Tufts Health Forward. Member Handbook

Transcription

1 2014 Tufts Health Forward Meber Handbook This health plan eets Miniu Creditable Coverage standards and will satisfy the individual andate that you have health insurance. Please see page 6 for additional inforation. Effective Date: October 1, 2014 Issue Date: October 1, 2014

2 Fairhaven Mattapoisett Acushnet West Bridgewater Belont Chilark West Tisbury Oak Bluffs Tisbury Scituate Norwell Duxbury Kingston Rockland Whitan Brockton Avon Holbrook Cohasset Orange Warwick Blandford Chester Huntington Granville Southwick Tolland Granby Pelha Ashby Townsend Ashburnha Athol Barre Hardwick Hubbardston Oakha Petersha Royalston Westinster Winchendon New Braintree Holland Sturbridge Webster East Longeadow Longeadow Princeton Rutland Holden Sterling West Boylston Clinton Shrewsbury Berlin Upton Holliston Medway Seekonk Soerset Dover Millis Sharon Rehoboth Dighton Berkley Freetown Bridgewater Halifax Rochester Lakeville Middleborough Carver Plypton Wellesley New Bedford Littleton Groton Harvard Acton Westford Boxborough Concord Carlisle Billerica Tewksbury Andover Dracut Dunstable Pepperell Hudson Stow Bolton Braintree Canton Dedha Needha Norwood Westwood Winchester Stoneha Arlington Essex Ipswich Manchester by-the-sea Marblehead Merriac Rockport Salisbury Saugus Swapscott West Newbury Aquinnah Gosnold Nahant Montgoery Russell Westport Dartouth Norton Foxborough Plainville Attleboro North Attleboro Mansfield Douglas Sutton Mendon Grafton Hopkinton Westfield West Springfield Agawa New Sale Phillipston Tepleton Marlborough Maynard Southborough Westborough Sherborn Blackstone Northbridge Franklin Ashland Hopedale Milford Millville Paler Warren Monson Wales Charlton Oxford Ludlow Ayer Tyngsborough Chelsford Holyoke Springfield Chicopee Southapton Ware Gardner Fitchburg Leoinster Lunenburg Shirley Lancaster Boylston Worcester Paxton North Brookfield West Brookfield Brookfield East Brookfield Leicester Auburn Millbury Brifield Southbridge Dudley Northborough Raynha Chelsea Natick Weston Wayland Wrentha North Reading Reading Woburn Middleton Danvers Hailton Wenha Beverly Peabody Sale Lynn Topsfield Gloucester Bedford Watertown Lynnfield Newton Brookline Boston Milton Walpole Quincy Norfolk Medfield Stoughton Weyouth Easton Abington Taunton Swansea Fall River Provincetown Truro Wellfleet Eastha Orleans Chatha Dennis Yarouth Sandwich Mashpee Bourne Falouth Wareha Harwich Brewster Barnstable Winthrop East Boston Everett Revere Methuen Haverhill Lowell Aesbury Newbury Groveland Georgetown Boxford North Andover Melrose Medford Lincoln Cabridge Malden Wakefield Soerville Newburyport Lawrence Hull South Hadley Plyouth Spencer Bellingha East Bridgewater Lexington Wilington Burlington Hingha Edgartown Rowley Waltha Hapden Wilbraha Fraingha Hanover Marshfield Pebroke Hanson Belchertown Uxbridge Marion Randolph Nantucket Sudbury Easthapton Adas Becket Cheshire Clarksburg Florida Hinsdale Lee Lenox Monterey North Adas Otis Peru Pittsfield Sandisfield Savoy Sheffield Washington Windsor Buckland Ashfield Charleont Colrain Conway Erving Gill Hawley Heath Monroe Montague Northfield Rowe Shelburne Whately Chesterfield Cuington Goshen Plainfield Tyringha New Marlborough Great Barrington Wendell New Ashford Hancock Lanesborough Williastown Dalton Richond Egreont Alford Mount Washington Northapton Middlefield Worthington Bernardston Greenfield Williasburg Sunderland Hatfield Hadley Shutesbury Leverett West Stockbridge Stockbridge Deerfield Leyden Aherst Westhapton SOUTHERN CENTRAL WESTERN NORTHERN GREATER BOSTON Tufts Health Forward Coverage Area Region border Tufts Health Plan Network Health coverage areas Service area border

3 Welcoe! This handbook is full of inforation about how your health plan works. If you want to know how to get care when you need it, what services are covered, or who to talk to when you have a question, you ll find the answers here. This page includes iportant inforation to keep handy. Contact us: , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays TTY: (for people with partial or total hearing loss) Web: Network-Health.org Mail: 101 Station Landing, Fourth Floor, Medford, MA We have bilingual staff available and we offer translation services in 200 languages. All translation services are free to ebers. Call us: If you ove or change your phone nuber Don t risk losing your health benefits because we can t find you. If you ove, you ust call the Coonwealth Health Insurance Connector Authority (Health Connector) and us to tell us your new address and phone nuber. You should also put the last naes of all Tufts Health Forward ebers of your household on your ailbox. The post office ay not deliver ail fro the Health Connector or us to soeone whose nae is not listed on the ailbox. If you ove, call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.., and Tufts Health Plan Network Health at , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays, to update your contact inforation. Also, tell the Health Connector about any changes in your incoe, faily size, eployent status, or disability status; if you becoe pregnant; or if you have additional health insurance. To find out if other household ebers are eligible for Coonwealth Care If other people in your hoe ay be eligible for Coonwealth Care, we can help! Call us at They can also call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. If you want to change your Priary Care Provider (PCP) You can switch your PCP up to three ties a year for any reason by calling us at or by visiting us at Network-Health.org. IN AN EMERGENCY GET CARE RIGHT AWAY: Take iediate action if you believe that you are in a life-threatening eergency situation. For edical or Behavioral Health (ental health and/or substance abuse) Eergencies, call 911 or go to the nearest eergency roo right away. For Behavioral Health Eergencies, you ay also call the local Eergency Services Progra (ESP) Provider in your area. Please call us at or visit us at Network-Health.org for a coplete list of eergency roos and ESPs in Massachusetts, or call the statewide directory at to find the closest ESP to you. You can also find this list in our printed Tufts Health Plan Network Health Provider Directory. Call us at to ask for a copy of the Provider Directory. Bring your Tufts Health Forward ID card with you. Tell your PCP and, if applicable, your Behavioral Health Provider within 48 hours of an Eergency to get any necessary follow-up care. You don t need Prior Authorization for any eergency care, including abulance transportation and Post-stabilization Care Services. IN AN URGENT CARE SITUATION, CALL YOUR PCP OR BEHAVIORAL HEALTH (MENTAL HEALTH AND/OR SUBSTANCE ABUSE) PROVIDER: If you need Urgent Care for a proble that is serious but does not put your life in danger or risk peranent daage to your health, call your PCP or Behavioral Health Provider. Your PCP or Behavioral Health Provider can usually address these health probles. You can contact any of your Providers offices 24 hours a day, seven days a week. Make an appointent if your Provider asks you to coe in. If you request an Urgent Care appointent, your Provider ust see you within 48 hours. Meber Services Tea hours: If you want to talk to a Meber Services Tea representative who can answer your questions, call us at , Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. We re also available at , 24 hours a day, seven days a week, to help with any edical or behavioral health questions or needs. 24/7 NurseLine: 888-MY-RN-LINE ( ), for general health inforation and support, 24 hours a day, seven days a week TTY: Visit us on the Web! Visit us at Network-Health.org to: Find a PCP, Specialist, or health center near you Find a Behavioral Health Provider near you Sign up for Tufts Health Plan Network Health Meber Connect, and: Change your address or phone nuber Choose or change your PCP Use the secure essaging center to send us inforation and questions Get answers to your questions Download the fors to get your Tufts Health Forward EXTRAS Get iportant inforation, such as: How we ake sure you get the best care possible (Quality Manageent and Iproveent Progra) How we ake sure you get the right care in the right place (Utilization Manageent Progra). Please note: We never reward our staff for denying care. How we use inforation your Providers give us to decide what services you need to ake you better or keep you healthy (Utilization Review) How you can file a Grievance or 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 ay collect, use, protect, and release inforation about you and your health (your Protected Health Inforation) according to our privacy policy Learn uch ore!

4 2014 Tufts Health Public Plans, Inc

5 Table of contents The benefits of Tufts Health Plan Network Health 6 Translation and other forats Your Tufts Health Forward Evidence of Coverage Miniu creditable coverage and andatory health insurance requireent Getting the care you need 7 In an Eergency, get care right away For Urgent Care, call your Provider You are covered for Post-stabilization Care Services Carry your Tufts Health Forward Meber ID Card Getting inforation about Tufts Health Forward Providers Choose your Priary Care Provider (PCP) When you need Prior Authorization Seeing Specialists We support Continuity of Care You can get a second opinion Getting hospital services Getting care away fro hoe Preius (for Preiu-paying Mebers) 12 Co-payents 12 Co-payent waivers (Plan Type I and IIa non-preiu-paying Mebers) Co-payent Caps Co-payent transfers Pharacy Co-payents (Plan Type I, II, and III Mebers) Medical Co-payents (Plan Type II and III Mebers) Care Manageent 14 Health and wellness support Disease anageent progras Care coordination Integrated care anageent Covered Services 18 Services we cover Access to Covered Services If you get a bill for a Covered Service Services not covered 23 Quality Manageent 24 Utilization Manageent 24 Experiental and/or investigational drugs and procedures Tufts Health Forward EXTRAS 25 Coverage 28 Renewing your coverage Effective Coverage Date Protecting your benefits 28 Disenrollent 28 Changing health plans Your rights and responsibilities 29 Your right to appeal As a Tufts Health Plan Network Health Meber, you have the right to Advance Directives As a Tufts Health Plan Network Health Meber, you have the responsibility to Additional inforation available to you How to resolve concerns with Tufts Health Plan Network Health 31 Inquiries Grievances Appeals External Review process Expedited External Reviews Questions or concerns? When you have additional insurance 35 Coordination of Benefits Subrogation Meber cooperation Motor vehicle accidents and/or work-related injury/illness Notice of Privacy Policy 36 Our responsibilities Your rights for privacy practices Glossary 38 Benefit and Co-payent Suary 43 Plan Type I Plan Type II Plan Type III A great health plan at a great price Keep this handbook it has all the inforation you need to ake the ost of your Tufts Health Forward ebership. If you have any questions, please call us at Mebers with partial or total hearing loss should call our TTY line at for assistance. 5

6 The benefits of Tufts Health Plan Network Health You deserve great care. We want you to get the ost out of your Tufts Health Forward ebership. You get all the benefits of your Coonwealth Care plan, PLUS additional free and discounted Tufts Health Forward EXTRAS. To bring you the best value in health care, we work with a high-quality Network of doctors, hospitals, and other Providers across Massachusetts. We serve Tufts Health Forward Mebers in all or parts of the following counties: Barnstable, Berkshire, Bristol, Essex, Franklin, Hapden, Hapshire, Middlesex, Norfolk, Plyouth, Suffolk, and Worcester. For a coplete listing of our Providers, or to see a ap of our Service Area, please visit Network-Health.org. Tufts Health Public Plans, Inc. is licensed as a health aintenance organization in Massachusetts, but does business under the nae Network Health. To help you understand what you need to know about your health plan, we have capitalized iportant words and ters throughout this Meber Handbook. You can find definitions for each starting on page 38. Translation and other forats If you have questions, need this docuent translated, need soeone to read this or other printed inforation to you, or want to learn ore about any of our benefits or Covered Services, call us at (TTY: for people with partial or total hearing loss), Monday through Friday, fro 8 a.. to 5 p.. We can give you inforation in other forats, such as Braille, large type size, and Aerican Sign Language video clips, and in different languages. We have bilingual staff available and we offer translation services in 200 languages. All translation services are free to Mebers. Your Tufts Health Forward Evidence of Coverage This Meber Handbook, including the Benefit and Co-payent Suary for each Plan Type at the end of this handbook, your Preferred Drug List, and any aendents we ay send you, ake up your Evidence of Coverage. These docuents are a contract between you and us. By signing and returning your enrollent application to the Health Connector, and choosing Tufts Health Plan Network Health as your Coonwealth Care plan, you applied for coverage fro us. You also agree to all the ters and conditions of Coonwealth Care that the Health Connector sets forth, and to the ters and conditions of this handbook. This handbook explains your rights, benefits, and responsibilities as a Tufts Health Forward Meber. It also explains our responsibilities to you. If there are any ajor plan changes, we ll notify you by ail 60 Days before the changes go into effect. Only an authorized officer of Tufts Health Plan Network Health can change this Meber Handbook and only in writing. No other actions, including any exceptions we ake on a case-by-case basis, change this Meber Handbook. Miniu creditable coverage and andatory health insurance requireent Massachusetts law requires that Massachusetts residents, 18 years of age and older, ust have health coverage that eets the Miniu Creditable Coverage standards that the Health Connector sets, unless waived by the Health Connector based on affordability or individual hardship. For ore inforation, call the Health Connector at 877-MA-ENROLL ( ) (TTY: ) or visit the Health Connector s website at MAhealthconnector.org. This health plan eets Miniu Creditable Coverage standards as part of the Massachusetts Health Care Refor Law. If you enroll in this plan, you will satisfy the statutory requireent that you have health insurance eeting these standards. 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 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a day, seven days a week. You can also visit us at Network-Health.org.

7 Getting the care you need In an Eergency, get care right away An Eergency is when you believe your life or health is in danger or would be if you do not get iediate care. Severe burn Severe headache Shortness of breath Voiting that won t stop Exaples of Behavioral Health Eergencies: Violent feelings toward yourself or others Hallucinations For edical and Behavioral Health (ental health and/or substance abuse) Eergencies, call 911, or go to the nearest eergency roo right away. For Behavioral Health Eergencies, you ay also call the local Eergency Services Progra (ESP) Provider in your area. Please call us at , or visit us at Network-Health.org, for a coplete list of eergency roos and ESPs in Massachusetts, or call the statewide directory at to find the closest ESP to you. You can also find this list in our printed Provider Directory. Call us at , Monday through Friday, fro 8 a.. to 5 p.., to ask for a copy of the Provider Directory. Bring your Tufts Health Forward ID Card with you. You don t need approval fro us or your Provider to get eergency care. You can get eergency care 24 hours a day, seven days a week, wherever you are, even when you re traveling. We also cover eergencyrelated abulance transportation and Post-stabilization Care Services, which is care to help you get better after an Eergency. A Provider will exaine and treat your eergency health needs before sending you hoe or oving you to another Hospital, if necessary. Tell your Priary Care Provider (PCP) and, if applicable, your Behavioral Health Provider what happened within 48 hours of an Eergency in order to get any necessary follow-up care. Exaples of edical Eergencies: Chest pain Bleeding that won t stop Broken bones Seizures or convulsions Dizziness or fainting Poisoning or drug overdose Serious accident Sudden confusion For Urgent Care, call your Provider An urgent situation is when you have a health proble that needs attention right away but you don t believe you re having an Eergency. Exaples are flu-like syptos that are getting worse or a cough or cold that is not getting better. Call your PCP or Behavioral Health Provider if you need Urgent Care. You can contact any of your Providers offices 24 hours a day, seven days a week. If appropriate, ake an appointent to visit your Provider. Your Provider ust see you within 48 hours for Urgent Care appointents. If your condition becoes an Eergency before your PCP or Behavioral Health Provider sees you, call 911 or go to the eergency roo. If you have a Behavioral Health concern, you ay also call your local ESP Provider. You are covered for Post-stabilization Care Services After an Eergency, you ay need Post-stabilization Care Services to help you get better and stay healthy. You can get these services at Hospitals and health care centers that provide eergency services. These services ight include Inpatient Services, additional tests, and outpatient care. Please call us at or use the Find a Doctor, Hospital, or Pharacy tool at Network-Health.org for a coplete list of eergency roos and ESP Providers in Massachusetts. You can also call the statewide directory at to find the closest ESP to you. Call us at if you would like a printed copy of our Provider Directory, which also has this inforation. For Coonwealth Care-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 7

8 Carry your Tufts Health Forward Meber ID Card Your Tufts Health Forward Meber ID Card has iportant inforation about you and your benefits that Providers and pharacists need. Each person in your faily with Tufts Health Forward will get a Tufts Health Forward Meber ID Card. Getting inforation about Tufts Health Forward Providers For the ost up-to-date inforation about Providers (doctors and other professionals who contract with us to provide health care), visit us at Network-Health.org and use the Find a Doctor, Hospital, or Pharacy tool. For a copy of our Provider Directory, or to get inforation about a Provider, call our Meber Services Tea at Our Provider Directory lists the following types of Tufts Health Forward Providers: Priary care sites Priary Care Providers (PCPs) Hospitals Specialty Providers Behavioral Health Providers In our Provider Directory, you can find iportant inforation like a Provider s address, phone nuber, hours of operation, handicap accessibility, and languages spoken. Our Provider Directory also lists all Tufts Health Forward pharacies, facilities, ancillary Providers, hospital eergency services, ESP Providers for Behavioral Health, and durable edical equipent suppliers. You can also find this inforation online at Network-Health.org. Choose your Priary Care Provider (PCP) A PCP is the Provider who anages your care. You can choose a doctor, a nurse practitioner, or a licensed physician assistant as your PCP. As a Tufts Health Forward Meber, you ust choose a PCP who is in our Tufts Health Forward Network. Your PCP is the Provider you should call for any noneergency health care that you need. You will receive the sae Medically Necessary Covered Services whether you choose a nurse practitioner, a licensed physician assistant, or a doctor as your PCP. To choose a Tufts Health Forward PCP and to find out where the PCP s office is located, please use the Find a Doctor, Hospital, or Pharacy tool at Network-Health.org or call us at You should choose a PCP in the region where you live. You can call your PCP s office 24 hours a day, seven days a week. If your PCP is not available, soebody else can help you. If you have probles contacting your PCP, or if you have any questions, please call our Meber Services Tea at Here s what your PCP can do for you: 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 edical records Recoend Specialists, when necessary Provide inforation on Covered Services that need Prior Authorization (perission) before you get treatent Write prescriptions, when necessary Help you get Behavioral Health services, when necessary PCP assignent If you don t choose a PCP within 15 Days of joining Tufts Health Plan Network Health, we ll choose one for you near to where you live and tell you your PCP s nae. We ll also choose a PCP for you if the PCP you chose is not available. You can choose a different PCP by calling us at or visiting Network-Health.org. Getting care after office hours Talk to your PCP to find out how to get care after noral business hours. Soe 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. A covering Provider is a Provider who can help you when your PCP is not available. If you have any probles seeing your PCP or any other Provider, please call us at Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a day, seven days a week. You can also visit us at Network-Health.org.

9 You can also get free health support fro our NurseLine 24 hours a day, seven days a week, to help you stay healthy. Call 888-MY-RN-LINE ( ) (TTY: ) anytie. You can get help in any languages. Reeber, the NurseLine staff do not give edical advice and do not replace your PCP. When you need Prior Authorization Your PCP will work with your other Providers to ake sure you get the care you need. For certain services, your PCP will need to ask us first for Prior Authorization before sending you to get those services. For ore inforation about which services need Prior Authorization, please see your Plan Type s Benefit and Co-payent Suary section in this Meber Handbook or, for the ost up-to-date list, visit us at Network-Health.org. Your PCP knows when and how to ask us for Prior Authorization if it is required. When your PCP asks, we ll decide if the service is Medically Necessary and if we have a qualified In-network Provider who can provide the service. 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. Nonpreferred In-network Providers and Out-of-network Providers need Prior Authorization fro us before you can see the. Please visit us at Network-Health.org for the ost up-to-date list of our In-network Providers. You don t need Prior Authorization for eergency health care, Post-stabilization Care Services, Faily-planning Services, and the first 12 in-network outpatient Behavioral Health visits. You can get eergency services fro any Massachusetts eergency care provider. You can get Faily-planning Services fro any Coonwealth Care-contracted Faily-planning Services provider. You do not need Prior Authorization for care provided by an in-network obstetrician, gynecologist, certified nurse idwife, or faily practitioner for an annual preventive gynecologic health exaination, including any follow-up care, aternity care, or treatent for an acute or eergency gynecological condition. If you becoe a Tufts Health Plan Network Health Meber by changing fro another Coonwealth Care plan, and a provider who does not contract with us is treating you, we ll review that treatent and ay let that provider continue to treat you. Reeber, you ust get Prior Authorization fro us to continue seeing that Out-of-network Provider. Standard Prior Authorizations We ll ake an initial decision about a Prior Authorization within two business days of obtaining all needed inforation. We ll let your Provider requesting the service know within 24 hours of our decision. We ll let you know in writing within one business day if we deny Authorization, and within two business days if we approve Authorization. Reeber: If we don t authorize your seeing a Provider or having a procedure that requires Prior Authorization, we won t pay for the services you receive. Concurrent review When you are a Hospital patient, or are getting treatent for a condition, we will review your situation to ensure that the right care is given in the right place. This is called a concurrent review. We ake concurrent review decisions within one business day of getting all the necessary inforation fro your Provider. Necessary inforation includes the results of any face-to-face clinical evaluation or second opinion. Your network Provider ust notify us of an eergency or urgent adission within 24 hours. If we approve a longer stay or extra services, we ll let your Provider know within one business day, and we ll ail to you and fax to your Provider a confiration within one business day after that. The notification will include the nuber of extended Days or the next review date, the new total nuber of Days or services we ve approved, and the date of adission or start of services. If we deny a longer stay or additional services, we ll let your Provider know within one business day, and we ll ail to you and fax to your Provider confiration of this Adverse Deterination within one business day after that. You can continue getting the service at no cost to you until we let you know about our concurrent review decision. Prior Authorization approvals and denials If we authorize the services, we will clearly tell you, your Provider, and your Authorized Representative, if you identify one, which services we agree to cover. The Provider providing the service ust have an authorization letter fro us before giving you care. If you need ore care than we authorized, your Provider will ask us to authorize additional services. If we approve the request for additional services, we ll send you, your Provider, and your Authorized Representative another authorization letter. For Coonwealth Care-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 9

10 If we don t authorize any of the services requested, authorize only soe of the services requested, or don t authorize the full aount, duration, or scope of the services requested, we ll send you, your Provider, and your Authorized Representative a denial or Adverse Deterination letter. We ll also send a notice if we decide to reduce, delay, or stop covering services that we have previously authorized. The Adverse Deterination letter we send will include a clinical explanation for our decision and will: Identify specific inforation we used Discuss your syptos or condition, diagnosis, and the specific reasons why the evidence your Provider sent us fails to eet the relevant edical review criteria Specify alternate treatent options that we cover Reference and include applicable clinical practice guidelines and review criteria Tell you or your Authorized Representative how to ask for an Appeal, including an Expedited Internal Appeal 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 section How to resolve concerns with Tufts Health Plan Network Health starting on page 31. Reconsideration of an Adverse Deterination If we have denied authorization for services, the Provider treating you can ask us to reconsider our decision. The reconsideration process will occur within one business day after we get the request. A clinical reviewer will conduct the reconsideration and talk to your Provider. If we don t change our decision, you, your Provider, or your Authorized Representative ay use the appeals process described starting on page 32. You don t have to ask us to reconsider an Adverse Deterination before requesting a Standard Internal Appeal or Expedited Internal Appeal. Seeing Specialists Specialists are Providers who have extra training and who focus on one kind of care or on one part of the body. Soeties you ay need to visit a Specialist, such as a cardiologist (heart doctor), deratologist (skin doctor), or ophthalologist (eye doctor). You can visit ost Specialists without Prior Authorization as long as the Specialist is a Preferred In-network Specialist. To find a Tufts Health Forward Specialist, talk to your PCP. You can also call us at or visit Network-Health.org and use the Find a Doctor, Hospital, or Pharacy tool to search for a Specialist. We also list Specialists in our Provider Directory; call us to get a copy. You should discuss your need to see a Specialist with your PCP first, and then call the Specialist to ake an appointent. If the Specialist your PCP wants to send you to is a Nonpreferred In-network Specialist or an Out-ofnetwork Specialist, your PCP will need to ask us for Prior Authorization before sending you to see this Specialist. We ay approve your PCP s request, deny your PCP s request, or ask your PCP to ake a different Prior Authorization request. You can find out which Providers require Prior Authorization by using the Find a Doctor, Hospital, or Pharacy tool at Network-Health.org, or by calling us at Reeber, if we don t give written approval for you to see a Nonpreferred In-network or an Out-of-network Specialist, we won t cover the services. If you still choose to get the services anyway, the Specialist will bill you and you will be responsible for paying the full cost of the care. For ore inforation about which services need Prior Authorization, please see your Plan Type s Benefit and Co-payent Suary section in this Meber Handbook. Referrals for specialty services Soe PCPs ay need to provide you with a Referral for certain specialty services. A Referral is a notification fro your PCP to us that you can get care fro a different Provider. The Referral helps your PCP better guide the care and services you get fro 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 10 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a day, seven days a week. You can also visit us at Network-Health.org.

11 Your PCP ay authorize a standing referral for certain specialty care fro a Preferred In-network Provider if your PCP and the specialist agree on a treatent plan for you of Medically Necessary Covered Services. Reeber, your PCP, not the Specialist treating you, ust request any additional referrals you ay need. If your PCP needs to give a Referral for these services, your Meber ID card will say PCP Referral Required. You should not be billed for any of these services if you get the fro an In-network Provider. You don t need a PCP Referral for any outpatient Behavioral Health or OB/GYN services for an annual preventive gynecologic health exaination, including any follow-up care, aternity care, or treatent for an acute or eergency gynecological condition. We support Continuity of Care New Mebers* If you are a new Tufts Health Plan Network Health Meber, we ll ake sure any care you are currently getting continues to go as soothly as possible. To ensure Continuity of Care, we ay be able to cover soe health services, including Behavioral Health services, fro a provider who isn t part of our Network. For exaple, we will cover: Care you receive fro your current OB/GYN, even if out-of-network, if you are at least three onths pregnant (eaning you are starting your fourth onth, based on your expected due date). You can continue seeing your current OB/GYN until you have the baby and a follow-up checkup within the first six weeks of delivery. Ongoing covered treatent or anageent of chronic issues (like dialysis, hoe health, cheotherapy, and radiation) for up to 30 Days, including previously authorized services or Covered Services. Ongoing care for up to 30 Days if the provider is your PCP Care fro your provider if you are terinally ill Existing Mebers* If your PCP or another Provider is disenrolled fro our Network for reasons not related to quality of care or Fraud, or if they are no longer in practice, we ll ake every effort to tell you at least 30 Days before the disenrollent. For exaple, we ay cover: Care you receive fro your current OB/GYN, even if out-of-network, if you are at least three onths pregnant (eaning you are starting your fourth onth, based on your expected due date). You can continue seeing your current OB/GYN until you have the baby and a follow-up checkup within the first six weeks of delivery. Ongoing covered treatent for a chronic or acute edical condition for up to 90 Days, or until that Provider copletes the active treatent, whichever coes first Ongoing care for up to 31 Days if the provider is your PCP Care fro your provider if you are terinally ill Your Provider ust ask us for and get Prior Authorization before you can see an Out-of-network Provider. You ay ask your Provider to ask for the Prior Authorization or to call our Meber Services Tea at You can see an Out-of-network Provider: When a participating In-network Provider is unavailable because of location When a delay in seeing a participating In-network Provider, other than eber-related delays, would result in interrupted access to Medically Necessary services If there isn t a participating In-network Provider with the qualifications and expertise that you need to get and stay better * We will allow you to continue treatent with an Out-ofnetwork Provider only if the provider agrees to our ters related to reiburseent, quality, Referrals, and additional Tufts Health Forward policies and procedures. You can get a second opinion Tufts Health Forward Mebers can get a second opinion fro a different Provider about a edical or behavioral health condition, or proposed treatent and care plan. You don t need Prior Authorization to get a second opinion fro an In-network Provider about a edical or behavioral health issue or concern. You can see the ost up-to-date list of our In-network Providers at Network-Health.org. Please call us at for help or for ore inforation about picking a Provider to see for the second opinion. For Coonwealth Care-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 11

12 Getting hospital services If you need hospital services for soething that isn t an Eergency, please ask your Provider to help you get these services. If you need hospital services for an Eergency, don t wait. Call 911 or go to the nearest eergency roo right away. For Behavioral Health Eergencies, call 911 or your local ESP Provider, or go to the nearest eergency roo right away. Getting care away fro hoe If you re traveling and need eergency care, go to the nearest eergency roo. 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, including out of the country, we ll only cover eergency care, Post-stabilization Care Services, and Urgent Care. We won t cover: Tests or treatent that your PCP asked for but that you decided to get outside of the Service Area Routine or follow-up care that can wait until you return to the Service Area, such as physical exas, flu shots, stitch reoval, and Behavioral Health counseling Care that you knew you were going to get before you left the Service Area, such as elective surgery When you get care outside of Tufts Health Plan Network Health s Service Area, the Provider ight ask you to pay for that care at the tie of service. If you re asked to pay for eergency care, Post-stabilization Care Services, or Urgent Care that you get outside of our Service Area, you should show your Tufts Health Forward Meber ID Card. The Provider shouldn t ask you to pay. If you do pay for any of these services, you ay ask us to reiburse you. You ay call our Meber Services Tea at for help with any bills that you ay get fro a Provider. Preius (for Preiu-paying Mebers) Soe Coonwealth Care Plan Types require you to pay a Preiu for your Coonwealth Care coverage. A Preiu is a onthly bill you pay directly to the Health Connector for your Coonwealth Care benefits. Please don t send your Preiu payents to us. Each onth, you ll get a bill fro the Health Connector. You ust send your payent to the Health Connector so that they get it by the 25th day of that onth. You ust pay this bill every onth for your health benefits to continue. Please follow the directions the Health Connector gives you for paying your Preius and ake your check or oney order out to Coonwealth Care. Please ail your payents to: Coonwealth Care P.O. Box Boston, MA You ay also pay your bill online. Please visit MAhealthconnector.org and click on E-Pay. You ay apply for a waiver or Preiu-payent reduction if you believe you have an extree financial hardship that affects your ability to pay. The Health Connector only considers certain events to create an extree financial hardship. You ay also qualify for a payent plan for your Preiu. If you have any questions about your Preiu, or want to learn ore about these options, please contact Coonwealth Care s custoer service center at 877-MA-ENROLL ( ) (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. Co-payents You re responsible for paying all of the Co-payents listed in your Plan Type s Benefit and Co-payent Suary starting on page 43 of this Meber Handbook. If you can t afford the Co-payent when you get a service, tell your Provider. You should never go without care you need because you can t afford the Co-payent. If you don t pay the Co-payent at the tie of your visit, you ll still owe the oney to the Provider. The Provider ay use a legal ethod to collect the oney fro you. We are not responsible for paying the Provider the Co-Payent that you owe. 12 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a day, seven days a week. You can also visit us at Network-Health.org.

13 Co-payent waivers (Plan Type I and IIa* non-preiu-paying Mebers) You ay apply for a co-payent waiver for up to 12 onths if you believe you have an extree financial hardship that affects your ability to pay Co-payents. The Health Connector considers only certain events to create extree financial hardship. If you want to learn ore about applying for a co-payent waiver, please call Coonwealth Care s custoer service center at 877-MA-ENROLL ( ) (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. * Plan Type IIa is the specific Plan Type (that ay or ay not have a Preiu) for individuals who earn between 100% and 150% of the Federal Poverty Level. To get incoe exaples for different faily sizes for Plan Type IIa Mebers, or if you have any questions, please visit Network-Health.org or call us at , Monday through Friday, fro 8 a.. to 5 p.. Co-payent Caps There s a yearly liit on how uch you have to pay in Co-payents. Once you reach your Plan Type s liit, you cannot be charged ore Co-payents unless your Plan Type changes. For ore inforation about your specific Plan Type s Co-payent Cap, and what to do when you ve reached this cap, see the sections Pharacy Co-payents and Medical Co-payents on this page. Co-payent transfers The Co-payents you pay during the Benefit Year (July 1 Deceber 31) count, even if you change health plans or your Plan Type changes. Because you don t have to pay Co-payents after you reach your Co-payent Cap, you ust call your old health plan to ask for a Co-payent Transfer Letter. You ust send us this letter within 45 Days of your coverage start date. The letter will tell us how uch you already paid in Co-payents during the Benefit Year (July 1 Deceber 31). If you didn t eet your Co-payent Cap, you ay still need to continue paying Co-Payents if your Plan Type changes or if you switch health plans. If you have any questions about this process, please call us at Pharacy Co-payents (Plan Type I, II, and III Mebers) A Pharacy Co-payent is a fixed aount you ust pay for a covered pharacy service. There is a yearly Co-payent Cap (or liit on what you will be charged) for pharacy services. Please see your Plan Type s Benefit and Co-payent Suary at the back of this handbook for your specific Plan Type Co-payents and Co-payent Caps. Once you ve been charged the axiu aount in Pharacy Co-payents in a Benefit Year (July 1 Deceber 31), you no longer have to pay Pharacy Co-payents. This is called a Pharacy Co-payent Cap. We ll send you a letter telling you that you have reached your Pharacy Co-payent Cap and that you don t have to pay any ore Pharacy Co-payents. You can t be charged additional Pharacy Co-payents for the rest of the Benefit Year unless your Coonwealth Care Plan Type changes. If your Plan Type changes, you ay have to start aking Pharacy Co-payents again, even if you had reached your Pharacy Co-payent Cap. We ll apply the Pharacy Co-payents you have already paid to your new Plan Type s Pharacy Co-payent Cap aount. Medical Co-payents (Plan Type II and III Mebers) A Medical Co-payent is a fixed aount you ay have to pay for Covered Services other than pharacy. You will need to pay a Co-payent for Covered Services, such as doctors visits, high-cost iaging (MRIs, PET, CT scans), eergency roo visits, and care you get in the Hospital. These services that require Co-payents count toward your yearly Medical Co-payent Cap. Once you ve been charged the axiu aount in Medical Co-payents in a Benefit Year (July 1 Deceber 31), you no longer have to pay Medical Co-payents. This is called a Medical Co-payent Cap. We ll send you a letter telling you that you ve reached your Medical Co-payent Cap and that you don t have to pay any ore Medical Co-payents. For Coonwealth Care-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 13

14 You can t be charged additional Medical Co-payents for the rest of the Benefit Year unless your Coonwealth Care Plan Type changes fro Plan Type II to Plan Type III. If you change fro Plan Type II to Plan Type III, you will have to start aking Medical Co-payents again, even if you had reached your Medical Co-payent Cap in your old Plan Type. We ll apply the Medical Co-payents you ve already paid to your new Plan Type s Medical Co-payent Cap aount. Care Manageent Care Manageent is everything we do to help keep you well and iprove your health. Our care anageent services include helping you ake and keep appointents, getting you health inforation, and coordinating your care with your Provider(s). There are four types of Care Manageent: health and wellness support; disease anageent; care coordination (transition of care and Behavioral Health [ental health and/or substance abuse] services); and integrated care anageent, which includes care coordination with coplex care anageent, intensive clinical anageent (ICM), social care anageent, and clinical counity outreach. Care Manageent doesn t replace the care you get fro your Priary Care Provider (PCP) or other Providers but helps support it. Please reeber to continue to schedule regular and ongoing visits with your Providers. Our care anagers work with your Providers to coordinate your care and ake sure you get the care you need when you need it. To help us do this, be sure to return the Your Health For we send you. Call us at to talk to our care anageent tea, Monday through Friday, fro 8 a.. to 5 p.., or to our on-call service at night and on weekends. Health and wellness support Health coaching for chronic probles We understand how iportant it is for you to feel in control of your health. Learning to take control of your health when you have an ongoing, chronic health proble (such as diabetes or astha) can feel overwheling. You can use our free health coaching services to help you. Learn how our health coaching can help you feel good about the health care decisions you ake. Visit us at Network-Health.org or call our 24/7 NurseLine at 888-MY-RN-LINE ( ) to find out about our health coaching services: Personalized health coaching Our health coaches are specially trained health professionals available Monday through Saturday, fro 8 a.. to 9 p.., to talk to you about your iediate or everyday health concerns. Valuable health inforation We have easy-to-understand articles on thousands of health topics for you at Network-Health.org. Healthy reinders throughout the year Depending on your health needs, we ay send you reinders about iportant tests or inforation you should discuss with your Providers. Maternal and child health progra We work closely with you and your Providers to ake sure you get ongoing prenatal care if you re pregnant. We can also help coordinate care you need after you deliver. For inforation about the benefits and services we offer pregnant Tufts Health Forward Mebers, see page 22. MassHealth offers iportant extra benefits for pregnant woen and their babies. If you are pregnant, check with us or with MassHealth to see if you are eligible. If you are, you ay transfer to our MassHealth plan, Tufts Health Together, for your health care coverage. If you re not eligible for MassHealth, you will continue to be a Tufts Health Forward Meber throughout your pregnancy. 24/7 NurseLine We have a 24-hour NurseLine for help with health questions, seven days a week. When you call our 24/7 NurseLine at 888-MY-RN-LINE ( ) (TTY: ), you can talk with a caring and supportive licensed health care professional at no cost. Staff ebers can give you general health inforation and support on health care topics such as syptos, diagnoses, treatents, tests, test results, and procedures your Provider orders. Staff ebers do not give edical advice and are not a replaceent for your Provider. Help with quitting soking Tufts Health Forward Mebers are eligible to receive free tobacco cessation counseling services and edications fro In-network Providers, including nicotine replaceent therapy. Mebers are covered for a iniu of 16 group and individual counseling sessions, without Prior Authorization, per Benefit Year (July 1 Deceber 31). 14 Have questions? Please call Tufts Health Plan Network Health s Meber Services Tea at (TTY: ), Monday through Friday, fro 8 a.. to 5 p.., excluding holidays. For help with any edical or behavioral health (ental health and/or substance abuse) questions or needs, you can call anytie, 24 hours a day, seven days a week. You can also visit us at Network-Health.org.

15 Mebers are eligible for a 90-day supply of all FDAapproved edications used for tobacco cessation each tie they attept to quit, up to a axiu of twice per Benefit Year (July 1 Deceber 31). There is a Co-payent of $3.65 for pharacy edications. The Massachusetts Sokers Helpline 800-QUIT-NOW ( ) provides free phone counseling for quitting tobacco and can also tell you about in-person counseling available in your area. To get daily tips on quitting soking in English and Spanish, call GET-A-TIP ( ). Disease anageent progras We want to help you get the best health care possible. We use Evidence-based guidelines (guidelines based on the best research) in our disease anageent progras. These progras help you live as healthfully as possible and feel your best. We have staff ebers who are experts on any health topics, so we can connect you with inforation and counity resources you can really use. For ore inforation, please visit us at Network-Health.org or call us at We have disease anageent progras for the following conditions: Astha There s a lot we can do to help keep astha fro keeping you down. Working with your Provider, we can help you avoid trips to the eergency roo and live life to its fullest. With our free in-hoe astha education progra, we can even send a nurse to your hoe to help you get started. The nurse can give you inforation and tools to help you understand astha and its causes, triggers, and syptos. A visiting nurse can also help you learn how to spot the warning signs of a flare-up (attack) before it happens, look for probles in your hoe that ay ake your astha worse, talk with you about an astha action plan, review and educate you about your edications, and take other steps to ake sure you get any other services you ight need. The visiting nurse, with Prior Authorization fro us, can also order supplies such as a attress and pillow covers for you. If you have astha or think you have astha, please contact our astha progra anager today at Diabetes Our diabetes progra has staff ebers available to help you anage type 1, type 2, and gestational (when you re pregnant) diabetes. Diabetes supplies and lab work are covered benefits, including heoglobin HbA1c and lipids tests, as are yearly dilated eye exas. One of our diabetes clinicians can arrange your health care with your PCP and any Specialists you ay need to see. You also can use our Behavioral Health and social care anageent progras. If you need it, you can take classes that are approved by the Aerican Diabetes Association. We stay in touch with our Mebers with diabetes. We ay send you helpful inforation, such as inforation about why certain tests are iportant and how you can better anage diabetes. Additionally, we ay call to reind you about yearly lab work and PCP appointents. Visiting Nurse Association (VNA) services are available to help you get any needed ongoing edical care. We also offer, when appropriate, diabetes education if you re hoebound. We work with Neighborhood Diabetes, an approved vendor for diabetic supplies. Their representatives can: Give you a free eter Visit you at hoe and teach you about using your eter Teach you less painful ways to test your blood Teach you about regular foot and eye care Teach you healthy eating habits Deliver supplies to your hoe for free Make sure you always have testing supplies when you need the If you want to learn ore, please call Neighborhood Diabetes at This progra is free to Tufts Health Plan Network Health Mebers. For ore inforation about the benefits and services we offer our Mebers who have diabetes, please see page 26. Care coordination Transition of care When you leave a 24-hour care facility (like an acute-care Hospital, a Rehabilitation Hospital, a transitional care unit, or a Skilled Nursing Facility), our care anagers will help you with a transition plan (the care you need to help you keep getting better). Our care anagers will work with ancillary providers, like VNA and Durable Medical For Coonwealth Care-related questions, please call the Health Connector s custoer service center at (TTY: ), Monday through Friday, fro 8 a.. to 6 p.. 15