Tufts Health Unify Member Handbook

Transcription

1 2018 Tufts Health Unify Member Handbook H7419_6002

2 Tufts Health Unify Member Handbook January 1, 2018 December 31, 2018 Your Health and Drug Coverage under the Tufts Health Unify Medicare-Medicaid Plan This handbook tells you about your coverage under Tufts Health Unify through December 31, It explains health care services, behavioral health coverage, prescription drug coverage, and long-term services and supports. Long-term services and supports provide the care you need at home and may reduce your chances of going to a nursing facility or hospital. This is an important legal document. Please keep it in a safe place. Tufts Health Unify (Medicare Medicaid Plan) is offered by Tufts Health Plan. When this Member Handbook says we, us, or our, it means Tufts Health Plan. When it says the plan or our plan, it means Tufts Health Unify. Disclaimers Tufts Health Unify is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees. Coverage under Tufts Health Unify qualifies as minimum essential coverage (MEC). It satisfies the Patient Protection and Affordable Care Act s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at Care-Act/Individuals-and-Families for more information on the individual shared responsibility requirement for MEC. Limitations and restrictions may apply. For more information, call Tufts Health Unify Member Services or read the Tufts Health Unify Member Handbook. This means that you may have to pay for some services and that you need to follow certain rules to have Tufts Health Unify pay for your services. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ), seven days a week, from 8 a.m. to 8 p.m. The call is free. Si habla español, tiene disponible los servicios de asistencia de idioma gratis. Llame (TTY: ), siete días a semana, de 8 a.m. a 8 p.m. La llamada es gratuita. TuftsHealthUnify.org. 1

3 You can get this document for free in other formats, such as large print, braille, or audio. Call (TTY: ), seven days a week, from 8 a.m. to 8 p.m. The call is free. Call Member Services to request materials in languages other than English or in an alternative format. Chapter 1: Getting started as a member Table of Contents A. Welcome to Tufts Health Unify... 3 B. What are Medicare and MassHealth... 3 Medicare... 3 MassHealth... 4 C. What are the advantages of this One Care Plan... 4 D. What is Tufts Health Unify s service area... 5 E. What makes you eligible to be a plan member... 6 F. What to expect when you first join a health plan... 6 G. What is a Personal Care Plan... 7 H. Does Tufts Health Unify have a monthly plan premium... 7 I. About the Member Handbook... 8 J. What other information will you get from us... 8 Your Tufts Health Unify Member ID Card... 8 Provider and Pharmacy Directory... 9 List of Covered Drugs Explanation of Benefits K. How can you keep your membership record up to date Do we keep your personal health information private

4 Chapter 1: Getting started as a member A. Welcome to Tufts Health Unify Tufts Health Unify is a One Care: MassHealth plus Medicare plan. A One Care plan is made up of doctors, hospitals, pharmacies, providers of long-term services and supports, and other health care providers. In a One Care plan, a Care Manager will work with you to develop a plan that meets your specific health needs. A Care Manager will also help you manage all your providers, services, and supports. They all work together to give you the care you need. Tufts Health Unify was approved by the Commonwealth of Massachusetts and CMS (the Centers for Medicare & Medicaid Services) to provide you services as part of One Care. One Care is a pilot program run by Massachusetts and the federal government to provide better health care for people who have both Medicare and MassHealth (Medicaid). This pilot program lets the state and federal government test new ways to improve how you get your Medicare and MassHealth health care services. With Tufts Health Unify, you get more from your health plan. We have established a network of primary care providers, hospitals, and other providers to bring you high-quality, affordable health care coverage under government-run programs, including Medicare and MassHealth. By joining Tufts Health Unify, you have access to a network of trusted doctors and specialists, a friendly and helpful Member Services team, great services, and information in your own language. Our plan is designed to meet the needs of people who have Medicare and MassHealth benefits. Tufts Health Unify will make sure these programs work together to get you the care you need. Tufts Health Public Plans, Inc. is licensed as a health maintenance organization in Massachusetts, and does business under the name Tufts Health Plan. B. What are Medicare and MassHealth Medicare Medicare is the federal health insurance program for: People 65 years of age or older; Some people under age 65 with certain disabilities; and People with end-stage renal disease (kidney failure). TuftsHealthUnify.org. 3

5 MassHealth MassHealth is the name of the Massachusetts Medicaid program. MassHealth is run by the federal government and the state. MassHealth helps people with limited incomes and resources pay for long-term services and supports and medical costs. It also covers extra services and drugs that are not covered by Medicare. Each state has its own Medicaid plan. That means that each state decides what counts as income and resources, and who qualifies for Medicaid in that state. Each state also decides which services are covered and what those services cost. States can decide how to run their own Medicaid programs as long as they follow the federal rules. Medicare and Massachusetts must approve Tufts Health Unify each year. You can get Medicare and Medicaid services through our plan as long as: You are eligible to participate in One Care; We still offer the plan in your county; and Medicare and Massachusetts approve the plan. Even if our plan stops operating, your eligibility for Medicare and MassHealth services will stay the same. C. What are the advantages of this One Care Plan You will now get all your covered Medicare and MassHealth services from Tufts Health Unify. This includes prescription drugs. You do not have to pay extra to join this health plan. Tufts Health Unify will help make your Medicare and MassHealth benefits work better together and work better for you. Here are some of the advantages of having Tufts Health Unify as your health plan. You will have a Care Team made up of people you choose. A Care Team is a group of people that will get to know your needs and work with you to help you create and carry out a Personal Care Plan. Your Care Team will talk with you about the services that are right for you. You will have a Care Manager who will work with you, the health plan, and your care team to make sure you get the care you need. If you need long-term services and supports (LTSS), you will also have an Independent Living and Long-Term Services and Supports Coordinator (also known as a Long-Term Supports (LTS) Coordinator). Long-term services and supports are for people who need help doing everyday tasks like taking a bath, getting dressed, making food, and taking medicine. o An LTS Coordinator will help you find and get the right LTSS services. 4

6 Chapter 1: Getting started as a member o Both the Care Manager and LTS Coordinator work with your Care Team to make sure you get the care you need. You will be able to take charge of your own care with help from your Care Team and Care Manager. The Care Team and Care Manager will work with you to come up with a Personal Care Plan specially designed to meet your health needs. They will help you get the right services and organize your care. The Care Team will be in charge of managing the services you need. For example: o o o Your Care Team will make sure that your doctors know about all your medicines so they can reduce any side effects. Your Care Team will make sure that all your doctors and other providers see your test results. Your Care Team will help you get appointments with doctors and other providers who can help you with any disability accommodations you need. D. What is Tufts Health Unify s service area Our service area includes these counties in Massachusetts: Suffolk and Worcester. Our service area includes parts of Middlesex County with the following ZIP codes: City/Town Zip Code Billerica 01821, Chelmsford Dracut Lowell 01850, 01851, 01852, 01853, North Billerica North Chelmsford Tewksbury Tyngsborough Westford Tufts Health Unify is only for people who live in our service area. If you move outside of our service area, you cannot stay in this plan. TuftsHealthUnify.org. 5

7 E. What makes you eligible to be a plan member You are eligible for our plan as long as you: Live in our service area; and Have both Medicare Part A and Medicare Part B and are eligible for Part D; and Are eligible for MassHealth Standard or MassHealth CommonHealth; and Are a United States citizen or are lawfully present in the United States; and Are not enrolled in a MassHealth Home and Community-based Services (HCBS) waiver; and Have no other health insurance. F. What to expect when you first join a health plan If Tufts Health Unify is a new plan for you, you can keep seeing your doctors and getting your current services for 90 days, or until your care plan is complete. If you are taking any Medicare Part D prescription drugs when you join our plan, you can get a temporary supply. We will help you to transition to another drug if necessary. Within the first 90 days of your enrollment in the plan, you will get an in-person health assessment. After the assessment, you and your Care Team will work together to develop your Personal Care Plan. Shortly after you become a Tufts Health Unify member, a member of the care management team will call you to set up your initial in-person comprehensive health assessment. Your Care Manager will coordinate your Care Team by working with you and all of your health and social care providers. Your Care Team may include your medical care providers (such as a primary care provider or a mental health or substance use counselor), and pharmacy professionals. Your Care Team may also include advocates, family members, caregivers, friends, mentors, and/or peer supports. Based on your health needs assessment, your Care Manager will also help you connect with and coordinate any additional nonmedical resources you may need, including: Long-term services and supports (LTSS), such as day habilitation or personal care assistants Community support services, such as peer support and counseling After the first 90 days, you will need to see doctors and other providers in the Tufts Health Unify network. A network provider is a provider who works with the health 6

8 Chapter 1: Getting started as a member plan. See Chapter 3, Section B, page 25, for more information on getting care from provider networks. G. What is a Personal Care Plan After your health assessment, your Care Team will meet with you to talk about the health services you need and want. Together, you and your Care Team will make a care plan. A Personal Care Plan lists the services you will get, and also how you will get them. A Personal Care Plan includes the services that you need for your physical and mental health care and long-term services and supports. The providers you see and medications you take will be a part of your Personal Care Plan. You will be able to list your health, independent living and recovery goals, as well as any concerns you may have and the steps needed to address them. Your One Care plan will work with you at all times and will work with your family, friends, and advocates if you choose. You will be at the center of the process of making your Personal Care Plan. Every year, your Care Team will work with you to update your care plan in case there is a change in the health services you need and want. Your personal care plan can also be updated as your goals or needs change throughout the year. H. Does Tufts Health Unify have a monthly plan premium You will not pay any monthly premiums to Tufts Health Unify for your health coverage. If you pay a premium to MassHealth for CommonHealth, you must continue to pay the premium to MassHealth to keep your coverage. Members who enter a nursing facility may have to pay a Patient Paid Amount to keep your MassHealth coverage. The Patient Paid Amount is the member's contribution to the cost of care in the facility. MassHealth will send you a detailed notice should you be expected to pay a Patient Paid Amount. TuftsHealthUnify.org. 7

9 I. About the Member Handbook This Member Handbook is part of our contract with you. This means that we must follow all of the rules in this document. If you think we have done something that goes against these rules, you may be able to appeal, or challenge, our action. For information about how to appeal, see Chapter 9, Section 5.3, page 130, or call MEDICARE ( ). The contract is in effect for the months you are enrolled in Tufts Health Unify between January 1, 2018, and December 31, J. What other information will you get from us You should have already gotten a Tufts Health Unify Member ID Card, information about how to access the Provider and Pharmacy Directory, and the List of Covered Drugs. Your Tufts Health Unify Member ID Card Under our plan, you will have just one card for your Medicare and MassHealth services, including long-term services and supports and prescription drugs. You must show this card when you get any services or prescriptions. Here is a sample card to show you what yours will look like: 8

10 Chapter 1: Getting started as a member If your card is damaged, lost, or stolen, call Member Services at right away. We will send you a new card. As long as you are a member of our plan, you should not use your red, white, and blue Medicare card or your MassHealth card to get services. Keep those cards in a safe place, in case you need them later. If you show your Medicare card instead of your Tufts Health Unify Member ID Card, the provider may bill Medicare instead of our plan, and you may get a bill. See Chapter 7, Section A, page 101, to see what to do if you get a bill from a provider. Provider and Pharmacy Directory The Provider and Pharmacy Directory lists the providers and pharmacies in the Tufts Health Unify network. While you are a member of our plan, you must use network providers to get covered services. You can ask for a new Provider and Pharmacy Directory at any time by calling Member Services at You can also see the Provider and Pharmacy Directory at TuftsHealthUnify.org or download it from this website. You can also use our Find a Doctor, Hospital, or Pharmacy tool to quickly find providers. Just go to TuftsHealthUnify.org. Our online tool has the most up-to-date information for the providers in our network. Both Member Services and our website can give you the current information about changes in our network. What are network providers Tufts Health Unify s network providers include: o o o Doctors, nurses, and other health care professionals that you can go to as a member of our plan; Clinics, hospitals, nursing facilities, and other places that provide health services in our plan; and Home health agencies, durable medical equipment suppliers, and others who provide goods and services that you get through Medicare or MassHealth. Network providers have agreed to accept payment from our plan for covered services as payment in full. You will not have to pay anything more for covered services. What are network pharmacies Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptions for our plan members. Use the Provider and Pharmacy Directory to find the network pharmacy you want to use. TuftsHealthUnify.org. 9

11 You must fill your prescriptions at one of our network pharmacies if you want our plan to help you pay for them. Call Member Services at for more information or to get a copy of the Provider and Pharmacy Directory. List of Covered Drugs The plan has a List of Covered Drugs or Formulary. We call it the Drug List for short. It tells which prescription drugs are covered by Tufts Health Unify. The Drug List also tells you if there are any rules or restrictions on any drugs, such as a limit on the amount you can get. See Chapter 5, Section C, page 87, for more information on these rules and restrictions. Each year, we will send you information about how to access a List of Covered Drugs. To get the most up-to-date information about which drugs are covered, visit TuftsHealthUnify.org or call The Explanation of Benefits When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Explanation of Benefits (or EOB). The Explanation of Benefits tells you the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 gives more information about the Explanation of Benefits and how it can help you keep track of your drug coverage. An Explanation of Benefits is also available when you ask for one. To get a copy, please contact Member Services. K. How can you keep your membership record up to date You can keep your membership record up to date by letting us know when your information changes. The plan s network providers and pharmacies need to have the right information about you. They use your membership record to know what services and drugs you get and how much they will cost you. Because of this, it is very important that you help us keep your information up to date. Let us know if any of these situations applies to you: If you have any changes to your name, address, or phone number 10

12 Chapter 1: Getting started as a member If you get other health insurance coverage, like coverage from your employer, your spouse s employer, or workers compensation If you have any liability claims, such as claims from an automobile accident If you are admitted to a nursing facility or hospital If you get care in an out-of-area or out-of-network hospital or emergency room If there s a change in who your caregiver (or anyone else responsible for you) is If you are part of a clinical research study If any information changes, please let us know by calling Member Services at You can also make changes to your membership record by signing up for Tufts Health Member Connect, our online self-service tool at TuftsHealthUnify.org. Tufts Health Member Connect helps you take charge of your health care, 24 hours a day, seven day a week. The tool makes it easy to: Access your care plan and connect with your Care Manager Update your contact information and order a new member ID card View or print a copy of your ID card Choose or change your primary care provider (PCP) Review medical history, including prescription medications, procedures, immunizations, and doctors visits Share your information with your family, caregiver, PCP, or others Check the status of a claim or an authorization Do we keep your personal health information private Yes. Laws require us to keep your medical records and personal health information private. We make sure that your health information is protected. For more information about how we protect your personal health information, see Chapter 8, Section D, page 108. TuftsHealthUnify.org. 11

13 Chapter 2: Important phone numbers and resources Table of Contents A. How to contact Tufts Health Unify Member Services Contact Member Services about: Questions about the plan Coverage decisions about your health care Appeals about your health care Complaints about your health care Coverage decisions about your drugs Appeals about your drugs Complaints about your drugs Questions about payment for health care or drugs you already paid for B. How to contact your Care Manager Contact your Care Manager about: Questions about your health care Questions about getting medical services, behavioral health services and long-term services and supports (LTSS) C. How to contact the 24/7 NurseLine Contact the 24/7 NurseLine about: Questions about your health care D. How to contact the Behavioral Health Crisis Line Contact the Behavioral Health Crisis Line if: You need help during a mental health crisis E. How to contact the State Health Insurance Assistance Program (SHIP) Contact SHINE about: TuftsHealthUnify.org. 12

14 Chapter 2: Important phone numbers and resources Questions about your Medicare health insurance F. How to contact Medicare G. How to contact MassHealth H. How to contact the Quality Improvement Organization (QIO) Contact the QIO about: Questions about your health care I. How to contact the One Care Ombudsman (OCO) TuftsHealthUnify.org. 13

15 A. How to contact Tufts Health Unify Member Services CALL This call is free. Member Services representatives are available Monday through Friday, from 8 a.m. to 8 p.m. Alternative technologies, such as voic and answering services, are available after hours, Saturday through Sunday, and on federal holidays. You can also ask for this information in other formats, such as Braille or large print. We have free interpreter services for people who do not speak English. TTY This call is free. This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. Member Services representatives are available Monday through Friday, from 8 a.m. to 8 p.m. Alternative technologies, such as voic and answering services, are available after hours, Saturday through Sunday, and on federal holidays. WRITE WEBSITE Tufts Health Plan Attn: Member Services P.O. Box 9194 Watertown, MA TuftsHealthUnify.org Contact Member Services about: Questions about the plan Coverage decisions about your health care A coverage decision about your health care is a decision about either your benefits and covered services or the amount of your health services we will cover. To learn more about coverage decisions, see Chapter 9, Section 4, page 125. Appeals about your health care An appeal is a way to ask us to change a coverage decision. To learn more about making an appeal, see Chapter 9, Section 5.3, page 130. Complaints about your health care 14

16 Chapter 2: Important phone numbers and resources You can call Member Services to make a complaint about us or any provider (including a non-network or network provider). A network provider is a provider who works with the health plan. You can also make a complaint about the quality of the care you got to us, or to the Quality Improvement Organization (see Section H below, page 21). If your complaint is about a coverage decision about your health care, you can make an appeal by calling Member Services. (See the section above.) You can also send a complaint about Tufts Health Unify right to Medicare. You can use an online form at home.aspx or call MEDICARE ( ) to ask for help. To learn more about making a complaint about your health care, see Chapter 9, Section 10, page 164. Coverage decisions about your drugs A coverage decision about your drugs is a decision about your benefits and covered drugs or the amount we will pay for your drugs. This applies to your Part D drugs, MassHealth prescription drugs, and MassHealth overthe-counter drugs. For more on coverage decisions about your prescription drugs, see Chapter 9, Section 6.4, page 144. Appeals about your drugs To learn more about making an appeal about your prescription drugs, see Chapter 9 Section 6.5, page 147. Complaints about your drugs You can make a complaint about us or any pharmacy. This includes a complaint about your prescription drugs. If your complaint is about a coverage decision about your prescription drugs, you can make an appeal. (See the section above and Chapter 9, Section 6.5, page 147.) You can send a complaint about Tufts Health Unify right to Medicare. You can use an online form at or call MEDICARE ( ) to ask for help. For more information on making a complaint about your prescription drugs, see Chapter 9, Section 10, page 164. Questions about payment for health care or drugs you already paid for For more information about paying a bill you got or to ask us how to pay you back for services or prescription drugs, see Chapter 7, page 100. TuftsHealthUnify.org. 15

17 If you ask us to pay a bill and we deny any part of your request, you can appeal our decision. See Chapter 9, Section 5.3, page 130, for more on appeals. B. How to contact your Care Manager CALL TTY WRITE WEBSITE This call is free. You can contact your Care Manager or a covering Care Manager, seven days a week, from 8 a.m. to 8 p.m. We have free interpreter services for people who do not speak English This call is free. This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. Seven days a week, from 8 a.m. to 8 p.m. Tufts Health Plan Attn: Member Services P.O. Box 9194 Watertown, MA TuftsHealthUnify.org Contact your Care Manager about: Questions about your health care Questions about getting medical services, behavioral health services and long-term services and supports (LTSS) Questions about available benefits Questions about transportation 16

18 Chapter 2: Important phone numbers and resources C. How to contact the 24/7 NurseLine Our NurseLine is available 24 hours a day, seven days a week, to provide you with general health information and support, including for any medical and behavioral health (mental health and/or substance abuse) questions that you may have. CALL TTY This call is free. 24 hours a day, seven days a week We have free interpreter services for people who do not speak English This call is free. 24 hours a day, seven days a week This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. Contact the 24/7 NurseLine Call Line about: Questions about your health care Getting educational materials regarding your condition Getting advice on your health and a symptom assessment for an illness or injury you may be experiencing D. How to contact the Behavioral Health Crisis Line CALL TTY This call is free. Seven days a week, from 8 a.m. to 8 p.m. We have free interpreter services for people who do not speak English This call is free. This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. Seven days a week, from 8 a.m. to 8 p.m. TuftsHealthUnify.org. 17

19 Contact the Behavioral Health Crisis Line if: You need help during a mental health crisis If you believe that you are having a medical Emergency, 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 are treatment centers that provide Behavioral Health (mental health and/or substance use disorder) emergency services 24 hours a day, seven days a week. To find the closest ESP Provider to you, call the statewide directory at You can also find a complete listing of emergency rooms and ESP Providers in Massachusetts at tuftshealthplan.com. E. How to contact the State Health Insurance Assistance Program (SHIP) The State Health Insurance Assistance Program (SHIP) gives free health insurance advice to people with Medicare. In Massachusetts, the SHIP is called SHINE (Serving the Health Insurance Needs of Everyone). SHINE is not connected with any insurance company or health plan. CALL AGE.INFO ( ) TTY WRITE WEBSITE (Massachusetts only) This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. Call the number above for the address of the SHINE program in your area. Contact SHINE about: Questions about your Medicare health insurance SHINE counselors can:» Help you understand your rights;» Help you understand your plan choices;» Answer your questions about changing to a new plan;» Help you make complaints about your health care or treatment; and» Help you fix problems with your bills. 18

20 Chapter 2: Important phone numbers and resources F. How to contact Medicare Medicare is a federal health insurance program. It covers people 65 years of age or older; some people under age 65 with disabilities; and people with end-stage renal disease (ESRD permanent kidney failure requiring dialysis or a kidney transplant). The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (CMS). CALL MEDICARE ( ) Calls to this number are free, 24 hours a day, 7 days a week. TTY WEBSITE This call is free. This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. This is the official website for Medicare. It gives you up-to-date information about Medicare. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print right from your computer. You can also find Medicare contacts in your state by selecting Forms, Help & Resources and then clicking on Phone numbers & websites. The Medicare website has the following tool to help you find plans in your area: Medicare Plan Finder: This tool provides personalized information about Medicare prescription drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) policies in your area. Select Find health & drug plans. If you don t have a computer, your local library or senior center may be able to help you visit this website using its computer. Or you can call Medicare at the number above and tell them what you are looking for. They will find the information on the website, print it out, and send it to you. TuftsHealthUnify.org. 19

21 G. How to contact MassHealth MassHealth helps with the cost of medical and long-term services and supports for people with limited incomes and resources. You are enrolled in Medicare and in MassHealth. If you have questions about the help you get from MassHealth, the contact information is below. CALL TTY This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. WRITE WEBSITE MassHealth Customer Service 55 Summer Street Boston, MA

22 Chapter 2: Important phone numbers and resources H. How to contact the Quality Improvement Organization (QIO) Massachusetts has a Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. The QIO is not connected with our plan. To get the contact information for the QIO, please call MassHealth Customer Service. CALL TTY This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. WRITE WEBSITE MassHealth Customer Service 55 Summer Street Boston, MA membersupport@mahealth.net Contact the QIO about: Questions about your health care You can make a complaint about the care you got if:» You have a problem with the quality of care;» You think your hospital stay is ending too soon; or» You think your home health care, skilled nursing facility care, or comprehensive outpatient rehabilitation facility (CORF) services are ending too soon. TuftsHealthUnify.org. 21

23 I. How to contact the One Care Ombudsman (OCO) The One Care Ombudsman (OCO) is an independent program that can help you if you have questions, concerns, or problems related to One Care. You can contact the OCO to get information or assistance. The OCO s services are free. The OCO can answer your questions or refer you to the right place to find what you need. The OCO can help you address a problem or concern with One Care or your One Care plan, Tufts Health Unify. The OCO will listen, investigate the issue, and discuss options with you to help solve the problem. The OCO helps with appeals. An appeal is a formal way of asking your One Care plan, MassHealth, or Medicare to review a decision about your services. The OCO can talk with you about how to make an appeal and what to expect during the appeal process. You can call, write, or visit the OCO at its office. CALL (toll-free) MassRelay 711 This number is for people who are deaf, hard of hearing, or speech disabled. You must have special telephone equipment to call it. WRITE WEBSITE One Care Ombudsman 11 Dartmouth Street, Suite 301 Malden, MA help@onecareombuds.org 22

24 Chapter 3: Using the plan s coverage for your health care and other covered services Table of Contents A. About services, covered services, providers, and network providers B. Rules for getting your health care and long-term services and supports covered by the plan C. Your Care Manager and Long-Term Supports (LTS) Coordinator D. Getting care from your primary care provider, specialists, other network providers, and out-of-network providers Getting care from a primary care provider How to get care from specialists and other network providers What if a network provider leaves our plan How to get care from out-of-network providers E. How to get long-term supports and services (LTSS) F. How to get behavioral health services G. How to get self-directed care H. How to get dental and vision services I. How to get covered services when you have a medical emergency or urgent need for care, or during a disaster Getting care when you have a medical emergency Getting urgently needed care Getting care during a disaster J. What if you are billed directly for services covered by our plan K. How are your health care services covered when you are in a clinical research study What is a clinical research study TuftsHealthUnify.org. 23

25 When you are in a clinical research study, who pays for what Learning more L. How are your health care services covered when you are in a religious nonmedical health care institution What is a religious nonmedical health care institution What care from a religious nonmedical health care institution is covered by our plan M. Rules for owning durable medical equipment (DME) Will you own your DME What happens if you switch to Medicare

26 Chapter 3: Using the plan s coverage for your health care and other covered services A. About services, covered services, providers, and network providers Services include medical care, behavioral health care, long-term services and supports, supplies, prescription and over-the-counter drugs, equipment, and others. Covered services are any of these services that our plan pays for. Covered services are listed in the Benefits Chart in Chapter 4, Section D, page 46. Providers are doctors, nurses, behavioral health specialists, and other people who give you services and care. The term providers also includes hospitals, home health agencies, clinics, and other places that give you health care services, medical equipment, and long-term services and supports. Network providers are providers who work with the health plan. These providers have agreed to accept our payment as full payment. B. Rules for getting your health care and long-term services and supports covered by the plan Tufts Health Unify covers services covered by Medicare and MassHealth. This includes behavioral health, long-term services and supports, and prescription and over-the-counter drugs. Tufts Health Unify will pay for the health care and services you get if you follow the plan rules that follow. The care you get must be a plan benefit. This means that it must be included in the plan s Benefits Chart. (The chart is in Chapter 4, Section D, page 46, of this handbook). The care must be Medically Necessary. Medically Necessary means that the services are reasonable and necessary: For the diagnosis and treatment of your illness or injury; or To improve the functioning of a malformed body member; or Otherwise Medically Necessary under Medicare law. In accordance with Medicaid law and regulation, and per MassHealth, services are Medically Necessary if: They could be reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions that endanger your life, TuftsHealthUnify.org. 25

27 cause you suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity; and There is no other medical service or place of service that is available, works as well, and is suitable for you that is less expensive. The quality of Medically Necessary services must meet professionally recognized standards of health care, and Medically Necessary services must also be supported by records including evidence of such medical necessity and quality. You must have a network primary care provider (PCP). As a plan member, you must choose a network provider to be your PCP. o To learn more about choosing a PCP, see page 29. o o o In most cases, your network PCP must give you approval before you can use other providers in the plan s network. This is called a referral. To learn more about referrals, see page 30. You do not need a referral from your PCP for emergency care or urgently needed care. You can also get other kinds of care without having a referral from your PCP. To learn more about this, see page 30. Please note: In your first 90 days with our plan, you may continue to see your current providers, at no cost to you, if they are not a part of our network. During the 90 days, our Care Manager will contact you to help you find providers in our network. After 90 days, we will no longer cover your care if you choose to see out-of-network providers. You must get your care from network providers. Usually, the plan will not cover care from a provider who does not work with the health plan. But sometimes this rule does not apply: o o o o The plan covers emergency or urgently needed care from an out-of-network provider. To learn more about what emergency or urgently needed care means, see page 35. If you need care that our plan covers, and our network providers cannot give it to you, then you can get the care from an out-of-network provider. In this situation, we will cover the care as if you got it from a network provider or at no cost to you. To learn about getting approval to see an out-of-network provider, see page 32. The plan covers kidney dialysis services when you are outside the plan s service area for a short time. You can get these services at a Medicarecertified dialysis facility. If you need Family-Planning services, you may get those services from any One Care plan provider or from any MassHealth contracted Family-Planning Services Provider. 26

28 Chapter 3: Using the plan s coverage for your health care and other covered services When you first join the plan, you can continue seeing the providers you see now for 90 days or until an alternative care plan has been agreed upon. There are exceptions in which you may continue to see your provider beyond 90 days. For example: o o o If you are currently in treatment for management of chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or covered services, you may be able to keep seeing him or her for up to another 90 calendar days. If your provider is your pregnancy care provider and you are in your second or third trimester of pregnancy, you may be able to keep seeing him or her up to and including your first postpartum visit (within the first six weeks of delivery). If you are terminally ill, you may be able to keep seeing him or her while you are sick. C. Your Care Manager and Long-Term Supports (LTS) Coordinator What is care coordination Care coordination means that our behavioral health, medical, and community service providers and social care managers work closely with each other, with your primary care provider, and with you to coordinate the care you need. We use Care Managers to make sure you get the best possible care and results. Your Care Manager can help you: o o o Make the transition between different care settings, such as from the hospital back home, or to an intermediate nursing facility Connect with an LTSS coordinator to find out what resources and benefits you can get in your community Manage your care with your providers and other health care and social services agencies working to improve your health How can you contact your Care Manager or LTS Coordinator Shortly after you become a Tufts Health Unify member, a member of the care management team will call you to set up your initial in-person comprehensive health assessment. Once your health assessment is complete, a Tufts Health Unify Care Manager is assigned to you and you are given contact information to reach this person. If you wish to speak to a Care Manager before completing your initial health assessment, you may call Your Care Manager can also help you reach your LTSS coordinator. How can you change your Care Manager A member may request to change his or her Care Manager at any time. Call Member TuftsHealthUnify.org. 27

29 Services at Or write to us at this address: Tufts Health Plan Attn: Member Services P.O. Box 9194 Watertown, MA D. Getting care from your primary care provider, specialists, other network providers, and out-of-network providers Getting care from a primary care provider You must choose a primary care provider (PCP) to provide and manage your care. What is a PCP, and what does a PCP do for you What is a PCP A PCP is the provider who manages your care. What types of providers may be a PCP You can choose an in-network doctor, nurse practitioner, or physician assistant as your PCP. PCPs must practice one of the following specialties: family practice, internal medicine, general practice, adolescent and pediatric medicine, or (for women only) obstetrics/gynecology. PCPs must be board-certified or eligible for board certification in their area of specialty. What is the role of a PCP in coordinating covered services Your PCP is the provider you should call for any kind of health care you need, unless you are having an emergency. You can call your PCP s office 24 hours a day, seven days a week. If your PCP is not available, someone else will be able to help you. Your PCP: o o o o o o o o Gives you regular checkups and health screenings, including behavioral health (mental health and/or substance use) screenings Makes sure you get the health care you need Arranges necessary tests, laboratory procedures, or hospital visits Keeps your medical records Recommends specialists, when needed Provides information on covered services that need prior authorization before you get treatment Prescribes medications, when necessary Helps you get behavioral health services, when necessary 28

30 Chapter 3: Using the plan s coverage for your health care and other covered services What is the role of a PCP in making a referral Your PCP provides you with any needed referrals before you get treatment. What is the role of a PCP when you need prior authorization (approval before you can get a service) Your PCP will ask us for approval when you need a service or when you need to get care from another network or out-of-network provider or location. Can a clinic be your PCP No. You must choose an in-network doctor, nurse practitioner, or physician assistant as your PCP. How do you choose your PCP To find a PCP and see where the PCP s office is located, please visit TuftsHealthUnify.org and use the Find a Doctor, Hospital, or Pharmacy tool. You can also call us to help you find and choose a PCP. If you don t choose a PCP, we ll choose a PCP we think is right for you and let you know your PCP s name and contact information. We ll also choose a PCP for you if the PCP you choose is not available. You can always choose a different PCP. Changing your PCP You may change your PCP for any reason, at any time. Also, it s possible that your PCP might leave our plan s network. In that case, you would have to find a new PCP. To change your PCP: Call us at When you call Member Services, your PCP changes take effect immediately. Or you can visit TuftsHealthUnify.org and use Tufts Health Member Connect, our online self-service tool. All PCP changes made online take effect within 24 hours. If your PCP or another provider is disenrolled from our network for reasons not related to quality of care, fraud, or other criminal conduct, or if they are no longer in practice, we ll make every effort to tell you at least 30 calendar days before the disenrollment. Whenever possible, we may be able to continue to cover some of your health care services if the following conditions apply to you: If the provider, including a PCP, is actively treating a chronic or acute medical condition, you may be able to keep seeing him or her through the current period of active treatment or for up to 90 calendar days after we tell you he or she is no longer part of our network. If the provider is your PCP, you may be able to keep seeing him or her for up to 31 calendar days after the PCP is disenrolled. TuftsHealthUnify.org. 29

31 If the provider is your pregnancy care provider and you are in your second or third trimester of pregnancy, you may be able to keep seeing him or her through delivery and a follow-up checkup within the first six weeks of delivery. If you are terminally ill, you may be able to keep seeing your provider 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 payment, quality, referrals, and other policies and procedures. You must call us at and tell us you want to keep seeing this provider. Services you can get without first getting approval from your PCP In most cases, you need a referral to see any provider that is not your PCP. A referral is approval from our plan. Sometimes you do not need a referral. You can get services like the ones listed below without first getting a referral or authorization from your PCP: Emergency services from network or out-of-network providers Urgently needed care from network providers Urgently needed care from out-of-network providers when you can t get to network providers (for example, when you are outside the plan s service area) Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are outside the plan s service area. (Please call Member Services before you leave the service area. We can help you get dialysis while you are away.) Flu shots, as long as you get them from a network provider Routine women s health care. This includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams, as long as you get them from a network provider. Post-stabilization care services Emergency transportation, including land and air and specialty care transport between facilities The first 12 outpatient behavioral health therapy visits each benefit year, as long as you get them from a network provider Laboratory services to maintain health and diagnose, treat, and prevent disease, including blood tests, urinalysis, Pap smears, throat cultures, and vaccines not covered by the Department of Public Health 30

32 Chapter 3: Using the plan s coverage for your health care and other covered services How to get care from specialists and other network providers: A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples. Oncologists care for patients with cancer. Cardiologists care for patients with heart problems. Orthopedists care for patients with bone, joint, or muscle problems. You may need prior authorization for specialist visits with a network provider. What is the role (if any) of the PCP in referring members to specialists and other providers If you need a specialist, you should discuss your need with your PCP first. Your PCP can recommend someone and will request prior authorization, if necessary. What is the process for getting prior authorization If the specialist you need to see requires prior authorization, your PCP will ask us for permission. We may approve your PCP s request, deny your PCP s request, or ask your PCP to make a different prior authorization request. If we don t give written approval for you to see an out-of-network provider, we won t cover the services. You have the right to appeal that decision. (See Chapter 9 for more information.) If you still choose to get the services, you will be responsible for payment. See the Benefits Chart in Chapter 4, Section D, page 46, for information about which services require prior authorization. Does the selection of a PCP result in being limited to specific specialists or hospitals to which that PCP refers Yes, your PCP may result in only being able to see specific specialists or hospitals to which the PCP refers. If you need a referral for specific services, your ID card will say PCP Referral Required. What if a network provider leaves our plan A network provider you are using might leave our plan. If one of your providers does leave our plan, you have certain rights and protections that are summarized below: Even though our network of providers may change during the year, we must give you uninterrupted access to qualified providers. We will make a good faith effort to give you at least 30 days notice so that you have time to select a new provider. We will help you select a new qualified provider to continue managing your health care needs. TuftsHealthUnify.org. 31