Tufts Health Extend. Member Handbook

Transcription

1 2014 Tufts Health Extend Member Handbook This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. Please see page 6 for additional information. Effective Date: October 2014 Issue Date: October 2014

2 Welcome! A great health plan at a great price With Tufts Health Plan Network Health, you get more from your health plan. Since 1997, we have partnered with a Network of Primary Care Providers (PCPs), Hospitals, and other Providers across Massachusetts to bring our Members access to highquality health care. By joining Tufts Health Extend you have access to thousands of great doctors and Specialists across the state, friendly and helpful Member Services Team representatives, and great service. We want you to get the most out of your membership. To help you understand what you need to know about your health plan, we have capitalized important words and terms throughout this Member Handbook. You will find definitions for each of these terms starting on page 40. Keep this handbook it has all the information you need to make the most of your Tufts Health Extend membership. Contact us: (TTY: , for people with partial or total hearing loss) Mail: 101 Station Landing, Fourth Floor, Medford, MA Translation services are available in 200 languages. Website: Network-Health.org Tufts Health Extend Member website: Network-Health.org/Extend Tufts Health Plan Network Health s Member Services Team hours: A Member Services Team representative can help you with any questions you may have. Call us at , Monday through Friday, from 8 a.m. to 5 p.m. 24/7 NurseLine: Talk to a caring and supportive health professional 24 hours a day, seven days a week, at no cost about any medical and behavioral health (mental health and/or substance abuse) issues and questions. 888-MY-RN-LINE ( ) TTY: Visit us on the web! Visit Network-Health.org to: Find a Primary Care Provider (PCP), Specialist, or health center near you Find a Behavioral Health Provider near you Order your free Tufts Health Extend EXTRAS Sign up for Network Health Member Connect, our online self-service tool, and: Choose or change your PCP Check if your PCP or other doctor needs to get Prior Authorization before you get a service Check the status of a Prior Authorization Order a new Tufts Health Plan Network Health Member ID Card Update your contact information 2014 Tufts Health Public Plans, Inc. Get important information, such as: How you can file a Grievance or request an Appeal How you have the right to request an External Review if we deny an Appeal, as well as your other rights and responsibilities How we make sure you get the best care possible (Quality Management and Improvement Program) How we make sure you get the right care in the right place (Utilization Management). Note: We never reward our staff for denying care. How we use information your Providers give us to decide what services you need to make you better or keep you healthy (Utilization Review) How we may collect, use, and release information about you and your health your Protected Health Information (PHI) according to our privacy policy And much more! Your Dependents Your family, including children up to age 26 or disabled children regardless of age, may also qualify for health insurance coverage under the plan. Call us at for more information. You can also call the Health Connector for plan-related questions at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. If you move If you move or change your phone number, don t forget to update your contact information. You must call the Health Connector and us to update your address and phone number in order to ensure you continue to receive your benefits. You should also put the last names of all Tufts Health Extend Members in your household on your mailbox. The post office may not deliver mail from the Health Connector or us to someone whose name is not listed on the mailbox. To update your contact information, please call: The Health Connector at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m., and Tufts Health Plan Network Health at (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. Also, let the Health Connector know about any changes in your income, family size, employment status, and disability status, if you become pregnant, or if you have additional health insurance. Translation services If you have questions, need this document translated, need someone to read this or other printed information to you, or want to learn more about any of our free EXTRAS or Covered Services, call us at , Monday through Friday, from 8 a.m. to 5 p.m. We offer translation services in 200 languages. All translation services are free to Members. Members with partial or total hearing loss should call our TTY line at for help.

3 Table of contents Your Evidence of Coverage 6 Minimum creditable coverage and mandatory health insurance requirement Your Member ID Card 6 Getting the care you need 6 Service Area information Access to Covered Services In an Emergency Post-stabilization Care Services Urgent Care situations Hospital services When you re away from home Tufts Health Plan Network Health Providers 9 Your Primary Care Provider (PCP) Specialists Seeing an Out-of-network provider Communication between Providers Getting a second opinion 11 Continuity of Care 11 New Members Existing Members Prior Authorization 12 Standard Prior Authorizations Concurrent review Prior Authorization approvals and denials Adverse Determination Premiums 13 Co-payments 13 Medical Co-payments Pharmacy Co-payments Covered Services 14 Services we cover If you get a bill for a Covered Service Services not covered Covered medications and pharmacy 19 Pharmacy program Step therapy program Specialty pharmacy program Quality Management 21 Utilization Management 21 Experimental and/or investigational drugs and procedures

4 Care Management 22 Health and wellness support Disease management programs Care coordination Integrated care management Tufts Health Extend EXTRAS 26 FREE rewards for healthy behaviors FREE Weight Watchers registration (plus $50 back on program costs) Acupuncture reimbursement Fitness reimbursement FREE rewards that keep your family safe FREE rewards and help with your health care needs Coverage 30 Effective Coverage Date Disenrollment Protecting your benefits 31 Your rights 31 Advance Directives Your rights for privacy practices Additional information available to you Your responsibilities 33 How to resolve concerns with Tufts Health Plan Network Health 33 When you have additional insurance 37 Coordination of Benefits Subrogation Motor vehicle accidents and/or work-related injury/illness Member cooperation Our responsibilities 38 Notice of Privacy Policy Multicultural Health Care Privacy Protection Policy Glossary 40 Benefit and Co-payment Summaries 45 Plan Type I Plan Type II Plan Type III A great health plan at a great price Keep this handbook it has all the information you need to make the most of your Tufts Health Extend membership. If you have any questions, please call us at Members with partial or total hearing loss should call our TTY line at for assistance.

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6 Your Evidence of Coverage This Member Handbook, the Benefit and Co-payment Summary for each Plan Type at the end of this handbook, your Preferred Drug List, and any amendments we may send you make up your Evidence of Coverage. These documents are a contract between you and us. By signing and returning your enrollment application to the Health Connector, and having Tufts Health Extend as your health plan, you applied for coverage from us. You also agree to all the terms and conditions the Health Connector sets forth and to the terms and conditions of this handbook. This handbook explains your rights, benefits, and responsibilities as a Tufts Health Extend Member. It also explains our responsibilities to you. If there are any major plan changes, we ll notify you by mail 60 days before the changes go into effect. Only an authorized officer of Tufts Health Plan Network Health can change this Member Handbook, and only in writing. No other action, including any exception we make on a case-by-case basis, changes this Member Handbook. Minimum creditable coverage and mandatory health insurance requirement The Massachusetts Health Care Reform Law requires that Massachusetts residents, 18 years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards that the Health Connector sets, unless waived from the health insurance requirement based on affordability or individual hardship. For more information, call the Health Connector at 877-MA-ENROLL ( ) or visit the Health Connector s website at MAhealthconnector.org. This health plan meets Minimum Creditable Coverage standards as part of the Massachusetts Health Care Reform Law. If you enroll in this plan, you will satisfy the statutory requirement that you have health insurance meeting these standards. Your Member ID Card Each person in your family with Tufts Health Extend will get a Tufts Health Extend Member ID Card. Your Member ID Card has important information about you and your benefits and also tells Providers and pharmacists that you are a Member of Tufts Health Extend. When you get the card(s), please check the information carefully to make sure all of it is correct. If you have any questions or concerns about your Member ID Card, if you lose it, or if you never receive it, call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m. Getting the care you need Service Area information Tufts Health Plan Network Health has developed a Network of Providers to make sure you get access to Covered Services. We serve Tufts Health Extend Members in most counties in the state of Massachusetts. For a complete listing of our Providers, please visit Network-Health.org. For more information about where we offer Tufts Health Extend, call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m. Access to Covered Services Access to Covered Services is how fast you should be able to get the care you need. Nonurgent Symptomatic Care is care you get when you re sick or hurt. Nonsymptomatic Care, also called Preventive Care, is care you get when you re well. Your Providers must give you the care you ask for within the following time frames: THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS. 6 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

7 Medical services Emergency care: Immediately Urgent Care: Within 48 hours of your asking for an appointment Primary Care: Nonurgent Symptomatic Care: Within 10 Days of your asking for an appointment Routine, Nonsymptomatic Care: Within 45 Days of your asking for an appointment Specialty care: Nonurgent Symptomatic Care: Within 30 Days of your asking for an appointment Routine, Nonsymptomatic Care: Within 60 Days of your asking for an appointment Behavioral Health (mental health and/or substance abuse) services Emergency care: Immediately Urgent Care: Within 48 hours of your asking for an appointment Emergency Services Program (ESP): Immediately Other services: Within 14 calendar days of your asking for an appointment If you re having any difficulty getting an appointment with or seeing your Provider, please call us at , Monday through Friday, from 8 a.m. to 5 p.m. In an Emergency An Emergency is when you believe your life or health is in danger or would be if you don t get immediate care. If you believe that you are in a medical emergency situation, take immediate action: Call 911 or go to the nearest emergency room right away. For Behavioral Health Emergencies, call 911 or your local Emergency Services Program (ESP) Provider, or go to the nearest emergency room right away. ESPs provide behavioral health crisis assessment, intervention, and stabilization services 24 hours a day, seven days a week, 365 days a year. Please call us at or use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org for a complete list of emergency rooms in Massachusetts. To find the closest ESP Provider to you, call the statewide directory of behavioral health ESPs in Massachusetts at Make sure to: Bring your Tufts Health Extend Member ID Card with you Tell your Primary Care Provider (PCP) and, if applicable, your Behavioral Health Provider about your Emergency within 48 hours in order to get any necessary follow-up care You don t need approval from your Provider to get emergency care. You can get emergency care 24 hours a day, seven days a week, wherever you are, even when you re traveling. We also cover emergency-related ambulance transportation and Post-stabilization Care Services, which are care to help you get better after an Emergency. A Provider will examine and treat your emergency health needs before sending you home or moving you to another Hospital, if necessary. Examples of medical Emergencies: Chest pain Bleeding that won t stop Broken bones Seizures or convulsions Dizziness or fainting Poisoning or drug overdose Serious accidents Sudden confusion Severe burns Severe headaches Shortness of breath Vomiting that won t stop Examples of Behavioral Health (mental health and/or substance abuse) Emergencies: Violent feelings toward yourself or others Hallucinations For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 7

8 Post-stabilization Care Services Post-stabilization Care Services include Inpatient Services, additional tests, or outpatient care that help you get better and maintain your health after an Emergency. Tufts Health Extend Members can get Post-stabilization Care Services at Hospitals and all health care centers that provide emergency services. Please call or use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org for a complete list of emergency rooms in Massachusetts and ESP Providers in Massachusetts. You can also call the statewide directory of behavioral health ESPs at to find the closest ESP to you. Urgent Care situations An Urgent Care situation is when you have a health problem that needs attention right away but you don t believe you re having an Emergency. You may experience a health problem that is serious but doesn t put your life in danger or risk permanent damage to your health. Examples would be when you have flu-like symptoms that are getting worse or when you have a cough or cold that is not getting better. Your PCP or, if applicable, your Behavioral Health Provider can usually address these health problems. In urgent situations, call your PCP or Behavioral Health Provider. You can contact any of your Providers offices 24 hours a day, seven days a week. If appropriate, make an appointment to visit your Provider. Your Provider must see you within 48 hours of your request for an Urgent Care appointment. If your condition gets worse before your PCP or Behavioral Health Provider sees you, call 911 or go to the emergency room. If you have a behavioral health concern, you may also call your local ESP Provider. Hospital services If you need hospital services for something that isn t an Emergency, please ask your Provider to help you get these services. If you need hospital services for an Emergency, don t wait. Call 911 or go to the nearest emergency room right away. For Behavioral Health Emergencies, call 911 or your local Emergency Services Program (ESP) Provider, or go to the nearest emergency room right away. When you re away from home If you re traveling and need emergency care, go to the nearest emergency room. If you need Urgent Care, call your PCP s office and follow your Provider s directions. For other routine health care issues, call your PCP. For routine behavioral health issues, call your Behavioral Health Provider. If you re outside of Tufts Health Plan Network Health s Service Area, we ll only cover emergency care, Post-stabilization Care Services, or Urgent Care. We won t cover: Nonemergency tests or treatment that your PCP asked for but that you decided to get outside of our Service Area Routine or follow-up care that can wait until you return to our Service Area, such as physical exams, flu shots, stitch removal, and Behavioral Health counseling Care that you knew you were going to get before you left our Service Area, such as elective surgery A Provider may ask you to pay for care you get outside of Tufts Health Plan Network Health s Service Area at the time of service. If you re asked to pay for emergency care, Post-stabilization Care Services, or Urgent Care that you get outside of our Service Area, you should show your Tufts Health Extend Member ID Card. The Provider shouldn t ask you to pay. If you do pay for any of these services, you may ask us to reimburse you. You may also call our Member Services Team at for help with any bills that you may get from a Provider. Note: Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. 8 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

9 Tufts Health Plan Network Health Providers For the most up-to-date information about Providers, such as a Provider s address, phone number, hours of operation, handicap accessibility, and languages spoken, visit our website at Network-Health.org and use the Find a Doctor, Hospital, or Pharmacy tool. We list the following types of Providers: Primary care sites Primary Care Providers (PCPs) Hospitals Specialty Providers Behavioral Health (mental health and/or substance abuse)providers The listing also includes all Tufts Health Extend pharmacies, facilities, ancillary Providers, hospital emergency services, ESP Providers for Behavioral Health, and Durable Medical Equipment suppliers. You can also call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m., to get this information. Other types of information we can give you include information about a Provider s professional qualifications, the names of any medical or professional school(s) attended, where a residency or training took place, malpractice information, and, for doctors, their board certification status. Your Primary Care Provider (PCP) A PCP is the Provider who manages your care. You can choose a doctor or a nurse practitioner as your PCP. As a Tufts Health Extend Member, you and your Dependents must have a PCP. You can choose a different PCP for each Member. To find a Tufts Health Extend PCP and to find out where the PCP s office is located, use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org. You can also call us at to help you find a PCP. Your PCP is the Provider you should call for any kind of health care need, unless you re having an Emergency. You can call your PCP s office 24 hours a day, seven days a week. If your PCP is not available, somebody else will be able to help you. If you have problems contacting your Provider or if you have any questions, please call our Member Services Team, Monday through Friday, from 8 a.m. to 5 p.m. We re also available 24 hours a day, seven days a week, for medical and behavioral health issues and questions at Your PCP can: Give you regular checkups and health screenings, including Behavioral Health screenings Make sure you get the health care you need Arrange necessary tests, laboratory procedures, or hospital visits Keep your medical records Recommend Specialists, when necessary Provide information on Covered Services that need Prior Authorization (permission) or Referrals before you get treatment Write prescriptions, when necessary Help you get Behavioral Health services, when necessary PCP assignment If you don t choose a PCP within 15 Days of joining Tufts Health Plan Network Health, we ll choose one we think is right for you. We ll also choose a PCP for you if the PCP you chose is not available. We ll send you a letter letting you know the name and contact information of the PCP that we have on file for you and any of your Dependents. Changing your PCP You can switch your PCP up to two times during a Benefit Year (July 1 December 31) for any reason. Just call us at or visit Network-Health.org. Once you change your PCP, you will get a PCP confirmation notice from us verifying the change was made. Getting care after office hours Talk to your PCP to find out about getting care after normal business hours. Some PCPs have longer office hours. If you need Urgent Care after regular business hours, call your PCP s office. PCPs have covering Providers who work after hours. If you have any problems seeing your PCP or any other Provider, please call us at , Monday through Friday, from 8 a.m. to 5 p.m. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 9

10 You can also get free health support from our 24/7 NurseLine to help you stay healthy 24 hours a day, seven days a week. Call 888-MY-RN-LINE ( ), TTY: , anytime. You can get help in many languages. Remember, the 24/7 NurseLine doesn t replace your PCP. Specialists Specialists are Providers who have extra training and who focus on one kind of care or on one part of the body. Sometimes you may need to visit a Specialist, such as a cardiologist (heart doctor), dermatologist (skin doctor), or ophthalmologist (eye doctor), or, for Behavioral Health services, a psychologist, psychiatrist, or social worker. You can visit most Specialists without Prior Authorization as long as the Specialist is a Preferred In-network Specialist (although you may still need a referral from your PCP see the following section). To find a Tufts Health Extend Specialist, talk to your PCP. You can also call or visit Network-Health.org and use the Find a Doctor, Hospital, or Pharmacy tool to search for a Specialist. You should discuss your need to see a Specialist with your PCP first and then call the Specialist to make an appointment. If the Specialist your PCP wants to send you to is a Nonpreferred In-network Specialist or an Out-of-network Specialist, your PCP will need to ask us for Prior Authorization before sending you to see this Specialist. We may approve your PCP s request, deny the request, or ask your PCP to make a different Prior Authorization request. By using the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org, you can check to see which Providers need Prior Authorization, or you can call us at to get this information. Remember, if we don t give written approval for you to see a Nonpreferred In-network or Out-of-network Specialist, we won t cover the services. If you still choose to get the services, you ll be responsible for payment. For more information about Prior Authorization, please see page 12 in this Member Handbook. Referrals for specialty services Some Tufts Health Extend Members may need their PCPs to give them a Referral for certain specialty services. A Referral is a notification from your PCP to us that you can get care from a different Provider. A Referral is different from a Prior Authorization because it does not require our approval. The Referral helps your PCP better guide the care and services you get from the doctors you see. These services include: Professional services, like a visit to a Specialist Outpatient hospital visits Surgical day care Your first evaluation for: Speech Therapy Occupational therapy Physical therapy If your PCP needs to give a Referral for these services, your Member ID Card will say PCP Referral Required. You should not be billed for any of these services if you get them from an In-network Provider. You won t need PCP Referrals for any outpatient Behavioral Health, emergency care services, Post-stabilization Care Services, Tufts Health Extend contracted Family-planning Services Provider, or any OB/GYN services. Seeing an Out-of-network provider Your Provider must ask us for and get Prior Authorization before you see an Out-of-network provider. You may ask your Provider to ask for the Prior Authorization or call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m. You can see an Out-of-network provider if: A participating In-network Provider is unavailable because of location A delay in seeing a participating In-network Provider, other than a member-related delay, would result in interrupted access to Medically Necessary services There isn t a participating In-network Provider with the qualifications and expertise that you need to get and stay better 10 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

11 Note: Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. Communication between Providers It s a good idea for Providers to share information about your care with other Providers. When more than one Provider is involved in your care, the sharing helps them communicate and coordinate the services that you get, which leads to better quality of care. You must give Providers permission to share your information. Your doctor or therapist can talk with you more about which Provider(s) should receive the information, and answer any questions you have before getting your permission. Getting a second opinion Tufts Health Extend Members can get a second opinion from a different Provider about a medical or behavioral health (mental health and/or substance abuse)condition, or proposed treatment and care plan. You can get a second opinion about a medical issue or concern from an In-network Provider without Prior Authorization. If you want to get a second opinion about a behavioral health issue or concern, we may need to give Prior Authorization. You can see the most up-to-date list of our In-network Providers at Network-Health.org. Please call us at for help or for more information about picking a Provider to see for the second opinion. Continuity of Care New Members* If you are a new Tufts Health Plan Network Health Member, we ll make sure any care you are currently getting continues to go as smoothly as possible. To ensure Continuity of Care, we may be able to cover some health services, including Behavioral Health (mental health and/or substance abuse) services, from a provider who isn t part of our Network. If: You are in the second or third trimester of your pregnancy, you can keep seeing your current OB/GYN (even if Out-of-network) through delivery and a follow-up checkup within six weeks of delivery. Your second trimester begins at the start of the fourth month of pregnancy based on your expected delivery date You are getting ongoing covered treatment or management of chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or Covered Services, you can continue to get care for up to 30 days You are seeing your Primary Care Provider (PCP), you can continue to get care for up to 30 days You are terminally ill, you can continue to get care while you are sick Existing Members* If your PCP or another Provider is disenrolled from our Network for reasons not related to quality of care or Fraud, we ll make every effort to tell you at least 30 Days before the disenrollment, and we may be able to provide coverage. If: Your Provider is your PCP, for up to 31 Days; or up to 90 if the Provider, including a PCP, is actively treating a chronic or acute medical condition or until that Provider completes the active treatment, whichever comes first You are in the second or third trimester of your pregnancy, you can keep seeing your current OB/GYN (even if Out-of-network) through delivery and a follow-up checkup within six weeks of delivery. Your second trimester begins at the start of the fourth month of pregnancy based on your expected delivery date. You are terminally ill, you can continue to get care while you are sick * We will allow you to get continued treatment by an Out-of-network provider only if the provider agrees to our terms related to reimbursement, quality, Referrals, and additional Tufts Health Extend policies and procedures. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 11

12 Prior Authorization Your Primary Care Provider (PCP) will work with your other Providers to make sure you get the care you need. For certain services, your PCP will need to ask us for Prior Authorization before sending you to get those services. For more information about which services need Prior Authorization, please see your Plan Type s Benefit and Co-payment Summary section starting on page 45 of this Member Handbook. Preferred In-network Providers are Providers you can see without your PCP or other Providers asking for Prior Authorization. Nonpreferred In-network Providers and Out-ofnetwork providers need Prior Authorization from us before you can see them. Your PCP will ask us for Prior Authorization when you need a service or need to get care from a Provider or at a location that requires prior approval. For these requests, we ll decide if the service is Medically Necessary and if we have a qualified In-network Provider who can provide the service instead. If we don t have an In-network Provider who can treat your health condition, we ll authorize an Out-of-network provider for you. For the most up-to-date listing of our In-network Providers, visit Network-Health.org. You don t need Prior Authorization for emergency health care, Post-stabilization Care Services, Family-planning Services, and the first 12 in-network outpatient Behavioral Health (mental health and/or substance abuse) or medical specialty (e.g., orthopedist, neurologist, oncologist) visits. You can get emergency services from any emergency care provider and Family-planning Services from any Tufts Health Extend-contracted Family-planning Services Provider. If you become a Tufts Health Plan Network Health Member by changing from another health plan, and you had already begun treatment (such as ongoing maternity care) with a provider who does not contract with us, we ll review that treatment and may approve your continued treatment by the same provider. Please see the section Continuity of Care earlier on page 11. Note: Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. Standard Prior Authorizations We ll make an initial decision about a Prior Authorization within two business days of obtaining all needed information. We ll let your Provider requesting the services know within 24 hours of our decision. We ll let you know in writing of our decision within one business day if we deny Authorization, and within two business days if we approve Authorization. If we don t give Prior Authorization before you see a Provider or have a procedure that requires one, you may be responsible for paying for the services you get. Concurrent review A concurrent review is a review we do when you re in a Hospital, during an inpatient stay or while you re getting treated, to decide what you should do next. We make concurrent review decisions within one business day of getting all necessary information from your Provider. Necessary information includes the results of any face-to-face clinical evaluation or second opinion. If we approve a longer stay or extra services, we ll let your Provider know within one business day and send written or electronic confirmation to you and your Provider within one business day thereafter. The notification will include the number of extended calendar days or the next review date, the new total number of calendar days or services we ve approved, and the date of admission or start of services. If we deny a longer stay or additional services, we ll let your Provider know within one business day and send written or electronic confirmation of this Adverse Determination to you and your Provider within one business day thereafter. You can continue getting the service at no cost to you until we let you know of our concurrent review decision. 12 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

13 Prior Authorization approvals and denials Once we review the request for services, we ll tell your Provider and/or you or your Authorized Representative, if you identify one, our decision. If we authorize the services, we ll send your Provider an authorization letter that will state the services we agree to cover. The Provider giving the services must have this authorization letter before you can get any services requiring an Authorization. Your Provider will ask us for additional Authorization if you need any services beyond what we authorized. If we approve the request for additional services, we ll send your Provider another authorization letter. If we don t authorize any of the services requested, authorize only some of the services requested, or don t authorize the full amount, duration, or scope of services requested, we ll send you, your Authorized Representative, and your Provider a denial letter. We won t pay for any unauthorized services. We ll also send you, your Authorized Representative, and your Provider a notice if we decide to reduce, put off, or stop providing previously authorized services. If you disagree with any of these decisions, you can request a Standard Internal Appeal. For details on requesting a Standard Internal Appeal, please see the How to resolve concerns with Tufts Health Plan Network Health section on page 33. Adverse Determination An Adverse Determination is when we decide not to authorize a service. Written notice of an Adverse Determination We ll tell you in writing of an Adverse Determination and include a clinical explanation for our decision. We will: Identify specific information we used Discuss your symptoms or condition, diagnosis, and the specific reasons why the evidence your Provider sent us fails to meet the relevant medical review criteria Specify alternate treatment options that we do cover Reference and include applicable clinical practice guidelines and review criteria Tell you or your Authorized Representative how to request a Standard Internal Appeal or an Expedited Internal Appeal Reconsideration of an Adverse Determination We ll give the Provider treating you the chance to ask us to reconsider an Adverse Determination involving an initial determination or a concurrent review. The reconsideration process will occur within one business day of our getting the request. A clinical reviewer will conduct the reconsideration and talk to your Provider. If we don t reverse our Adverse Determination, you or your Authorized Representative or your Provider may use the appeals process described starting on page 34. You don t have to ask us to reconsider an Adverse Determination before requesting a Standard Internal Appeal or Expedited Internal Appeal. Premiums Some Tufts Health Extend Plan Types require you to pay a Premium for you and any of your Dependents health insurance coverage. A Premium is a weekly amount you pay the Health Connector to get your plan benefits. This amount is deducted directly from your weekly unemployment benefit check for you and any of your Dependents. If the Premium isn t deducted directly from your check, then the Health Connector will invoice you for the amount owed. We are not responsible for paying the Health Connector any Premiums that you owe. Please note, children 19 years of age and under, disabled individuals, and pregnant women are exempt from paying Premiums. You may apply for a hardship waiver if you can t afford to pay your share of the premium amount. To qualify for this waiver, you must meet certain income requirements. To learn more, contact the Health Connector at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. Co-payments You re responsible for paying all of the Co-payments listed in your Plan Type s Benefit and Co-payment Summary starting on page 45 of this Member Handbook. If you can t afford the Co-payment when you get a service, tell your Provider. You should never go without care you need because you can t afford the Co-payment. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 13

14 If you don t pay the Co-payment at the time of your visit, you ll still owe the money to the Provider. The Provider may use a legal method to collect the money from you. We are not responsible for paying the Provider the Co-payment that you owe. American Indians and Alaskan Natives do not need to pay Co-payments for services received through the Indian Health Service. American Indians and Alaskan Natives who make less than 300% of the Federal Poverty Level never pay Co-payments regardless of where a service is received. Medical Co-payments (Plan Type II and III Members only) A Medical Co-payment is a fixed amount you may have to pay for Covered Services other than pharmacy services. You will need to pay a Co-payment for Covered Services, such as doctors visits, high-cost imaging (MRIs, PET, CT scans), emergency room visits, and care you get in the Hospital. These services that require Co-payments count toward your yearly Medical Co-payment Cap. Once you ve been charged the maximum in Medical Co-payments in a Benefit Year (January 1 December 31), you no longer have to pay Medical Co-payments until the next Benefit Year. This is called a Medical Co-payment Cap. We ll send you a letter telling you that you reached your Medical Co-payment Cap and that you don t have to pay any more Medical Co-payments until the beginning of the next Benefit Year. Co-payment Caps are listed in your Plan Type s Benefit and Co-payment Summary starting on page 45 of this Member Handbook. You can t be charged additional Medical Co-payments for the rest of the year unless your Tufts Health Extend Plan Type changes from Plan Type II to Plan Type III. If your Plan Type changes, you will have to start making Medical Co-payments again, even if you had reached your Medical Co-payment Cap in your previous Plan Type. We ll apply the Medical Co-payments you ve already paid to your new Plan Type s Medical Co-payment Cap amount. Pharmacy Co-payments (Plan Type I, II, and III Members) A Pharmacy Co-payment is a fixed amount you must pay for a covered pharmacy service. There is a yearly Co-payment Cap (or limit on what you will be charged) for pharmacy services. Please see your Plan Type s Benefit and Co-payment Summary starting on page 45 of this Member Handbook for your specific Plan Type Co-payments and Co-payment Caps. Once you ve been charged the maximum in Pharmacy Co-payments in a Benefit Year (January 1 December 31), you no longer have to pay Pharmacy Co-payments until the next Benefit Year. This is called a Pharmacy Co-payment Cap. We ll send you a letter telling you that you reached your Pharmacy Co-payment Cap and that you don t have to pay any more Pharmacy Co-payments until the beginning of the next Benefit Year. You can t be charged additional Pharmacy Co-payments for the rest of the year unless your Tufts Health Extend Plan Type changes. If your Plan Type changes, you may have to start making Pharmacy Co-payments again, even if you had reached your Pharmacy Co-payment Cap. We ll apply the Pharmacy Co-payments you have already paid to your new Plan Type s Pharmacy Co-payment Cap amount. Please note: Tufts Health Extend Members who are or become pregnant are excluded from paying Pharmacy Co-payments during the duration of their pregnancy. You will first need to notify the Health Connector at , and us by calling Be sure to tell your pharmacist that you are excluded from paying Co-payments when you drop off your prescriptions. Covered Services We cover the Medically Necessary Covered Services listed in this handbook. Services or service categories not specifically listed as covered are not covered under this agreement. The following section lists services we cover for Tufts Health Extend Members. We ll authorize, arrange, coordinate, and provide to Members all Medically Necessary Covered Services. The Covered Services for each of the Plan Types are listed in the Benefit and Co-payment Summary section starting on page 45 of this Member Handbook. Check the summary 14 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

15 for your Plan Type and for a list of services covered and other limitations, including Prior Authorization requirements for Tufts Health Extend Members. If you have any questions, call us at We can give you more information about any of these Covered Services. Covered Services are only covered if they are Medically Necessary. Medically Necessary services are those Covered Services that we determine consistent with generally accepted principles of medical practice, meaning that they re the least intensive and most cost-effective available, and are: The most appropriate available supply or service for you based on potential benefits and harm to you Known to be effective in improving health outcomes based on scientific evidence, professional standards, and expert opinion In addition to any limitations in the Benefit and Co-payment Summary, we may limit, or require Prior Authorization for, Covered Services on the basis of Medical Necessity. Services we cover Preventive Care services for adults age 21 and older You should visit your Primary Care Provider (PCP) for Preventive Care, also known as Nonsymptomatic Care. Examples of covered Preventive Care for adults age 21 and older include: Checkups: every one to three years Blood pressure checks: at least every two years Cholesterol screening: every five years Pelvic exams and Pap smears (for women): the first Pap test and pelvic exam should happen three years after first sexual intercourse or by age 21 and continue every one to three years depending on risk factors Breast cancer screening (mammogram for women): every year after turning 40 Colorectal cancer screening: every 10 years, starting at age 50 Flu shot: every year Eye exams: once every 24 months Preventive Care and well-child care for all children It s important for children, teens, and young adults to see their PCP for regular checkups so they can stay healthy. Children who are under age 21 should see their PCP for checkups at least once every year, even if they are well. As part of a well-child checkup, your child s PCP will check your child s development, health, vision, dental health, hearing, behavioral health (mental health and/or substance abuse), and need for immunizations. We pay your child s PCP for well-child checkups, so make sure to schedule them. It is at these checkups that your child s PCP can find and treat small problems before they become big ones. The following are the ages to take a child for full physical exams and screenings: At one to two weeks At one month At two months At four months At six months At nine months At 12 months At 15 months At 18 months At ages 2 through 20, children should visit their PCP once a year Children should also visit their PCP any time you are concerned about a medical, emotional, or behavioral health need, even if it is not time for a regular checkup. Outpatient medical care Abortion services We cover abortion services you get from a Tufts Health Extend Provider. We must give Prior Authorization for an abortion from a provider who does not participate in our Network, unless the service is provided for a full-time out-of-state dependent student between 18 and 26 years of age. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 15

16 Community health center visits and office visits We cover community health center and office visits to Tufts Health Extend Providers for Primary Care or for specialty services. We must give Prior Authorization for office visits to all Out-of-network providers and Nonpreferred In-network Providers, unless the service is provided for a full-time out-of-state dependent student between 18 and 26 years of age. Call us at to find out more. We cover community health center and office visits with/for: Your PCP Specialists Eye care (vision care) Outpatient surgery We cover surgical procedures performed in an outpatient surgical center or hospital operating room. Laboratory services We cover laboratory services (including blood tests, urinalyses, Pap smears, and throat cultures) that your Provider orders to diagnose, treat, and prevent disease and to maintain your health. Radiology services We cover radiology services, including X-rays, mammography, MRIs, PET, and CT scans. Some of these services MRIs, MRAs, CT scans, outpatient nuclear cardiology, and PET require Prior Authorization for In-network and Out-of-network providers. Call us at for more information. Inpatient medical care We cover 24-hour inpatient medical services delivered in a licensed hospital setting with Prior Authorization. Inpatient Behavioral Health (mental health and/or substance abuse) services We cover Medically Necessary 24-hour clinical intervention services for mental health and/or substance abuse diagnoses delivered in a licensed hospital setting. Outpatient Behavioral Health (mental health and/or substance abuse) services We cover Medically Necessary mental health and/or substance abuse services provided in a face-to-face encounter in an ambulatory care setting, including: Individual, group, and family counseling Medication visits Community crisis counseling Family and case consultation Diagnostic evaluation Psychological testing Narcotic treatment services Electroconvulsive therapy Rehabilitation services We must give Authorization for inpatient rehabilitation services. Cardiac rehabilitation We cover outpatient cardiac rehabilitation when Medically Necessary. Cardiac rehabilitation is the multidisciplinary treatment of people with documented cardiovascular disease. Home health care We cover certain home health services, including: Durable Medical Equipment Part-time or intermittent skilled nursing care Physical, occupational, and speech therapy Part-time or intermittent home health aide services Inpatient Skilled Nursing Facility We cover daily skilled nursing care in an inpatient setting for a maximum of 100 Days per Benefit Year (July 1 December 31) at a Skilled Nursing Facility when Medically Necessary and with Prior Authorization. The maximum number of days is in combination with inpatient rehabilitation hospital days. See next section. 16 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

17 Inpatient Rehabilitation Hospital We cover daily rehabilitative services provided in an inpatient setting for a maximum of 100 Days per Benefit Year (January 1 December 31) at an inpatient Rehabilitation Hospital when Medically Necessary and with Prior Authorization. The maximum number of Days is in combination with Days at a Skilled Nursing Facility. See previous section. Short-term outpatient rehabilitation physical, speech, and occupational therapy We provide physical and occupational therapy coverage, with Prior Authorization, or in some cases Referrals, for evaluation and restorative short-term treatment you need to attain your highest level of independent functioning. Care is provided in the timeliest manner possible and when we determine that the therapy will result in significant, sustained measurable improvement of your condition. We also cover the diagnosis and treatment of speech, hearing, and language disorders when you get services from a registered therapist as part of a formal treatment plan for speech loss or impairment. In some cases, your PCP may need to give a Referral. We must give Prior Authorization for all rehabilitation therapy services, including ongoing treatment plans (maximum combined 20-visit limit for physical, occupational, and speech therapy unless we give Prior Authorization). Other benefits Durable Medical Euipment (DME) We cover certain DME. Coverage includes but is not limited to the rental or purchase of medical equipment, some replacement parts, and repairs, with Prior Authorization. Emergency transportation We cover ground ambulance services in an Emergency. We cover nonemergency ambulance transportation only when Medically Necessary and when we give Prior Authorization. We don t cover transportation to and from medical appointments. We cover Hospital-to-Hospital transfers, which don t need Prior Authorization. We don t cover emergency transportation by air without Prior Authorization. Family-planning Services We cover Family-planning Services. These services include family-planning medical and counseling services, follow-up health care, and education. Hospice We cover hospice care for terminally ill Members who agree with their Providers not to continue a curative treatment program. We cover a package of services, including nursing; medical and social services; provider care; counseling (for example, bereavement, dietary, spiritual); physical, occupational, and speech language therapies; homemaker/ home health aide services; medical supplies; drugs; biological supplies; short-term inpatient care services; and institutional care services. The 100-calendar-day limitation pertaining to care at a Skilled Nursing Facility and a Rehabilitation Hospital described on your Plan Type s Benefit and Co payment Summary does not apply to hospice services. Nutritional counseling We cover nutritional counseling when Medically Necessary. Organ transplant We cover human organ transplants, with Prior Authorization. Transplants must be nonexperimental surgical procedures provided within the Tufts Health Plan Network Health Provider Network. Coverage includes living and cadaver donors costs. We don t cover donor charges for Members who donate organs to nonmembers or recipients of transplants who aren t Tufts Health Plan Network Health members. We don t cover personal searches for solid organs or stem cell donation outside the organ bank. Orthotics We provide coverage for nondental braces and other mechanical or molded devices when Medically Necessary. We cover shoe inserts only for Members who have diabetes with Prior Authorization. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 17

18 Oxygen and respiratory therapy equipment services We cover oxygen and respiratory therapy equipment, including ambulatory liquid oxygen systems and refills, aspirators, compressor-driven nebulizers, intermittent positive pressure breathers, oxygen, oxygen gas, oxygen generating devices, and oxygen-therapy equipment rental, with Prior Authorization. Podiatry We cover Medically Necessary nonroutine podiatry services for Members when a licensed in-network podiatrist performs the service. We cover routine foot care only for Members who have diabetes. Prenatal care We provide inpatient and outpatient maternity benefits with precertification of the pregnancy by a Tufts Health Extend Provider. If you re pregnant, call Tufts Health Plan Network Health and the Health Connector as soon as your pregnancy is confirmed to be sure you get the best care for you and your baby. Prosthetics We cover certain prosthetic devices, including evaluation, fabrication, fitting, and the provision of the prosthesis, with Prior Authorization. Supplies We cover prescribed, Medically Necessary disposable medical supplies used to treat a specific medical condition, with Prior Authorization. Vision care We cover routine eye exams for Members once every 24 months from ophthalmologists or optometrists who are part of our Network. We also cover one pair of eyeglasses once every 24 months. You can choose from the free frame selection, or, if you choose any other frame, we pay up to a maximum credit of $80 and you pay the difference. For all Plan Types, Members with diabetes are eligible for and encouraged to get yearly vision exams. If you get a bill for a Covered Service You shouldn t get a bill for any Covered Services unless you obtained nonemergency services from an Out-of network provider or Nonpreferred In-network Provider without Prior Authorization (this excludes Dependents between 18 and 26 years of age who are full-time, out-of-state students please see the section Prior Authorization on page 12 for more information). However, you may get a bill for Co-payments for some Covered Services. You will not be held responsible for paying for services that were not provided, including missed appointments. If you get a bill that you believe is a mistake, don t pay it, and call us at We can help. Services not covered Acupuncture (except to treat substance abuse) Biofeedback Chiropractic services Cosmetic services and procedures, unless required to restore bodily function or correct a functional physical impairment after an accidental injury, prior surgical procedure, or congenital/birth defect. (Prior Authorization is required. No benefits are provided solely for the purpose of making you look better, whether or not these services are meant to make you feel better about yourself or treat a mental condition.) Custodial care Diagnosis and treatment for infertility, including in-vitro fertilization and gamete intrafallopian transfer (GIFT) procedure Some types of Durable Medical Equipment (DME): Elevators Back-up equipment Whirlpool equipment, used for soothing/comfort Hospital-type beds requiring installation in a home Hygienic equipment that does not serve a primary medical purpose Nonmedical equipment otherwise available to Members that does not serve a primary medical purpose Bed lifters, not primarily medical Nonhospital beds and mattresses Hospital-type beds in full, queen, and king sizes 18 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

19 Cushions, pads, and pillows, except when Medically Necessary and we give Prior Authorization Pulse tachometers Educational testing and evaluations Exams a third party requires (e.g., physical, psychiatric, and psychological examinations or testing a third party such as an employer, court, or school requires) Experimental or investigational treatment Routine podiatry/foot care, except as noted on page 18 Gender reassignment surgery and any services, drugs, or supplies related to such surgery Hearing aids Laser eyesight correction or any other eye surgery to treat a condition that another treatment besides surgery can correct Out-of-network providers, unless we give Prior Authorization (except emergency services, which never need Prior Authorization)* Services from Nonpreferred In-network Providers, unless we give Prior Authorization (except emergency services, which never need Prior Authorization)* Personal comfort items, including air conditioners, air purifiers, chair lifts, dehumidifiers, radios, telephones, and televisions Reversal of voluntary sterilization Any service or supply that is not Medically Necessary A Provider s charge for shipping and handling, or copying of records Medications, devices, treatments, and procedures that have not been demonstrated to be medically effective Routine care, including routine prenatal care, when you re outside our Service Area* Services for which there would be no charge in the absence of insurance Special equipment you need for sports or job purposes Any dental services, except emergency dental care and oral surgery by a Provider as a result of an injury, accident, or other condition A service or supply, which is not covered by or at the direction of a Tufts Health Extend Provider, except for emergency services Gym or health club memberships Replacement of DME or prosthetics due to loss, intentional damage, or negligence Services for which we did not give required Prior Authorization * Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. Covered medications and pharmacy Pharmacy program We aim to provide high-quality, cost-effective options for drug therapy. We work with your Providers and pharmacists to make sure we cover the most important and useful drugs for a variety of conditions and diseases. We cover first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your doctor writes a prescription and it is filled at a pharmacy. Our pharmacy program doesn t cover all drugs and prescriptions. Some drugs must meet certain clinical guidelines before we can cover them. Your Provider must ask us for Prior Authorization before we ll cover one of these drugs. Please see the section Prior Authorization for drugs below for more information. Prior Authorization for drugs Some drugs always require Prior Authorization, which means your Provider must ask us for approval before we ll cover the drug. One of our clinicians will review this request. We ll cover the drug according to our clinical guidelines if: There is a medical reason you need the particular drug Depending on the drug, other drugs on the Preferred Drug List (PDL) have not worked If we don t approve the request for Prior Authorization, you or your Authorized Representative, if you identify one, can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. If you want more information about our pharmacy program, visit Network-Health.org or call us at For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 19

20 Preferred Drug List We use a Preferred Drug List (PDL) as our list of covered drugs. We update the PDL every three months. The PDL applies only to drugs you get at retail, mail-order, and specialty pharmacies, if covered under your Plan Type. The PDL doesn t apply to drugs you get if you re in the Hospital. For the most current PDL, call or visit Network-Health.org. Exclusions We don t cover certain drugs. If it is Medically Necessary for you to take a drug that we don t cover, your Provider must ask us for and get Prior Authorization before we ll cover the drug. One of our clinicians will review the request. If we don t approve the request for Prior Authorization, you or your Authorized Representative can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. If you want more information about our pharmacy program, call or visit Network-Health.org. We don t cover: Any drug products used for cosmetic purposes Contraceptive implants* Experimental and/or investigational drugs Immunization agents administered or dispensed at a pharmacy, except for the influenza virus vaccine for Members who are at least 18 years old, when given by a pharmacist between September 15 and March 31 at a participating pharmacy* Infertility agents Medical supplies* Mifepristone (Mifeprex)* Any drugs related to gender reassignment surgery, specifically including, but not limited to, presurgery and postsurgery hormone therapy * May be covered as a nonpharmacy benefit. Generic drugs Generic drugs have the same active ingredients and work the same as brand-name drugs. When generic drugs are available, we won t cover the brand-name drug without giving Prior Authorization. If you and your Provider feel a generic drug is not right for treating your health condition and that a brand-name drug is Medically Necessary, your Provider can ask us for Prior Authorization. One of our clinicians will then review the request. Please see the section Prior Authorization for drugs on page 19 for more information. If we don t approve the request for Prior Authorization, you or your Authorized Representative can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. If you want more information about our pharmacy program, visit Network-Health.org or call us at New-to-market drugs We review new drugs for safety and effectiveness before we add them to our Preferred Drug List (PDL). A Provider who feels a new-to-market drug is Medically Necessary for you before we ve reviewed it can submit a request for Prior Authorization. One of our clinicians will review this request. If we approve the request, we ll cover the drug according to our clinical guidelines. If we don t approve, you or your Authorized Representative can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. Quantity limits To make sure the drugs you take are safe and that you are getting the right amount, we may limit how much you can get at one time. Your Provider can ask us for Prior Authorization if you need more than we cover. One of our clinicians will review the request. We ll cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we don t approve the request for Prior Authorization, you or your Authorized Representative can appeal the decision. To learn more about appealing our decision, please see the Grievances and Appeals sections starting on page 33. If you want more information, visit Network-Health.org or call us at For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.