntact the One Care Ombudsman (OCO) at (interpreters are available fr nn-english speakers). Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. Yu can als the OCO at [email protected]. Sectin 9.2: Next steps fr MassHealth services Yu als have mre appeal rights if yu made a level 1 appeal and a level 2 appeal fr MassHealth services, and bth yur appeals have been turned dwn. Yu can ask fr a review f yur appeal by a judge. If yu need assistance at any stage f the appeals prcess, yu can cntact the One Care Ombudsman (OCO) at (interpreters are available fr nn-english speakers). Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. Yu can als the OCO at [email protected]. 142

144 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Sectin 10: Hw t make a cmplaint What kinds f prblems shuld be cmplaints The cmplaint prcess is used fr certain types f prblems nly, such as prblems related t quality f care, waiting times, and custmer service. Here are examples f the kinds f prblems handled by the cmplaint prcess. Cmplaints abut quality Yu are unhappy with the quality f care, such as the care yu gt in the hspital. Cmplaints abut privacy Yu think that smene did nt respect yur right t privacy, r shared infrmatin abut yu that is cnfidential. Cmplaints abut pr custmer service A health care prvider r staff was rude r disrespectful t yu. Tufts Health Unify staff treated yu prly. Yu think yu are being pushed ut f the plan. At a glance: Hw t make a cmplaint Call member services r send us a letter telling us abut yur cmplaint. If yur cmplaint is abut quality f care, yu have mre chices. Yu can: 1. Make yur cmplaint t the quality imprvement rganizatin, 2. Make yur cmplaint t member services and t the quality imprvement rganizatin, r 3. Make yur cmplaint t Medicare. Cmplaints abut accessibility The health care services and facilities in a dctr r prvider s ffice are nt accessible t yu. Cmplaints abut mental health parity Mental health services are nt available in the same way that physical health services are available. Fr mre infrmatin, please see Sectin 10.5, page 146. Cmplaints abut waiting times Yu are having truble getting an appintment, r waiting t lng t get it. Yu have been kept waiting t lng by dctrs, pharmacists, r ther health prfessinals, r by member services r ther plan staff. Cmplaints abut cleanliness Yu think the clinic, hspital, r prvider s ffice is nt clean. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 143

145 Cmplaints abut language access Yur dctr r prvider des nt prvide yu with an interpreter during yur appintment. Cmplaints abut cmmunicatins frm us Yu think we failed t give yu a ntice r letter that yu shuld have received. Yu think the written infrmatin we sent yu is t difficult t understand. Cmplaints abut the timeliness f ur actins related t cverage decisins r appeals Yu believe that we are nt meeting ur deadlines fr making a cverage decisin r answering yur appeal. Yu believe that, after getting a cverage r appeal decisin in yur favr, we are nt meeting the deadlines fr apprving r giving yu the service r paying yu back fr certain medical services. Yu believe we did nt frward yur case t the IRE n time. The legal term fr a cmplaint is a grievance. The legal term fr making a cmplaint is filing a grievance. Sectin 10.1: Details and deadlines Call member services at The cmplaint must be made within 60 calendar days after yu had the prblem that yu want t cmplain abut. If there is anything else yu need t d, member services will tell yu. Yu can als make yur cmplaint in writing and send it t us. If yu put yur cmplaint in writing, we will respnd t yur cmplaint in writing. Yu r yur appinted representative may file a cmplaint with us in the fllwing ways, by: Telephne: (TTY: ) Mail: Tufts Health Plan Netwrk Health Attn: Appeal and Grievance Team 101 Statin Landing, Furth Flr Medfrd, MA via the Cntact us sectin f ur website at TuftsHealthUnify.rg Fax: In persn: at ur 101 Statin Landing (Medfrd, Mass.) address, Mnday thrugh Friday, frm 8 a.m. t 5 p.m., excluding hlidays 144

146 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Once we get yur cmplaint request, we ll:» Tell yu and yur appinted representative in writing within ne business day that we gt yur request» Lk int the substance f yur request, including any aspect f clinical care invlved» Reslve yur cmplaint within 30 calendar days frm when we get yur request and let yu and yur appinted representative knw f the utcme in writing» Dcument the substance f yur cmplaint request and the actins taken» Prvide interpreter services, if necessary If yu are making a cmplaint because we denied yur request fr a fast cverage decisin r a fast appeal, we will autmatically give yu a fast decisin and respnd t yur cmplaint within 24 hurs. The legal term fr fast cmplaint is expedited grievance. If pssible, we will answer yu right away. If yu call us with a cmplaint, we may be able t give yu an answer n the same phne call. If yur health cnditin requires us t answer quickly, we will d that. Mst cmplaints are answered in 30 calendar days. If we need mre infrmatin and the delay is in yur best interest, r if yu ask fr mre time, we can take up t 14 mre calendar days (44 calendar days ttal) t answer yur cmplaint. If we d nt agree with sme r all f yur cmplaint, we will tell yu and give yu ur reasns. We will respnd, whether we agree with the cmplaint r nt. Sectin 10.2: Yu can file cmplaints with the Office f Civil Rights If yu have a cmplaint abut disability access r abut language assistance, yu can file a cmplaint with the Office f Civil Rights at the Department f Health and Human Services. T cntact the Office f Civil Rights Regin I fr Bstn (Cnnecticut, Maine, Massachusetts, New Hampshire, Rhde Island, and Vermnt) call Yu may als have rights under the Americans with Disability Act. If yu feel yur rights prtected under the Americans with Disabilities Act have nt been respected, yu may file a cmplaint with Tufts Health Unify. Call member services at The cmplaint must be made within 60 calendar days after yu had the prblem that yu want t cmplain abut. If there is anything else yu need t d, member services will tell yu. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 145

147 Yu can make yur cmplaint in writing and send it t us. If yu put yur cmplaint in writing, we will respnd t yur cmplaint in writing. Yu can cntact the One Care Ombudsman fr assistance by calling (MassRelay: dial 711) r ing [email protected]. Sectin 10.3: Yu can make cmplaints abut quality f care t the quality imprvement rganizatin When yur cmplaint is abut quality f care, yu als have tw chices. If yu prefer, yu can make yur cmplaint abut the quality f care directly t the quality imprvement rganizatin (withut making the cmplaint t us). Or yu can make yur cmplaint t us and als t the quality imprvement rganizatin. Or yu can make yur cmplaint t us and als t the quality imprvement rganizatin. If yu make a cmplaint t this rganizatin, we will wrk with them t reslve yur cmplaint. The quality imprvement rganizatin is a grup f practicing dctrs and ther health care experts paid by the federal gvernment t check and imprve the care given t Medicare patients. The phne number fr the quality imprvement rganizatin is Sectin 10.4: Yu can tell Medicare abut yur cmplaint Yu can als send yur cmplaint t Medicare. G t Medicare.gv/MedicareCmplaintFrm/hme.aspx. Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. If yu have any ther feedback r cncerns, r if yu feel the plan is nt addressing yur prblem, please call 800-MEDICARE ( ). TTY/TDD users (peple wh are deaf, hard f hearing, r speech disabled) can call The call is free. Sectin 10.5: Cmplaints abut mental health parity Federal and state laws require that all managed care rganizatins, including Tufts Health Unify, prvide behaviral health services t MassHealth members in the same way they prvide physical health services. This is what is referred t as parity. In general, this means that: 1. Tufts Health Unify must prvide the same level f benefits fr mental health and substance abuse prblems yu may have as fr ther physical prblems yu may have; 2. Tufts Health Unify cannt have stricter prir authrizatin requirements and treatment limitatins fr mental health and substance abuse services than it des fr physical health services; 3. Tufts Health Unify must prvide yu and yur prvider with the medical necessity criteria used by Tufts Health Unify fr prir authrizatin upn yur r yur prvider s request; and 146

148 Tufts Health Unify Member Handbk Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 4. Tufts Health Unify must als prvide yu within a reasnable time frame the reasn fr any denial f authrizatin fr mental r substance abuse services. If yu think that Tufts Health Unify is nt prviding parity as explained abve, yu have the right t file a grievance with Tufts Health Unify. Fr mre infrmatin abut grievances and hw t file them, please see Sectin 10, page 143 f yur Member Handbk. Yu may als file a grievance with MassHealth. Yu can d this by calling the MassHealth custmer service center at (TTY: , fr peple wh are deaf, hard f hearing, r speech disabled), Mnday thrugh Friday, 8 a.m. t 5 p.m. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 147

149 Tufts Health Unify Member Handbk Chapter 10: Ending yur membership in Tufts Health Unify Table f cntents Intrductin A. When can yu end yur membership in Tufts Health Unify B. Hw d yu end yur membership in ur plan C. Hw d yu jin a different One Care plan D. If yu leave ur plan and yu d nt want a different One Care plan, hw d yu get Medicare and MassHealth services E. Are there any ther ptins F. Until yur membership ends, yu will keep getting yur Medicare and MassHealth services and drugs thrugh ur plan G. Yur membership will end in certain situatins H. We cannt ask MassHealth r Medicare t have yu leave ur plan fr any reasn related t yur health r yur disability I. Where can yu get mre infrmatin abut ending yur plan membership Intrductin This chapter talks abut ways yu can end yur membership in Tufts Health Unify. It als gives yu infrmatin abut ptins fr health cverage if yu leave Tufts Health Unify. As lng as yu are still eligible fr Medicare and MassHealth, yu can leave Tufts Health Unify withut lsing yur Medicare and MassHealth benefits. If yu are ver age 65 and yu decide t leave One Care, yu will nt be able t enrll in a One Care plan later. If yu think yu want t end yur membership in ur plan, there are a few ways yu can get mre infrmatin abut what will happen and hw yu can still get Medicare and MassHealth services. Call MassHealth custmer service at TTY users (peple wh are deaf, hard f hearing, r speech disabled) may call Call Medicare at 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (peple wh are deaf, hard f hearing, r speech disabled) may call Cntact a SHINE cunselr at If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 148

150 Tufts Health Unify Member Handbk Chapter 10: Ending yur membership in Tufts Health Unify A. When can yu end yur membership in Tufts Health Unify Yu can end yur membership in Tufts Health Unify at any time. Yur membership will end n the last day f the mnth that we get yur request t leave ur plan. Fr example, if we get yur request n January 25, yur cverage with ur plan will end n January 31. Fr infrmatin n Medicare ptins when yu leave ur plan, see the table n page 164. Fr infrmatin abut yur MassHealth services when yu leave ur plan, see page 164. Befre yu end yur membership in Tufts Health Unify, yu shuld talk t yur Tufts Health Unify care manager t make sure yu still get the care yu need while yu mve t yur new cverage. B. Hw d yu end yur membership in ur plan If yu decide t end yur membership, call MassHealth r Medicare and tell them yu want t leave Tufts Health Unify. Call MassHealth custmer service at , Mnday thrugh Friday, 8 a.m. t 5 p.m. TTY users (peple wh are deaf, hard f hearing, r speech disabled) may call ; r Send MassHealth an Enrllment Decisin Frm. Yu can get the frm at mass.gv/necare r by calling if yu need us t mail yu ne; r When MassHealth custmer service is clsed, call Medicare at 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call When yu call 800-MEDICARE, yu can als enrll in anther Medicare health r drug plan. Mre infrmatin n getting yur Medicare services when yu leave ur plan is in the chart n page 164. Yur cverage with Tufts Health Unify will end n the last day f the mnth that we get yur request. C. Hw d yu jin a different One Care plan If yu want t keep getting yur Medicare and MassHealth benefits tgether frm a single plan, yu can jin a different One Care plan. T enrll in a different One Care plan: Call MassHealth custmer service at TTY users (peple wh are deaf, hard f hearing, r speech disabled) may call ; Tell them yu want t leave Tufts Health Unify and jin a different One Care plan. If yu are nt sure what plan yu want t jin, they can tell yu abut the One Care plans in yur area; r If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 149

151 Send MassHealth an Enrllment Decisin Frm. Yu can get the frm at mass.gv/necare r by calling , if yu need us t mail yu ne. D. If yu leave ur plan and yu d nt want a different One Care plan, hw d yu get Medicare and MassHealth services If yu d nt want t enrll in a different One Care plan after yu leave Tufts Health Unify, yu will usually g back t getting yur Medicare and MassHealth services separately. Yu will get yur MassHealth services directly frm dctrs and ther prviders by using yur MassHealth card. This is called fee-fr-service. Yur MassHealth services include mst lng-term services and supprts (LTSS) and behaviral health care. Yu will have a chice abut hw t get yur Medicare benefits. 1. Yu can change t: A Medicare health plan, such as a Medicare Advantage Plan r Prgrams f All-inclusive Care fr the Elderly (PACE) Here is what t d: Call Medicare at 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users shuld call t enrll in the new Medicare-nly health plan. If yu need help r mre infrmatin: Call the SHINE prgram (Serving Health Insurance Needs f Everyne) at 800-AGE-INFO ( ). Yur cverage with Tufts Health Unify will end n the last day f the mnth befre yur new plan s cverage begins. 150

152 Tufts Health Unify Member Handbk Chapter 10: Ending yur membership in Tufts Health Unify 2. Yu can change t: Original Medicare with a separate Medicare prescriptin drug plan Here is what t d: Call Medicare at 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users shuld call t enrll in Original Medicare with a separate Medicare prescriptin drug plan. If yu need help r mre infrmatin: Call the SHINE prgram (Serving Health Insurance Needs f Everyne) at 800-AGE-INFO ( ). Yur cverage with Tufts Health Unify will end n the last day f the mnth befre yur Original Medicare cverage begins. 3. Yu can change t: Original Medicare withut a separate Medicare prescriptin drug plan NOTE: If yu switch t Original Medicare and d nt enrll in a separate Medicare prescriptin drug plan, Medicare may enrll yu in a drug plan, unless yu tell Medicare yu dn t want t jin. Yu shuld nly drp prescriptin drug cverage if yu get drug cverage frm an emplyer, unin, r ther surce. If yu have questins abut whether yu need drug cverage, call the SHINE prgram at 800-AGE-INFO. Here is what t d: Call Medicare at 800-MEDICARE ( ), 24 hurs a day, seven days a week. TTY users shuld call t enrll in Original Medicare and pt ut f a separate Medicare prescriptin drug plan. If yu need help r mre infrmatin: Call the SHINE prgram at 800-AGE-INFO ( ). Yur cverage with Tufts Health Unify will end n the last day f the mnth befre yur Original Medicare cverage begins. E. Are there any ther ptins Sme peple wh decide nt t jin a One Care plan may be able t jin a different kind f plan t get their Medicare and MassHealth benefits tgether. If yu are age 55 r lder, yu may be eligible t enrll in the Prgram f All-Inclusive Care fr the Elderly (PACE) (additinal criteria apply). PACE helps lder adults stay in the cmmunity instead f getting nursing facility care. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 151

153 If yu are age 65 r lder when yu leave Tufts Health Unify, yu may be able t jin a senir care ptins (SCO) plan. T find ut abut PACE r SCO plans and whether yu can jin ne, call MassHealth custmer service at TTY users (peple wh are deaf, hard f hearing, r speech disabled) may call F. Until yur membership ends, yu will keep getting yur Medicare and MassHealth services and drugs thrugh ur plan If yu leave Tufts Health Unify, yu must keep getting yur health care and drugs thrugh ur plan until the next mnth starts. Yu shuld use ur netwrk pharmacies t get yur prescriptins filled. Usually, yur prescriptin drugs are cvered nly if they are filled at a netwrk pharmacy, including thrugh ur mail-rder pharmacy services. If yu are hspitalized n the day that yur membership ends, yur hspital stay will usually be cvered by ur plan until yu are discharged. This will happen even if yur new health cverage begins befre yu are discharged. G. Yur membership will end in certain situatins These are the cases when MassHealth r Medicare must end yur membership in ur plan: If there is a break in yur Medicare Part A and Part B cverage If yu are n lnger eligible fr MassHealth (ur plan is fr peple wh are eligible fr bth Medicare and MassHealth) If yu jin a MassHealth hme and cmmunity-based services waiver prgram If yu mve ut f ur service area If yu mve int an Intermediate Care Facility perated by the Massachusetts Department f Develpmental Services If yu g t prisn If yu have r get ther cmprehensive insurance fr prescriptin drugs r medical care If yu let smene else use yur ID card t get care If yur membership ends fr this reasn, Medicare may ask the Inspectr General t investigate yur case, and MassHealth may ask the Bureau f Special Investigatins t investigate yur case. We can als ask yu t leave ur plan if yu cntinuusly behave in a way that is s disruptive that we cannt prvide care fr yu r ther members f ur plan. We can nly make yu leave if we get permissin frm Medicare and MassHealth first. 152

154 Tufts Health Unify Member Handbk Chapter 10: Ending yur membership in Tufts Health Unify H. We cannt ask MassHealth r Medicare t have yu leave ur plan fr any reasn related t yur health r yur disability If yu feel that we are asking yu t leave ur plan fr a reasn related t yur health r disability, yu shuld call Medicare at 800-MEDICARE ( ). TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call Yu may call 24 hurs a day, seven days a week. Yu shuld als call MassHealth custmer service at TTY users may call Yu may als call the One Care Ombudsman (OCO) at (tll free), Mnday thrugh Friday, frm 8:30 a.m. t 4:30 p.m. Peple wh are deaf, hard f hearing, r speech disabled shuld dial 711 fr MassRelay. Yu can als the OCO at [email protected]. I. Where can yu get mre infrmatin abut ending yur plan membership If yu have questins r wuld like mre infrmatin abut when yur membership may end, yu can call member services at If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 153

155 Chapter 11: Legal ntices Table f cntents A. Ntice abut laws B. Ntice abut nndiscriminatin C. Ntice abut Tufts Health Unify as a secnd payer D. Ntice f Privacy Practices E. Ntice abut the relatinship between Tufts Health Unify and prviders A. Ntice abut laws Many laws apply t this Member Handbk. These laws may affect yur rights and respnsibilities, even if the laws are nt included r explained in this handbk. The main laws that apply t this handbk are federal laws abut the Medicare and Medicaid prgrams and state laws abut the Medicaid prgram. Other federal and state laws may apply t. B. Ntice abut nndiscriminatin Every cmpany r agency that wrks with Medicare must bey the law. One f the things this means is that yu cannt be treated differently because f yur race, disability, religin, sex, sexual rientatin, gender identity, health, ethnicity, creed, age, r natinal rigin. If yu think that yu have nt been treated fairly fr any f these reasns, call the Department f Health and Human Services Office fr Civil Rights at TTY users (peple wh are deaf, hard f hearing, r speech disabled) shuld call Yu can als visit hhs.gv/cr/ffice/index.html fr mre infrmatin. C. Ntice abut Tufts Health Unify as a secnd payer Smetimes smene else has t pay first fr the services that yu get frm us. Fr example, if yu are in a car accident r if yu are injured at wrk, insurance r wrkers cmpensatin has t pay first. Then, if needed, we will pay. Tufts Health Unify has the right and the respnsibility t cllect payment fr cvered services when smene else has t pay first. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 154

156 Tufts Health Unify Member Handbk Chapter 11: Legal ntices Subrgatin Subrgatin is the prcess by which Tufts Health Unify gets back sme r all f the csts f yur health care frm anther insurer. Examples f ther insurers include: Yur mtr vehicle r hmewner s insurance The mtr vehicle r hmewner s insurance f an individual wh caused yur illness r injury Wrkers cmpensatin If an insurer ther than Tufts Health Unify shuld pay fr services related t an illness r injury, Tufts Health Unify has the right t ask that insurer t repay us. Unless therwise required by law, cverage under this plicy by Tufts Health Unify will be secndary when anther plan including, withut limitatin, medical payment cverage under an autmbile r hme insurance plicy prvides yu with cverage fr health care services. Health plan s right f reimbursement If yu get mney frm a lawsuit r settlement fr an illness r injury, Tufts Health Unify has a right t ask yu t repay the cst f cvered services that we paid fr. We cannt make yu repay us mre than the amunt f mney yu gt frm the lawsuit r settlement. As a member f Tufts Health Unify, yu agree t: Let us knw f any events that may affect Tufts Health Unify s rights f subrgatin r reimbursement Cperate with Tufts Health Unify when we ask fr infrmatin and assistance with crdinatin f benefits, subrgatin, r reimbursement Sign dcuments t help Tufts Health Unify with its rights t subrgatin and reimbursement Authrize Tufts Health Unify t investigate, request, and release infrmatin that is necessary t carry ut crdinatin f benefits, subrgatin, and reimbursement t the extent allwed by law If yu are nt willing t help us, yu may have t pay us back fr csts we may incur, including reasnable attrneys fees, in enfrcing ur rights under this plan. D. Ntice f Privacy Practices This ntice describes hw health infrmatin abut yu may be used and disclsed, and hw yu can get this infrmatin. Please review the Ntice f Privacy Practices carefully. If yu have any questins, please call ur privacy fficer. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 155

157 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Tufts Health Plan Netwrk Health is cmmitted t safeguarding the privacy f ur members prtected health infrmatin (PHI). PHI is infrmatin that: Identifies yu (r can reasnably be used t identify yu); and Relates t yur physical r mental health r cnditin, the prvisin f health care t yu, r the payment fr that care. We are required by law t maintain the privacy f yur PHI and t prvide yu with ntice f ur legal duties and privacy practices with respect t yur PHI. This Ntice f Privacy Practices describes hw we may cllect, use, and disclse yur PHI, and yur rights cncerning yur PHI. This ntice applies t all members f Tufts Health Plan Netwrk Health s health benefit plans. Hw we btain PHI. As a managed care plan, we engage in rutine activities that result in ur being given PHI frm surces ther than yu. Fr example, health care prviders such as physicians and hspitals submit claim frms cntaining PHI t enable us t pay them fr the cvered health care services they have prvided t yu. Hw we use and disclse yur PHI. We use and disclse PHI in a number f ways t carry ut ur respnsibilities as a managed care plan. The fllwing describes the types f uses and disclsures f PHI that federal law permits us t make withut yur specific authrizatin: Treatment: We may use and disclse yur PHI t health care prviders t help them treat yu. Fr example, ur care managers may disclse PHI t a hme health care agency t make sure yu get the services yu need after discharge frm a hspital. Payment purpses: We use and disclse yur PHI fr payment purpses, such as paying dctrs and hspitals fr cvered services. Payment purpses als include activities such as determining eligibility fr benefits, reviewing services fr medical necessity, perfrming utilizatin review, btaining premiums, crdinating benefits, subrgatin, and cllectin activities. Health care peratins: We use and disclse yur PHI fr health care peratins. Fr example, this includes crdinating/managing care, assessing and imprving the quality f health care services, reviewing the qualificatins and perfrmance f prviders, reviewing health plan perfrmance, cnducting medical reviews, and reslving grievances. It als includes business activities such as underwriting, rating, placing r replacing cverage, determining cverage plicies, business planning, btaining reinsurance, arranging fr legal and auditing services (including fraud and abuse detectin prgrams), and btaining accreditatins and licenses. We d nt use r disclse PHI that is genetic infrmatin fr underwriting purpses. Health and wellness infrmatin: We may use yur PHI t cntact yu with infrmatin abut appintment reminders; treatment alternatives; therapies; health care prviders; settings f care; 156

158 Tufts Health Unify Member Handbk Chapter 11: Legal ntices r ther health-related benefits, services, and prducts that may be f interest t yu. Fr example, we might send yu infrmatin abut smking cessatin prgrams. Organizatins that assist us: In cnnectin with treatment, payment, and health care peratins, we may share yur PHI with ur affiliates and third-party business assciates that perfrm activities fr us r n ur behalf (fr example, ur pharmacy benefit manager). We will btain assurances frm ur business assciates that they will apprpriately safeguard yur infrmatin. Plan spnsrs: If yu are enrlled in Tufts Health Plan Netwrk Health thrugh yur current r frmer place f wrk, yu are enrlled in a grup health plan. We may disclse PHI t the grup health plan s plan spnsr usually yur emplyer fr plan administratin purpses. A plan spnsr f an insured health benefit plan must certify that it will prtect the PHI in accrdance with law. Public health and safety; health versight: We may disclse yur PHI as fllws: t a public health authrity fr public health activities, such as respnding t public health investigatins; when authrized by law, t apprpriate authrities, if we reasnably believe yu are a victim f abuse, neglect, r dmestic vilence; when we believe in gd faith that it is necessary t prevent r lessen a serius and imminent threat t yur r thers health r safety; r t health versight agencies fr certain activities, such as audits, disciplinary actins, and licensure activity. Legal prcess; law enfrcement; specialized gvernment activities: We may disclse yur PHI in the curse f legal prceedings; in certain cases, in respnse t a subpena, discvery request, r ther lawful prcess; t law enfrcement fficials fr such purpses as respnding t a warrant r subpena; t the gvernment agency with which we cntract t prvide yur insurance; r fr specialized gvernmental activities, such as natinal security. Research; death; rgan dnatin: We may disclse yur PHI t researchers, prvided that certain established measures are taken t prtect yur privacy. We may disclse PHI, in certain instances, t crners, medical examiners, and in cnnectin with rgan dnatin. Wrkers cmpensatin: We may disclse yur PHI when authrized by wrkers cmpensatin laws. Family and friends: We may disclse PHI t a family member, relative, r friend r anyne else yu identify as fllws: (i) when yu are present prir t the use r disclsure and yu agree; r (ii) when yu are nt present (r yu are incapacitated r in an emergency situatin) if, in the exercise f ur prfessinal judgment and in ur experience with cmmn practice, we determine that the disclsure is in yur best interests. In these cases we will nly disclse the PHI that is directly relevant t the persn s invlvement in yur health care r payment related t yur health care. Persnal representatives: Unless prhibited by law, we may disclse yur PHI t yur persnal representative, if yu have ne. A persnal representative is a persn wh has legal authrity t act n yur behalf regarding yur health care r health care benefits. Fr example, an individual If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 157

159 named in a durable pwer f attrney r a parent r guardian f an unemancipated minr are persnal representatives. Cmmunicatins: We will cmmunicate infrmatin cntaining PHI t the address r telephne number we have n recrd fr the subscriber f yur health benefits plan. Als, we may mail infrmatin cntaining yur PHI t the subscriber. Fr example, cmmunicatin regarding member requests fr reimbursement may be addressed t the subscriber. We will nt make separate mailings fr enrlled dependents at different addresses, unless we are requested t d s and agree t the request. See belw Right t receive cnfidential cmmunicatins fr mre infrmatin n hw t make such a request. Required by law: We may use r disclse yur PHI when we are required t d s by law. Fr example, we must disclse yur PHI t the U.S. Department f Health and Human Services upn request if they wish t determine whether we are in cmpliance with federal privacy laws. If ne f the abve reasns des nt apply, we will nt use r disclse yur PHI withut yur written permissin ( authrizatin ). Yu may give us written authrizatin t use r disclse yur PHI t anyne fr any purpse. Yu may later change yur mind and revke yur authrizatin in writing. Hwever, yur written revcatin will nt affect actins we ve already taken in reliance n yur authrizatin. Where state r ther federal laws ffer yu greater privacy prtectins, we will fllw thse mre stringent requirements. Fr example, under certain circumstances, recrds that cntain infrmatin abut alchl abuse treatment, drug abuse preventin r treatment, AIDS-related testing r treatment, r certain privileged cmmunicatins may nt be disclsed withut yur written authrizatin. In additin, when applicable we must have yur written authrizatin befre using r disclsing medical r treatment infrmatin fr a member appeal. See belw Wh t cntact fr questins r cmplaints if yu wuld like mre infrmatin. Hw we prtect PHI within ur rganizatin. Tufts Health Plan Netwrk Health prtects ral, written, and electrnic PHI thrughut ur rganizatin. We d nt sell PHI t anyne. We have many internal plicies and prcedures designed t cntrl and prtect the internal security f yur PHI. These plicies and prcedures address, fr example, use f PHI by ur emplyees. In additin, we train all emplyees abut these plicies and prcedures. Our plicies and prcedures are evaluated and updated fr cmpliance with applicable laws. Yur individual rights. The fllwing is a summary f yur rights with respect t yur PHI: Right f access t PHI: Yu have the right t inspect and get a cpy f mst PHI Tufts Health Plan Netwrk Health has abut yu, r a summary explanatin f PHI if agreed t in advance by yu. Requests must be made in writing and reasnably describe the infrmatin yu wuld like t inspect r cpy. If yur PHI is maintained electrnically, yu will als have the right t request a cpy in electrnic frmat. We have the right t charge a reasnable cst-based fee fr paper r electrnic cpies as established by state r federal law. Under certain circumstances, we may deny yur request. If we d s, we will send yu a written ntice f denial describing the basis f ur denial. Yu may request that we send a cpy f yur PHI directly t anther persn that yu designate. Yur request must be in writing, be signed by yu, and clearly identify the persn and the address where the PHI shuld be sent. 158

160 Tufts Health Unify Member Handbk Chapter 11: Legal ntices Right t request restrictins: Yu have the right t ask that we restrict uses r disclsures f yur PHI t carry ut treatment, payment, and health care peratins, and that we restrict disclsures t family members r friends. We will cnsider the request. Hwever, we are nt required t agree t it and, in certain cases, federal law des nt permit a restrictin. Requests may be made verbally r in writing t Tufts Health Plan Netwrk Health. Right t receive cnfidential cmmunicatins: Yu have the right t ask us t send cmmunicatins f yur PHI t yu at an address f yur chice r t ask that we cmmunicate with yu in a certain way. Fr example, yu may ask us t mail yur infrmatin t an address ther than the subscriber s address. We will accmmdate yur request if yu state that disclsure f yur PHI thrugh ur usual means culd endanger yu, if yur request is reasnable, if it specifies the alternative means r lcatin, and if it cntains infrmatin as t hw payment, if any, will be handled. Requests may be made verbally r in writing t Tufts Health Plan Netwrk Health. Right t amend PHI: Yu have the right t have us amend mst PHI we have abut yu. We may deny yur request under certain circumstances. If we deny yur request, we will send yu a written ntice f denial. This ntice will describe the reasn fr ur denial and yur right t submit a written statement disagreeing with the denial. Requests must be in writing t Tufts Health Plan Netwrk Health and must include a reasn t supprt the requested amendment. Right t receive an accunting f disclsures: Yu have the right t a written accunting f the disclsures f yur PHI that we made in the last six years prir t the date yu request the accunting. Hwever, except as therwise prvided by law, this right des nt apply t: (i) disclsures we made fr treatment, payment, r health care peratins; (ii) disclsures made t yu r peple yu have designated; (iii) disclsures yu r yur persnal representative has authrized; (iv) disclsures made befre April 14, 2003; and (v) certain ther disclsures, such as disclsures fr natinal security purpses. If yu request an accunting mre than nce in a 12-mnth perid, we may charge yu a reasnable fee. All requests fr an accunting f disclsures must be made in writing t Tufts Health Plan Netwrk Health. Right t authrize ther use and disclsure: Yu have the right t authrize any use r disclsure f PHI that is nt specified within this ntice. Fr example, we wuld need yur written authrizatin t use r disclse yur PHI fr marketing, r if we intended t sell yur PHI. Yu may revke an authrizatin at any time, in writing, except t the extent that we have taken an actin in reliance n the use r disclsure indicated in the authrizatin. Right t receive a privacy breach ntice: Yu have the right t receive written ntificatin if we discver a breach f yur unsecured PHI and determine thrugh a risk assessment that ntificatin is required. Right t this ntice: Yu have a right t receive a paper cpy f this ntice frm us upn request. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 159

161 Hw t exercise yur rights: T exercise any f the individual rights described abve r fr mre infrmatin, please call member services at (TTY: ) r write t: Tufts Health Plan Netwrk Health Attn: Cmpliance Department 101 Statin Landing, Furth Flr Medfrd, MA Effective date f ntice. This ntice takes effect Octber 1, We must fllw the privacy practices described in this ntice while it is in effect. This ntice will remain in effect until we change it. This ntice replaces any ther infrmatin yu have previusly received frm us with respect t the privacy f yur medical infrmatin. Changes t the Ntice f Privacy Practices. We may change the terms f this ntice at any time in the future and make the new ntice effective fr all PHI that we maintain, whether created r received befre r after the effective date f the new ntice. Whenever we make an imprtant change, we will publish the updated ntice n ur website at TuftsHealthUnify.rg. In additin, we will use ne f ur peridic mailings t infrm subscribers abut the updated ntice. Wh t cntact fr questins r cmplaints. If yu wuld like mre infrmatin r a paper cpy f this ntice, please cntact a member services representative at the number listed abve. Yu can als dwnlad a cpy frm ur website at TuftsHealthUnify.rg. If yu believe yur privacy rights may have been vilated, yu have a right t cmplain t Tufts Health Plan Netwrk Health by calling the Privacy Officer at r by writing t: Tufts Health Plan Netwrk Health Attn: Privacy Officer 101 Statin Landing, Furth Flr Medfrd, MA Yu als have a right t cmplain t the Secretary f Health and Human Services. We will nt retaliate against yu fr filing a cmplaint. E. Ntice abut the relatinship between Tufts Health Unify and prviders Tufts Health Unify arranges health care services. Tufts Health Unify has cntractual agreements with prviders practicing in their private ffices thrughut the service area. These prviders are independent. They are nt Tufts Health Unify emplyees r representatives. Prviders are nt authrized t change this Member Handbk r assume r create any bligatin fr Tufts Health Unify. 160

162 Chapter 12: Definitins f imprtant wrds Activities f daily living things that peple d n a nrmal day, like eating, using the tilet, getting dressed, bathing, r brushing their teeth. Advance directive a type f legal dcument, smetimes called a living will, a durable pwer f attrney fr health care, r health care prxy, with written instructins that yu create t manage yur care if yu are n lnger capable f making decisins abut yur wn health care. A living will gives instructins fr treatment in the case f life-saving r life-sustaining situatins. A health care prxy r a durable pwer f attrney fr health care lets yu chse smene specifically t make decisins fr yu if yu becme ill r incapacitated. Adverse actin an actin, r lack f actin, by Tufts Health Unify that yu can appeal. This includes: Tufts Health Unify denied r apprved a limited service yur dctr requested; Tufts Health Unify reduced, suspended, r ended cverage that we had already apprved; Tufts Health Unify did nt pay fr an item r service that yu think is a cvered service; Tufts Health Unify did nt reslve yur service authrizatin request within the required time frames; Yu culd nt get a cvered service frm a prvider in Tufts Health Unify s netwrk within a reasnable amunt f time; and Tufts Health Unify did nt act within the time frames fr reviewing a cverage decisin and giving yu a decisin. Aid paid pending getting yur benefits while yu are waiting fr an appeal decisin. This cntinued cverage is called aid paid pending. Ambulatry surgical center a facility that prvides utpatient surgical services t patients wh d nt need hspital care and wh are nt expected t need mre than 24 hurs f care in the facility. Appeal a frmal way fr yu t challenge ur decisin if yu think we made a mistake. Yu can ask us t change r reverse ur decisin by filing an appeal. Fr example, yu may ask fr an appeal if we dn t pay fr a drug, item, r service yu think yu shuld be able t receive. Chapter 9, Sectin 5.3, page 114 explains appeals, including telling yu hw t make an appeal. Appinted representative refers t smene yu give written permissin t act n yur behalf regarding a specific grievance, appeal, r external review (fair hearing). If yu are unable t pick an appinted representative, yur prvider, a guardian, cnservatr, r hlder f a pwer f attrney may be yur appinted representative. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 161

163 Tufts Health Unify Member Handbk Chapter 12: Definitins f imprtant wrds Appintment f Representative frm refers t the Centers fr Medicare & Medicaid Services (CMS) frm CMS-1696, which may be cmpleted by a member t appint a representative. Bth the member making the appintment and the representative accepting the appintment (including attrneys) must sign, date, and cmplete this frm r ther equivalent written ntice t act n the member s behalf. Balance-billing when a prvider (like a dctr r hspital) bills a patient t get mre mney after the plan pays fr services. We d nt allw prviders t balance-bill yu. Because Tufts Health Unify pays the entire cst fr yur services, yu shuld nt get any bills frm prviders. Call member services if yu get any bills that yu d nt understand. Behaviral health services treatments fr mental health and/r substance abuse. Brand-name drug a prescriptin drug that is made and sld by the cmpany that first made the drug. Brand-name drugs have the same ingredients as the generic versins f the drugs. Generic drugs are made and sld by ther drug cmpanies. Care crdinatin care crdinatin means that ur behaviral health, medical, and cmmunity service prviders and scial care managers wrk clsely with each ther, with yur primary care prvider, and with yu t crdinate the care yu need. We use care managers t make sure yu get the best pssible care and results. Care manager ne main persn wh wrks with yu, Tufts Health Unify, and yur care prviders t make sure that yu get the care yu need. Care team a team that may include dctrs, nurses, cunselrs, ther health prfessinals, and thers wh yu chse wh help yu get the care yu need. Yur care team will als help yu make an individualized care plan. Centers fr Medicare & Medicaid Services (CMS) the federal agency in charge f Medicare. Chapter 2, Sectin F, page 17 explains hw t cntact CMS. Clinical research study a clinical research study (als called a clinical trial) is a way fr dctrs t test new types f health care r drugs. They ask fr vlunteers t help with the study. This kind f study helps dctrs decide if a new kind f health care r drug wrks and if it is safe. Cmplaint r grievance a written r spken statement saying that yu have a cncern abut yur cvered services r care. This includes any cncerns abut the quality f yur care, ur netwrk prviders, r ur netwrk pharmacies. Cmprehensive utpatient rehabilitatin facility (CORF) a facility that mainly prvides rehabilitatin services after an illness, accident, r majr peratin. It prvides a variety f services, including physical therapy, scial r psychlgical services, respiratry therapy, ccupatinal therapy, speech therapy, and hme envirnment evaluatin services. Cverage decisin a decisin abut which benefits we cver. This includes decisins abut cvered drugs and services, r the amunt that we will pay fr yur health services. Chapter 9, Sectin 5.2, page 112 explains hw t ask us fr a cverage decisin. 162

164 Cvered drugs the term we use t mean all f the drugs that ur plan cvers. Cvered services the general term we use t mean all f the health care, lng-term services and supprts (LTSS), supplies, prescriptin and ver-the-cunter drugs, equipment, and ther services that ur plan cvers. Disenrllment the prcess f ending yur membership in ur plan. Disenrllment may be vluntary (yur wn chice) r invluntary (nt yur wn chice fr example, if yu are n lnger eligible fr MassHealth). Drug tier a grup f drugs f the same type (fr example, brand name generic, r ver-the-cunter drugs). Every drug n the List f Cvered Drugs is in ne f three tiers. Durable medical equipment (DME) certain items that yur dctr rders fr yur use. Walkers, wheelchairs, and hspital beds are sme examples. Emergency a medical cnditin that a prudent laypersn, with an average knwledge f health and medicine, wuld expect is s serius that if it des nt get immediate medical attentin it culd result in death, serius dysfunctin f a bdy rgan r part, r harm t the functin f a bdy part, r, with respect t a pregnant wman, place her r her unbrn child s physical r mental health in serius jepardy. Medical symptms f an emergency include severe pain, difficulty breathing, r uncntrlled bleeding. Emergency care cvered services needed t treat a medical emergency, given by a prvider trained t give emergency services. Enrllment the prcess f becming a member in ur plan. Excepted medical treatment any care that is nt vluntary and is required under federal, state, r lcal law. See als Nnexcepted medical treatment. Exceptin permissin t get cverage fr a drug that is nt nrmally cvered by ur plan r t use the drug withut certain rules and limitatins. Excluded drugs drugs nt cvered by the plan. Generic drug a prescriptin drug that is apprved by the federal gvernment t use in place f a brand-name drug. A generic drug has the same ingredients as a brand-name drug. It is usually cheaper and wrks just as well as the brand-name drug. Grievance see Cmplaint r grievance. Health plan an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care managers t help yu manage all yur prviders and services. They all wrk tgether t make sure yu get the care yu need. Health assessment a review f a patient s medical histry and current cnditin. It is used t determine the patient s health and hw it might change in the future. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 163

165 Tufts Health Unify Member Handbk Chapter 12: Definitins f imprtant wrds Hme health aide a persn wh prvides services that d nt need the skills f a licensed nurse r therapist, like help with persnal care (fr example, bathing, using the tilet, dressing, r ding the exercises that a prvider rders). Hme health aides d nt have a nursing license r prvide therapy. Hspice a prgram f care and supprt fr peple wh are terminally ill t help them live cmfrtably. A specially trained team f prfessinals and caregivers prvide care fr the whle persn, including physical, emtinal, scial, and spiritual needs. Services include nursing; medical scial services; physician; cunseling, including bereavement, dietary, spiritual, r ther types f cunseling; physical, ccupatinal, and speech language therapy; hmemaker/hme health aide; medical supplies, drugs, bilgical supplies; and shrt-term inpatient care. An enrllee wh has six mnths r less t live has the right t elect hspice. Tufts Health Unify must give yu a list f hspice prviders in yur gegraphic area. Independent-living and lng-term services and supprts (IL-LTSS) crdinatr a persn wh wrks with yu and yur care team t make sure yu get the services and supprts yu need fr independent living (als knwn as a lng-term services and supprts (LTSS) crdinatr). Independent review entity (IRE) the independent rganizatin hired by Medicare t review External (Level 2) Appeals if we dn t decide fully in favr f yur internal appeal. Individualized care plan (ICP) a plan that describes which health services yu will get and hw yu will get them. (Als knwn as a care plan.) Inpatient a term used when yu have been fficially admitted t the hspital fr skilled medical services. If yu were nt fficially admitted, yu might still be cnsidered utpatient instead f inpatient, even if yu stay in the hspital vernight. Level 1 appeal a request by a member t a plan t review an adverse actin (als called an internal appeal). Level 2 appeal an appeal sent t an independent rganizatin nt cnnected t the plan t review the plan s decisin n a level 1 appeal (the first stage in an external appeal fr a Medicare service). List f Cvered Drugs (Drug List) a list f prescriptin drugs cvered by Tufts Health Unify. We chse the drugs n this list with the help f dctrs and pharmacists. The Drug List tells yu if there are any rules yu need t fllw t get yur drugs. The Drug List is smetimes called a frmulary. Lng-term services and supprts (LTSS) assistance s that yu can stay at hme instead f ging t a nursing hme r a hspital. Maintenance drugs drugs that yu take n a regular basis fr a chrnic r lng-term medical cnditin. MassHealth the Medicaid prgram f the Cmmnwealth f Massachusetts. 164

166 MassHealth Bard f Hearings (BOH) the Bard f Hearings within the Massachusetts Executive Office f Health and Human Services (EOHHS) Office f MassHealth. Medicaid (r Medical Assistance) a prgram run by the federal and state gvernments that helps peple with limited incmes and resurces pay fr lng-term services and supprts (LTSS) and medical csts. It cvers extra services and drugs nt cvered by Medicare. Medicaid prgrams change frm state t state, but mst health care csts are cvered if yu qualify fr bth Medicare and MassHealth. See Chapter 2, Sectin G, page 18 fr infrmatin abut hw t cntact MassHealth in yur state. MassHealth is the Medicaid prgram f the Cmmnwealth f Massachusetts. Medical emergency see Emergency. Medically accepted indicatin the use f a drug is apprved by the Fd and Drug Administratin (FDA) r supprted by certain apprved reference bks. Medically necessary services that are reasnable and necessary: Fr the diagnsis and treatment f yur illness r injury; r T imprve the functining f a malfrmed bdy member; r Otherwise medically necessary under Medicare law. In accrdance with Medicaid law and regulatin, services are medically necessary if: They culd be reasnably calculated t prevent, diagnse, prevent the wrsening f, alleviate, crrect, r cure cnditins that endanger yur life, cause yu suffering r pain, cause physical defrmity r malfunctin, threaten t cause r t aggravate a disability, r result in illness r infirmity; and There is n ther medical service r place f service that is available, wrks as well, and is suitable fr yu that is less expensive. The quality f medically necessary services must meet prfessinally recgnized standards f health care, and medically necessary services must als be supprted by recrds including evidence f such medical necessity and quality. Medicare the federal health insurance prgram fr certain peple: thse wh are 65 years f age r lder, thse under age 65 with certain disabilities, and thse with end-stage renal disease (generally, this means thse with permanent kidney failure wh need dialysis r a kidney transplant). Peple with Medicare can get their Medicare health cverage thrugh Original Medicare r a managed care plan (see Health plan ). Medicare-cvered services services cvered by Medicare Part A and Part B. All Medicare health plans, including ur plan, must cver all f the services that are cvered by Medicare Part A and Part B. Medicare-MassHealth enrllee a persn wh qualifies fr bth Medicare and MassHealth cverage. A Medicare-MassHealth enrllee is als called a dual-eligible beneficiary. Medicare Part A the Medicare prgram that cvers mst medically necessary hspital, skilled nursing facility, hme health, and hspice care. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 165

167 Tufts Health Unify Member Handbk Chapter 12: Definitins f imprtant wrds Medicare Part B the Medicare prgram that cvers services (like lab tests, surgeries, and dctr visits) and supplies (like wheelchairs and walkers) that are medically necessary t treat a disease r cnditin. Medicare Part B als cvers many preventive and screening services. Medicare Part C the Medicare prgram that lets private health insurance cmpanies prvide Medicare benefits thrugh a health plan called a Medicare Advantage Plan. Medicare Part D the Medicare prescriptin drug benefit prgram. (We call this prgram Part D fr shrt.) Part D cvers utpatient prescriptin drugs, vaccines, and sme supplies nt cvered by Medicare Part A r Part B r MassHealth. Tufts Health Unify includes Medicare Part D. Medicare Part D drugs drugs that can be cvered under Medicare Part D. (See the Drug List fr cvered drugs.) Cngress specifically excluded certain categries f drugs frm cverage as Part D drugs, but MassHealth may cver sme f these drugs. Member (member f ur plan, r plan member) a persn with Medicare and MassHealth wh qualifies t get cvered services, has enrlled in ur plan, and whse enrllment has been cnfirmed by the Centers fr Medicare & Medicaid Services (CMS) and MassHealth. Member Handbk and disclsure infrmatin this dcument and certain thers: yur enrllment frm, and any ther attachments, riders, r ther ptinal-cverage-selected dcuments, which explain yur cverage, ur respnsibilities, and yur rights and respnsibilities as a member f ur plan. Member services a department within ur plan whse jb it is t answer yur questins abut yur membership, benefits, grievances, and appeals. See Chapter 2, Sectin A, page 11 fr infrmatin abut hw t cntact member services. Mdel f care a care mdel designed fr the Massachusetts dual-eligible demnstratin (the Demnstratin) t imprve the health and well-being f all enrllees and enhance access t medical, behaviral health, lng-term services and supprts, and scial services fr enrlled dual-eligible enrllees. The main gal f Tufts Health Unify s care management prgram is t achieve member wellness and self-management by ensuring that health care and related needs are met and that apprpriate interventins ccur as early as pssible. Tufts Health Unify s mdel f care is based n the fllwing cre principles and bjectives, which frm the fundatin fr measurable imprved health utcmes fr the dual-eligible ppulatin and cst savings fr the state and federal gvernments: Increasing access Imprving health utcmes thrugh hlistic care delivery Develping an interdisciplinary care team (ICT) that will allw a single pint f cntact fr the member Prviding infrmatin systems supprt and centralized enrllee recrd/care plan platfrm Managing transitins f care Fcusing n primary care Engaging and educating the member 166

168 Identifying members with cmplex needs and prviding mre intensive care management Creating affrdability with n cst sharing and n c-payments Netwrk pharmacy a pharmacy (drug stre) that has agreed t fill prescriptins fr ur plan members. We call them netwrk pharmacies because they have agreed t wrk with ur plan. In mst cases, yur prescriptins are cvered nly if they are filled at ne f ur netwrk pharmacies. Netwrk prvider prvider is the general term that we use fr dctrs, nurses, and thers wh give yu health care services and care. The term als includes hspitals, hme health agencies, clinics, and ther places that give yu health care services, medical equipment, and lng-term services and supprts (LTSS). They are licensed r certified by Medicare and by the state t prvide health care services. We call them netwrk prviders when they agree t wrk with the health plan and accept ur payment and nt charge ur members an extra amunt. While yu are a member f ur plan, yu must use netwrk prviders t get cvered services. Netwrk prviders are als called plan prviders. Nnexcepted medical treatment any care that is vluntary and nt required by any federal, state, r lcal law. See als Excepted medical treatment. Nursing hme r facility a place that prvides care fr peple wh cannt get their care at hme but wh d nt need t be in the hspital. Ombudsman a persn r rganizatin in yur state that helps yu if yu are having prblems with ur plan. The mbudsman s services are free. Organizatin determinatin a decisin by a plan, r ne f its prviders, abut whether services are cvered, r hw much yu have t pay fr cvered services. Organizatin determinatins are called cverage decisins in this handbk. Chapter 9 explains hw t ask us fr a cverage decisin. Original Medicare (traditinal Medicare r fee-fr-service Medicare) Medicare ffered by the gvernment. Under Original Medicare, Medicare pays dctrs, hspitals, and ther health care prviders. These payment amunts are set by Cngress. Yu can g t any dctr, hspital, r ther health care prvider that accepts Medicare. Original Medicare has tw parts: Part A (hspital insurance) and Part B (medical insurance). Original Medicare is available everywhere in the United States. If yu d nt want t be in ur plan, yu can chse Original Medicare. Out-f-netwrk pharmacy a pharmacy that has nt agreed t wrk with ur plan t prvide cvered drugs t members f ur plan. Mst drugs yu get frm ut-f-netwrk pharmacies are nt cvered by ur plan, unless certain cnditins are met. Out-f-netwrk prvider r Out-f-netwrk facility a prvider r facility that is nt emplyed, wned, r perated by ur plan and has nt agreed t wrk with us t prvide cvered services t members f ur plan. Chapter 3, Sectin D, page 24 explains ut-f-netwrk prviders r facilities. Persnal health infrmatin (als called prtected health infrmatin) (PHI) infrmatin abut yu and yur health, such as yur name, address, scial security number, physician If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 167

169 Tufts Health Unify Member Handbk Chapter 12: Definitins f imprtant wrds visits, and medical histry. See Tufts Health Unify s Ntice f Privacy Practices fr mre infrmatin abut hw Tufts Health Unify prtects, uses, and disclses yur PHI, as well as yur rights with respect t yur PHI. Plan benefit care that is included in the plan s Benefits Charts (the charts are in Chapter 4, Sectin D, page 40 f this handbk). Pst-stabilizatin care services that help yu get better and stay healthy after an emergency health cnditin. Yu can get pst-stabilizatin care services at hspitals and all health care centers that prvide emergency services. Primary care prvider (PCP) yur PCP is the dctr r ther prvider that yu see first fr mst health prblems. He r she makes sure yu get the care yu need t stay healthy. He r she will wrk with yur care team. He r she als may talk with ther dctrs and health care prviders abut yur care and may refer yu t them. See Chapter 3, Sectin D, page 24 fr infrmatin abut getting care frm PCPs. See als, prvider. Primary care prvider (PCP) referral a written ntificatin frm yur PCP t us that yu can get care frm a different prvider. The PCP referral helps yur PCP better guide the care and services yu get frm the prviders yu see. Prir authrizatin (permissin) apprval needed befre yu can get certain services r drugs. Sme netwrk medical services are cvered nly if yur dctr r ther netwrk prvider gets prir authrizatin frm ur plan. Cvered services that need prir authrizatin are marked in the Benefits Charts in Chapter 4, Sectin D, page 40. Sme drugs are cvered nly if yu get prir authrizatin frm us. Cvered drugs that need prir authrizatin are marked in the List f Cvered Drugs. Prvider a dctr, nurse, behaviral health specialist, r ther persn wh gives yu services and care. The term prvider als includes hspitals, hme health agencies, clinics, and ther places that give yu health care services, medical equipment, and lng-term services and supprts (LTSS). Quality imprvement rganizatin (QIO) a grup f dctrs and ther health care experts wh help imprve the quality f care fr peple with Medicare. They are paid by the federal gvernment t check n and imprve the care given t patients. See Chapter 2, Sectin H, page 18 fr infrmatin abut hw t cntact the QIO fr yur state. Quantity limits a limit n the amunt f a drug yu can have. There may be limits n the amunt f the drug that we cver fr each prescriptin r n hw many refills yu can get. Rehabilitatin services treatment yu get t help yu recver frm an illness, accident, r majr peratin, including physical therapy, speech and language therapy, and ccupatinal therapy. See Chapter 4, Sectin D, page 40 t learn mre abut rehabilitatin services. Referral authrizatin (permissin) befre yu can use ther prviders in the plan s netwrk. 168

170 Secnd pinin a cnsultatin yu can get n a medical prcedure frm a netwrk prvider. Yur primary care prvider will refer yu t a cntracted netwrk prvider fr a secnd pinin. We must give prir authrizatin when yur prvider wants yu t get a secnd pinin frm a prvider wh is nt part f the Tufts Health Unify prvider netwrk. Tufts Health Unify will pay fr any csts related t yur getting a secnd pinin frm a cntracted netwrk prvider r, with prir authrizatin, frm a prvider wh is nt part f the Tufts Health Unify prvider netwrk. Service area a specific area cvered by a health plan (sme health plans accept members nly if they live in a certain area). Fr plans that limit which dctrs and hspitals yu may use, it is als generally the area where yu can get rutine (nnemergency) services. The plan may disenrll yu if yu mve ut f the plan s service area. Skilled nursing facility (SNF) a nursing facility with the staff and equipment t give skilled nursing care and, in mst cases, skilled rehabilitatin services and ther related health services. Skilled nursing facility (SNF) care skilled nursing care and rehabilitatin services prvided n a cntinuus, daily basis in a skilled nursing facility. Examples f SNF care include physical therapy r intravenus (IV) injectins that a registered nurse r a dctr can give. Specialist a dctr wh prvides health care fr a specific disease r part f the bdy. Step therapy a cverage rule that requires yu t first try anther drug befre we will cver the drug yu are asking fr. Subrgatin a prcess f substituting ne creditr fr anther, which applies if yu have a legal right t payment frm an individual r rganizatin because anther party was respnsible fr yur illness r injury. We may use this subrgatin right, with r withut yur cnsent, t recver frm the respnsible party r that party s insurer the cst f services prvided r expenses incurred by us that are related t yur illness r injury. Supplemental Security Incme (SSI) a mnthly benefit paid by Scial Security t peple with limited incmes and resurces wh are disabled, blind, r age 65 and lder. SSI benefits are nt the same as Scial Security benefits. Urgent care includes services that are nt emergency r rutine primary care but which yu will need prmptly t help yu get better. Urgently needed care care yu get fr a sudden illness, injury, r cnditin that is nt an emergency but needs care right away. Yu can get urgently needed care frm ut-f-netwrk prviders when netwrk prviders are unavailable r yu cannt get t them. If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 169

171 Multi-language Interpreter Services English: We have free interpreter services t answer any questins yu may have abut ur health r drug plan. T get an interpreter, just call us at Smene wh speaks English can help yu. This is a free service. Spanish: Tenems servicis de intérprete sin cst algun para respnder cualquier pregunta que pueda tener sbre nuestr plan de salud medicaments. Para hablar cn un intérprete, pr favr llame al Alguien que hable españl le pdrá ayudar. Este es un servici gratuit. Chinese Mandarin: Chinese Cantnese: Tagalg: Mayrn kaming libreng serbisy sa pagsasaling-wika upang masagt ang anumang mga katanungan niny hinggil sa aming planng pangkalusugan panggamt. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayng tulungan ng isang nakakapagsalita ng Tagalg. It ay libreng serbisy. French: Nus prpsns des services gratuits d'interprétatin pur répndre à tutes vs questins relatives à ntre régime de santé u d'assurance-médicaments. Pur accéder au service d'interprétatin, il vus suffit de nus appeler au Un interlcuteur parlant Français purra vus aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kstenlser Dlmetscherservice beantwrtet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dlmetscher erreichen Sie unter Man wird Ihnen drt auf Deutsch weiterhelfen. Dieser Service ist kstenls. Krean: Russian: Arabic: H7419_4465 CMS Accepted

172 Multi-language Interpreter Services Italian: È dispnibile un servizi di interpretariat gratuit per rispndere a eventuali dmande sul nstr pian sanitari e farmaceutic. Per un interprete, cntattare il numer Un nstr incaricat che parla Italianvi frnirà l'assistenza necessaria. È un servizi gratuit. Prtugués: Dispms de serviçs de interpretaçã gratuits para respnder a qualquer questã que tenha acerca d nss plan de saúde u de medicaçã. Para bter um intérprete, cntacte-ns através d númer Irá encntrar alguém que fale idima Prtuguês para ajudar. Este serviç é gratuit. French Crele: Nu genyen sèvis entèprèt gratis pu repnn tut kesyn u ta genyen knsènan plan medikal swa dwòg nu an. Pu jwenn yn entèprèt, jis rele nu nan Yn mun ki pale Kreyòl kapab ede w. Sa a se yn sèvis ki gratis. Plish: Umżliwiamy bezpłatne skrzystanie z usług tłumacza ustneg, który pmże w uzyskaniu dpwiedzi na temat planu zdrwtneg lub dawkwania leków. Aby skrzystać z pmcy tłumacza znająceg język plski, należy zadzwnić pd numer Ta usługa jest bezpłatna. Japanese: Latian: Cambdian:

173 If yu have questins, please call Tufts Health Unify at (TTY: ), seven days a week, frm 8 a.m. t 8 p.m. The call is free. Fr mre infrmatin, visit TuftsHealthUnify.rg. 4818A 11134