MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) FAMILY ASSISTANCE

Transcription

1 MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) FAMILY ASSISTANCE ABBREVIATIONS BH = Behavioral health IN = In-network MM = Medical management team at Tufts Health Plan = Out-of-network PA = Prior authorization PCP = Primary care provider Benefit year = March 1 December 31 Annual co-payment maximum per calendar year per member Medical and BH = $0 Pharmacy = $250 Prior authorizations and referrals If we require prior authorization, providers must submit a prior authorization request five business days prior to the service start date. All rendered by providers require prior authorization. Some members may require a PCP referral for specialty. We only need to be notified if the Service requires a Prior Authorization, refer to PA required column below. Service Coverage/Limits/Conditions Related payment policy Co-payment PA required? Abortion Covered Acupuncture Covered if medically necessary to treat substance $0 IN and use. Acute inpatient stay Covered if medically necessary Acute Inpatient Hospital $0 IN and Admissions Adult day health Not covered Not covered Not covered Adult dentures Covered by MassHealth as a wraparound service. MM can assist in coordinating with requesting $0 Contact MassHealth at provider. Adult foster care Not covered Not covered Not covered Allergy shots Covered if medically necessary Ambulatory surgery/ Same-day surgery/ Outpatient surgery/ Surgical day care Covered if medically necessary when surgical procedure performed at IN outpatient facility. Includes outpatient, surgical and related diagnostic and medical/dental. Anesthesia Covered if medically necessary. Anesthesia, Obstetric Anesthesia $0 IN for certain Use the Site Search function on the THP Provider page $0 IN for dental Audiologist Exams and evaluations covered if medically necessary Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 1

2 Biofeedback Not covered Not covered Not covered Bone density testing Covered if medically necessary. $0 Breast pumps Breast pumps, one per birth or as medically necessary, including double electric pumps, are provided to expectant and new mothers as specifically prescribed by their attending physicians and consistent with state and federal law. $0 IN: Electric hospitalgrade pumps pumps Cardiac catheterization Covered if medically necessary Cardiac rehabilitation Covered if medically necessary Care management Covered when provided by Tufts Health Plan care managers Chapter 766 Covered by MassHealth $0 Contact MassHealth at Chemotherapy/ Covered if medically necessary Radiation therapy Chiropractic Covered for up to 20 visits per benefit year for Chiropractic manipulative treatment, office visits, radiology or any combination of these Cosmetic surgery Not covered Not covered Not covered CPAP/BiPAP May cover continuous positive airway pressure DME $0 IN and machine (CPAP) and bilevel positive airway pressure machine (BiPAP) if medically necessary after sleep study is completed and reviewed Custodial care Not covered Not covered Not covered Day habilitation Not covered Not covered Not covered Dental, emergency Covered if medically necessary. Includes emergency dental and oral surgery performed in an outpatient setting to treat a medical or BH condition. Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 2

3 Dental, nonemergency Covered if medically necessary to treat a medical condition. MassHealth covers nonemergency dental as a wraparound service as follows: Members younger than 21 preventive/basic Members 21 and older extractions and one cleaning per year $0 IN and Diabetes selfmanagement training Diagnostic procedures Diagnostic testing Dialysis Drug screening Durable medical equipment (DME) Early Intervention (EI) Covered if medically necessary. Includes educational and training by a physician or other accredited provider (registered nurse, physician assistant, nurse practitioner and licensed dietitian) to treat prediabetes or diabetes. Covered if medically necessary. Includes colonoscopy, endoscopy, sigmoidoscopy and gastroscopy. Covered if medically necessary. Includes labs, X-rays, EKGs, EEGs and ultrasounds. Covered if medically necessary. Includes labs, drugs, tubing change, adapter change, training related to hemodialysis and peritoneal dialysis (intermittent, continuous cycling and continuous ambulatory). Covered if medically necessary. Not covered when court-ordered, legally required, or when required for residential monitoring.. Covered if medically necessary. Includes medical and surgical supplies. Covered if medically necessary for members ages 3 and younger. Includes intake screenings, evaluation and assessments, child- and center-based individual visits, and community child group, early intervention-only child group and parent-focused group sessions. Contact MassHealth at $0 Upper GI Endoscopy requires a PA $0 except labs Drug Screening DME $0 IN: See payment policy Nebulizers: None Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 3

4 Emergency Covered for medical and BH emergency Emergency Room $0 Notification required provided within the U.S. within 24 hours, if Exams/Other treatment Experimental Family planning Fluoride varnish Not covered, including related to or for the purpose of employment, education, licensing or court order Not covered. See our list of experimental and investigational procedures. Covered for basic. Includes birth control and intrauterine devices (IUDs). Family planning, medical and counseling, follow-up health care, outreach and community education may be obtained from any MassHealth family-planning service provider without PA. Covered for members ages 3 and younger. Covered if medically necessary, as determined by the Caries Assessment Tool (CAT), for members younger than 21 who are eligible for dental. Clinical Trials Payment Policy Not covered Not covered admitted Not covered Not covered Genetic testing Covered if medically necessary Genetic Testing $0 IN and Group adult foster care Not covered Not covered Not covered Hearing aids Covered if medically necessary. Includes ear mold, ear impressions and loan of a hearing aid if necessary. No PA required for batteries, accessories, aid, instruction for use/care/maintenance and servicing during the lifetime of the hearing aid. Hepatitis B vaccine Members ages 19 and older Tufts Health Plan covers vaccine and administration Members younger than 19 MassHealth covers vaccine and Tufts Health Plan covers administration Vaccine and Immunization $0 IN: Monaural (one ear) more than $500 or binaural (two ears) more than $1,000 Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 4

5 Home health care Home Health Care Covered if medically necessary when a member demonstrates a need for nursing and/or therapy. Includes part- time or intermittent skilled nursing, physical/ occupational/speech therapies and part-time or intermittent home health aide in the home. $0 IN only if request is for daily visits or for requests greater than 6 months regardless of service (e.g., skilled nursing, PT, OT and speech) Home infusion therapy Covered if medically necessary $0 IN: Some drugs may require PA Hospice care Covered if medically necessary $0 IN and Human papillomavirus Covered if medically necessary for males and females Vaccine and (HPV) vaccine Immunization Infertility ages 9 26 Covered if medically necessary. Vaccine administration covered. Not covered if required for traveling outside U.S. Covered only for the diagnosis of infertility and treatment of an underlying medical condition. Not covered for other infertility and their diagnosis and treatment, such as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), reversal of voluntary sterilization and sperm banking. Immunization Vaccine and Immunization Inpatient hospitalization Covered if medically necessary $0 IN and Elective admissions: Submit PA form 5 business days prior to admission Institutional care at a chronic or rehabilitation hospital Covered for all levels of care, if provided at either a chronic or rehabilitation hospital or any combination thereof, up to 100 days per benefit year. $0 IN and Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 5

6 Intensive early intervention Covered by MassHealth $0 Contact MassHealth at Keep Teens Healthy Covered by MassHealth $0 Contact MassHealth at Laboratory Covered if medically necessary to maintain health and diagnose, treat and prevent disease. Includes blood tests, urinalysis, Pap smears, throat cultures and vaccines not covered by the Department of Public Health. Please reference Drug Screening and Genetic Testing above. Maternity care/ Covered. IN or providers must submit a Prenatal Facility Maternity Prenatal visits Registration Form to MM. Medical outside Not covered Not covered Not covered the U.S. or its territories Mobile Outpatient Cardiac Telemetry (MOCT) Covered if medically necessary $0 IN and Nuclear cardiology Nurse practitioner Nutritional counseling Nutritional supplements Covered if medically necessary. Submit PA requests to National Imaging Associates. Not covered unless credentialed for billing as a PCP. Covered if rendered by an accredited provider (physician, licensed dietitian, licensed nutritionist, registered nurse, physician assistant or nurse practitioner). Includes nutritional, diagnostic, therapy and counseling for a medical condition. Covered if medically necessary and formula prescribed for a medical condition. Not covered for nutritional supplements covered by Women, Infants, and Children Radiology Imaging Nurse Practitioner as a Primary Care Provider $0 IN and : Submit PA requests to National Imaging Associates. DME $0 IN and (WIC) Nutrition Program. Nutritional therapy Covered if medically necessary Observation day Covered if medically necessary Observation $0 IN: Stays longer than 48 hours Organ/Bone marrow transplants Coverage determined upon review by MM. Experimental and investigational transplants not covered. $0 IN and Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 6

7 Orthotics Covered if medically necessary. Includes braces and Orthotic $0 IN and other mechanical or molded devices to support or correct any defect of form or function of the human body. Includes repairs. Limit of one pair of shoes per 12-month period for diabetics. Shoe inserts covered for diabetics only. For members older than 21, certain limitations apply. Outpatient hospital Covered if medically necessary $0 See specific service for PA requirement Outpatient therapy physical, occupational, speech and hearing Outpatient Therapy $0 IN: After initial evaluation and 11 visits for PT and OT Over-the-counter (OTC) drugs Oxygen and respiratory therapy equipment Covered if medically necessary. Includes individual treatment, comprehensive evaluation and group therapy. Children ages 3 and older may receive through the school department Children younger than 3 may receive through the early intervention program Select OTC drugs are covered if requested with a prescription written by an IN or physician. Must be obtained at a participating pharmacy. Examples include: Aspirin/Acetaminophen/Ibuprofen Allergy medication/decongestant Diabetic supplies (e.g., strips, lancets) Multivitamins and iron/calcium supplements Covered if medically necessary. Includes ambulatory liquid oxygen systems and refills, aspirators, compressor-driven nebulizers, intermittent positive pressure breather, oxygen, oxygen gas, oxygengenerating devices and oxygen therapy equipment Contraceptive agents: $0 Covered OTC drugs: $0-$3.65 for a 30-day supply IN: After 30 visits for ST and hearing See Over-the-Counter list on website DME $0 IN: See payment policy rental. Pacemaker implant Covered if medically necessary Pain management Covered if medically necessary Anesthesia $0 IN and : Submit PA requests to National Imaging Associates. Personal care attendant Personal emergency response systems (PERS) Not covered $0 Not covered Covered if medically necessary Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 7

8 Pharmacy Co-payments for a one-month supply via participating pharmacies. Co-payments due at time of service. No copayment for: Birth control and family-planning supplies Diabetic supplies $0 as indicated $1 for certain covered generic drugs used to treat diabetes, high blood pressure, and See our Preferred Drug List for PA requirements Spacers or peak flow meters high cholesterol Members younger than 21 $3.65 for certain Members while pregnant or up to 60 days after covered generic, giving birth OTC, and brand Prescription diabetes/asthma supplies name drugs Tufts Health Plan pharmacy copayments Physician assistant Not covered unless credentialed for billing as a PCP Physician Podiatry Preventive pediatric health screening and diagnostic Private duty nursing/ Continuous skilled nursing Prosthetic and devices Covered, including PCP and specialty. Some members may require PCP referral for specialty. However, no Prior Authorization or notification is required for IN. Covered for medical conditions. Includes medical, radiological, surgical and laboratory care. Includes routine foot care for diabetics. $0 PCP: Specialty: Podiatry Covered for members younger than 21 Not covered Not covered Not covered Covered. Includes evaluation, fabrication, fitting, provision of prosthesis and repairs. For members older than 21, certain limitations apply. Prosthetic $0 IN and Pulmonary function test Covered if medically necessary Pulmonary rehabilitation Covered if medically necessary Radiation therapy, internal selective Covered if medically necessary Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 8

9 Radiology/X-rays Covered if medically necessary. Advanced imaging (MRI, MRA, CAT, nuclear cardiology and PET) require PA through NIA. Radiology Imaging, Therapeutic Radiology $0 IN and : Contact National Imaging Associates to request PA. School-based health Covered if medically necessary center Shingles vaccine Covered only for members 50 and older Vaccine and Immunization Sleep study Covered if medically necessary Specialist Covered if medically necessary. Some members may Specialty require PCP referral for specialty. However, no Prior Authorization or notification is required for IN. Referral Requirement Stress test Covered if medically necessary Temporomandibular Covered for surgery if medically necessary. Not $0 IN and joint (TMJ) treatment covered for physical therapy, corrective devices and/or other treatments. Tobacco cessation Covered for individual and group tobacco-cessation $0-$3.65 counseling rendered by an IN provider. Includes specific medication obtained from a pharmacy and nicotine-replacement therapy. Transportation, Covered if medically necessary. Includes land and air. Ambulance Transport emergency Includes specialty care transport between facilities. Transportation, Not covered Ambulance Transport Not covered Not covered nonemergency Transsexual surgery Covered if medically necessary $0 IN and Urgent care Covered if medically necessary IN and, if billed with place-of-service code 20 Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 9

10 Vaccines Covered if medically necessary. Vaccine administration Vaccine and covered. Not covered if required for traveling outside U.S. Immunization Vasectomy Covered, except for reversal of voluntary sterilization Vision Medical THP covers routine eye exams once every 24 months for Vision non-diabetic members and members age 21+, and once every 12 months for diabetic members and members younger than 21. THP covers medically necessary vision training; ocular prosthesis; contacts, as treatment for a medical condition, such as keratoconus; and bandage lenses. Vision $0 Vision Therapy: IN and All other Vision Medical: Vision Non-Medical MassHealth covers all non-medical vision care, including eyeglasses and other visual aids. $0 Contact MassHealth at for wraparound benefits Vocational rehabilitation Not covered Not covered Not covered Wigs Covered if medically necessary pursuant to 130 CMR Must be ordered or prescribed by a provider. Must be reasonably priced pursuant to 130 CMR (A)(2). Medical Benefit Summary Grid: Tufts Health Together (MassHealth) Family Assistance 10