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 membersupprt@mahealth.net 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 help@necarembuds.rg 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