Covered Services List

2018 Tufts Health Together Covered Services List MCO-6113 ENG 11137

COVERED SERVICES LIST MassHealth Standard or CommonHealth Coverage, MassHealth CarePlus, and MassHealth Family Assistance Please refer to the following pages for exact details and/or limitations, including prior authorization requirements for members with MassHealth CarePlus, Family Assistance, and Standard or CommonHealth coverage. Each plan may have different covered services and benefits available to our members. MassHealth Standard or CommonHealth Coverage...5 MassHealth CarePlus Coverage...21 MassHealth Family Assistance Coverage...33

DISCRIMINATION IS AGAINST THE LAW Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Tufts Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Tufts Health Plan at 888.257.1985. If you believe that Tufts Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Tufts Health Plan Attention: Civil Rights Coordinator, Legal Dept. 705 Mount Auburn Street Watertown, MA 02472 Phone: 888.880.8699 ext. 48000, [TTY number 711 or 800.439.2370] Fax: 617.972.9048 Email: OCRCoordinator@tufts-health.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Tufts Health Plan Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building THP-OCR-NOTICE-0118

Washington, D.C. 20201 Phone: 800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. tuftshealthplan.com 888.257.1985 Important plan information is enclosed. We can give you information in other formats, such as braille and large print, and also in different languages upon request.

For no-cost translation in English, call 888.257.1985. Arabic للحصول على خدمة الترجمة المجانية باللغة العربية يرجى االتصال على الرقم 257-1985- 888 Chinese 若需免費的中文版本, 請撥打 888.257.1985 French Pour demander une traduction gratuite en français, composez le 888.257.1985. German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die folgende Telefonnummer an: 888.257.1985. Greek Για δωρεάν μετάφραση στα ελληνικά, καλέστε στο 888.257.1985. Haitian Creole Pou tradiksyon gratis nan Kreyòl Ayisyen, rele 888.257.1985. Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero 888.257.1985. Japanese 日本語の無料翻訳については 888.257.1985 に電話してください Khmer (Cambodian) សម រ ប សសវ បកប ម របស យឥតគ តថ ល ជ ភ ស ប ម រ ស មទ រស ព ទស ក ន ស ម 888.257.1985 Korean 한국어로무료통역을원하시면, 888.257.1985 로전화하십시오. Laotian ສາລ ບການແປພາສາເປ ນພາສາລາວທ ໄດ ບ ເສຍຄ າໃຊ ຈ າຍ, ໃຫ ໂທຫາເບ 888.257.1985. Navajo Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 888.257.1985. برای ترجمه رایگان به فارسی به شماره تلفن 888.257.1985 زنگ بزنید. naisrep Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer 888.257.1985. Portuguese Para tradução grátis para português, ligue para o número 888.257.1985. Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру 888.257.1985. Spanish Para servicio de traducción gratuito en español, llame al 888.257.1985. Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 888.257.1985. Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số 888.257.1985. List-Languages-THP-Number-07/16

and Referral Requirements for Covered Services for Members with MassHealth Standard or CommonHealth Coverage This is a list of prior authorization and/or referral requirements for all covered services and benefits for MassHealth Standard and CommonHealth members enrolled in our health plan. We will coordinate all covered services listed below. It is your responsibility to always carry your health plan and your MassHealth identification cards and show them to your providers at all appointments. You can call our member services team for more information about services and benefits. Please see the telephone number and hours of operation for member services at the bottom of every page of this document. If you have questions about: Medical services Behavioral health services Pharmacy services Dental services Please call: 888.257.1985 (TTY: 711 for people with partial or total hearing loss) See below for hours of operation 888.257.1985 (TTY: 711 for people with partial or total hearing loss) View our drug list at tuftshealthplan.com or call member services at 888.257.1985 (TTY: 711 for people with partial or total hearing loss) DentaQuest customer service at 800.207.5019 (TTY: 800.466.7566) or Translation Line at 800.207.5019. Hours: 8 a.m. to 6 p.m., Monday through Friday. In the chart below, if the column under Prior Authorization Required Services? has a, some or all of these services will need before you receive these Your provider will work with us to request a PA. If the column under Services? has a, then some or all of these services require a referral from your PCP before you receive these Please keep in mind that services and benefits change from time to time. This listing of PA and/or referral requirements for covered services is for your general information only. Please call our member services team for the most up-to-date information. MassHealth regulations control the services and benefits available to you. To access MassHealth regulations: Go to MassHealth s website at mass.gov/masshealth; or 5

Call MassHealth customer service at 800.841.2900 (TTY: 800.497.4648 for people with partial or total hearing loss), Monday through Friday, from 8 a.m. to 5 p.m. MassHealth Covered Services for Standard and CommonHealth Members Emergency Services Medical and Behavioral Health or Services? or Emergency Transportation Services Ambulance (air and land) transport that generally is not scheduled, but is needed on an Emergency basis, including Specialty Care Transport that is an ambulance transport of a critically injured or ill member from one facility to another, requiring care beyond the scope of a paramedic Emergency Inpatient and Outpatient Services Emergency Services Programs Medically Necessary services that are available seven days per week, 24 hours per day, to provide assessment, treatment or stabilization or any combination of these services to any member who is experiencing a mental health or substance use disorder Youth Mobile Crisis Intervention Youth (under the age of 21) serving component of an Emergency Services Program (ESP) provider Medical Services Abortion Services Acupuncture Treatment For pain relief or anesthesia Acute Inpatient Hospital Services Includes all inpatient services, such as daily physician intervention, 6

MassHealth Covered Services for Standard and CommonHealth Members surgery, obstetrics, radiology, laboratory and other diagnostic and treatment procedures, and includes Administratively Necessary Days (AND) Adult Day Health Services Center-based services offered by adult day health providers may include: Nursing services and health oversight therapy Assistance with activities of daily living Nutritional and dietary services Counseling activities Care management Transportation Adult Dentures Full and partial dentures, and repairs to said dentures, for adults ages 21 and older Adult Group Foster Care Residential-based services offered by adult foster care providers may include: Assistance with activities of daily living, instrumental activities of daily living and personal care Care management Nursing services and oversight or Services? or Ambulatory Surgery Services Outpatient, surgical, related diagnostic and medical and dental services Audiologist (Hearing) Services 7

MassHealth Covered Services for Standard and CommonHealth Members Breast Pumps One per birth or as medically necessary, including double electric pumps, are provided to expectant and new mothers as specifically prescribed by their attending physicians and consistent with state and federal law Chiropractic Manipulative treatment, office visits and radiology We may establish a limit of 20 visits from October 1 September 30. Chronic Disease and Rehabilitation Hospital and Skilled Nursing Facility Services The first 100 days are covered by us and covered by MassHealth thereafter Day Habilitation Services Center-based services for members with mental retardation or developmental disabilities offered by day habilitation providers may include: Nursing services and health care supervision Developmental skills training Therapy services Assistance with activities of daily living Dental Services Emergency-related dental care Oral surgery performed in an outpatient hospital or ambulatory surgery setting that is medically necessary to treat an underlying medical condition Dental Services (prevention and maintenance) Preventive and basic services for the prevention and control of or Services? or 8

MassHealth Covered Services for Standard and CommonHealth Members or Services? or dental diseases and the maintenance of oral health for children and adults Dialysis Services Durable Medical Equipment Including but not limited to the purchase or rental of medical equipment, replacement parts and repair for such items Enteral Nutritional Supplements (formula) may be covered under your Durable Medical Equipment (DME) benefit Early Intervention Services Family-Planning Services Hearing Aid Services Home Health Services Hospice Services Infertility Diagnosis of infertility and treatment of underlying medical condition Intensive Early Intervention Services Provided to eligible children under 3 years of age who have a diagnosis of autism spectrum disorder Laboratory Services All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health 9

MassHealth Covered Services for Standard and CommonHealth Members Orthotic Services Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. For individuals over age 21, certain limitations apply. Outpatient Hospital Services Services provided at an outpatient hospital. For example: Outpatient surgical and related diagnostic, medical and dental services Office visits for primary care and specialists OB/GYN and prenatal care Therapy services (physical, occupational and speech) Diabetes self-management training Medical nutritional therapy Tobacco-cessation services Fluoride varnish to prevent tooth decay in children and teens or Services? or Oxygen and Respiratory Therapy Equipment Personal Care Attendant Services to assist members with activities of daily living and instrumental activities of daily living. For example: Bathing Feeding Dressing Medication management Physician (primary and specialty), Nurse Practitioners acting as s, and Nurse Midwife Services 10

MassHealth Covered Services for Standard and CommonHealth Members or Services? or For example: Office visits for primary care and specialists OB/GYN and prenatal care Diabetes self-management training Medical nutritional therapy Tobacco-cessation services Fluoride varnish to prevent tooth decay in children and teens Podiatrist Services (Foot Care) Private Duty Nursing/Continuous Skilled Nursing A nursing visit of more than two continuous hours of nursing This service can be provided by either a home health agency or independent nurse. Prosthetic Services Radiology and Diagnostic Services For example: X-rays Magnetic resonance imaging (MRI) and other imaging studies Radiation oncology services performed at radiation oncology centers (ROCs) that are independent of an acute outpatient hospital or physician service Skilled Nursing Facility, Chronic Disease and Rehabilitation Hospital Services The first 100 days are covered by your health plan and covered by MassHealth thereafter 11

MassHealth Covered Services for Standard and CommonHealth Members Therapy Services For example: Occupational therapy Physical therapy Speech/language therapy Transportation Services (n-emergency) n-emergency transportation by land ambulance, chair car, taxi and common carriers that generally are pre-arranged to transport a member to and from covered medical care in Massachusetts or within 50 miles or less of the Massachusetts border n-emergency transportation to an out-of-state location ambulance and other common carriers that generally are pre-arranged to transport a member to a service that is located outside a 50-mile radius of the Massachusetts border Vision Care For example: Comprehensive eye exams once every year for members under 21 and once every 24 months for members 21 and over, and whenever medically necessary Vision training Ocular prosthesis Contacts, when medically necessary, as a medical treatment for a medical condition, such as keratoconus Bandage lenses Vision Care (non-medical component) Prescription and dispensing of ophthalmic materials, including eye or Services? or 12

MassHealth Covered Services for Standard and CommonHealth Members glasses and other visual aids, excluding contacts Wigs As prescribed by a physician related to a medical condition or Services? or Pharmacy Services (See co-payment information in your Member Handbook) Prescription Medicines Over-the-Counter Medicines Behavioral Health (Mental Health and Substance Use Disorder) Services Inpatient Services 24-hour services that provide clinical intervention for mental health or substance use diagnoses Inpatient Mental Health Services Hospital services to evaluate and treat an acute psychiatric condition Inpatient Substance Use Disorder Services (Level IV) Hospital services that provide a detoxification regime of medically directed care and treatment Observation/Holding Beds Hospital services for a period of up to 24 hours in order to assess, stabilize and identify appropriate resources for members Administratively Necessary Day (AND) Services Day(s) of inpatient hospitalization for members who are ready for discharge but an appropriate setting is not available Residential Rehabilitation Services (Level 3.1) Adult Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 13

MassHealth Covered Services for Standard and CommonHealth Members 24-hour residential environment that provides a structured and comprehensive rehabilitation environment Family Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 24-hour residential environment for families in which a member has a substance use disorder and is either pregnant, has custody of a child or has a physical reunification plan Transitional Age Youth and Young Adult Residential Rehabilitation Services for Substance Use Disorder (Level 3.1) 24-hour developmentally appropriate residential environment with enhanced staffing support designed for either transitional age youth or young adults Youth Residential Rehabilitation Services for Substance Use Disorder (Level 3.1) 24-hour developmentally appropriate residential environment with enhanced staffing support designed specifically for youth, ages 13-17 or Services? or Diversionary Services Those mental health or substance use disorder services that are provided as an alternative to inpatient services or provided to support a member returning to the community after a 24-hour acute placement or to provide intensive support to maintain functioning in the community. These services are provided in a 24-hour facility or a non-24-hour setting. 24-hour Diversionary Services Community Crisis Stabilization Services provided as an alternative to hospitalization, providing 24-hour observation and supervision Community-Based Acute Treatment for Children and 14

MassHealth Covered Services for Standard and CommonHealth Members Adolescents (CBAT) Mental health services provided on a 24-hour basis with sufficient clinical staff to ensure safety for children or adolescents Acute Treatment Services (ATS) for Substance Use Disorders (Level III.7) 24-hour medically monitored addiction treatment services that provide evaluation and withdrawal management Clinical Support Services for Substance Use Disorders (Level III.5) 24-hour treatment services that can be used independently or following Acute Treatment Services for substance use disorders Transitional Care Unit (TCU) Community-based therapeutic programs offering high levels of supervision, support and intensity of service n-24-hour Diversionary Services Community Support Program (CSP) An array of services delivered by a community-based, mobile multidisciplinary team Partial Hospitalization (PHP) An alternative to inpatient services, PHP offers short-term day mental health programming available five to seven days a week Psychiatric Day Treatment A program of a combination of diagnostic, treatment and rehabilitative services Structured Outpatient Addiction Program (SOAP) Clinically intensive, structured day and/or evening substance use disorder services or Services? or 15

MassHealth Covered Services for Standard and CommonHealth Members Intensive Outpatient Program (IOP) A clinically-intensive service designed to improve functional status, provide stabilization in the community and divert an admission to inpatient service Recovery Coaching A non-clinical service provided by peers who have substance use disorder experience and are certified recovery coaches Recovery Support Navigators A specialized care coordination service intended to engage members with substance use disorder in accessing and continuing substance use disorder treatment Outpatient Behavioral Health Services or Services? or Family Consultation Meeting with a member s family to identify and plan for services, coordinate a treatment plan, and review progress or revise the treatment plan Case Consultation A meeting with the treating provider, PCP and other BH professionals to identify and plan for services, coordinate a treatment plan, review progress and revise the treatment plan Diagnostic Evaluation An assessment of a member s level of functioning to diagnose and design a treatment plan Dialectical Behavioral Therapy (DBT) An outpatient treatment that combines strategies from behavioral cognitive and supportive psychotherapies Psychiatric Consultation on an Inpatient Medical Unit 16

MassHealth Covered Services for Standard and CommonHealth Members Meeting between a psychiatrist or Advanced Practice Registered Nurse Clinical Specialist and a member at the request of the medical unit to assess the member s mental status and consult on a behavioral health or psychopharmacological plan Medication Visit An individual visit specifically for psychopharmacological evaluation, prescription, review and/or monitoring by a psychiatrist or R.N. clinical specialist Couples/Family Treatment Psychotherapeutic and counseling techniques in the treatment of a member and his/her partner and/or family simultaneously in the same session Group Treatment Psychotherapeutic or counseling techniques in the treatment of a group Individual Treatment Psychotherapeutic or counseling techniques in the treatment of an individual Inpatient-Outpatient Bridge Visit Consultation conducted by an outpatient provider while a member remains on an inpatient psychiatric unit Assessment for Safe and Appropriate Placement (ASAP) An assessment, required by MGL 119 Sec. 33B, conducted by a diagnostician with specialized training and experience in the evaluation and treatment of sexually abusive youth or arsonists or Services? or Collateral Contact A communication between a provider and individuals who are involved in the care or treatment of a member under 21 years of age 17

MassHealth Covered Services for Standard and CommonHealth Members Acupuncture Treatment The insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, an electric current, heat to the needles or skin, or both, as an aid to persons who are withdrawing from dependence on substances or in recovery from addiction Opioid Replacement Therapy Medically monitored administration of methadone, buprenorphine or other U.S. Food and Drug Administration (FDA)-approved medications to opiate-addicted individuals, in conformance with FDA and Drug Enforcement Administration (DEA) regulations Ambulatory Detoxification (Level II.d) Outpatient services for members who are experiencing a serious episode of excessive substance use or withdrawal complications Psychological Testing The use of standardized test instruments to assess a covered individual s cognitive, emotional, neuropsychological, verbal and defensive functioning on the central assumption that individuals have identifiable and measurable differences that can be elicited by means of objective testing Special Education Psychological Testing Psychological, emotional or neuropsychological testing that is requested by school personnel responsible for initiating referrals for diagnosis and evaluation of children who qualify for special education programs pursuant to Mass Gen. Law 71B or Services? or Applied Behavioral Analysis Service that focuses on the analysis, design, implementation and evaluation of social and other environmental modifications to 18

MassHealth Covered Services for Standard and CommonHealth Members produce meaningful changes in human behavior Intensive Home and Community-Based Services for Youth Family Support Training A service provided to the parent/caregiver of a youth (under the age of 21), in any setting where the youth resides, such as the home and other community settings Intensive Care Coordination A service that provides targeted case management services to individuals under 21 with a Serious Emotional Disturbance, including individuals with co-occurring conditions In-home Behavioral Services This service usually includes a combination of behavior management therapy and behavior management monitoring In-home Therapy Services A service provided to the parent/caregiver of a youth (under the age of 21) in any setting where the youth resides, such as the home and other community settings Therapeutic Mentoring Services This service provides a structured, one-to-one mentoring relationship between a therapeutic mentor and a child or adolescent for the purpose of addressing daily living, social and communication needs Other Behavioral Health Services Electro-Convulsive Therapy (ECT) A therapeutic service that initiates seizure activity with an electric impulse while the individual is under anesthesia. It is administered in a facility that is licensed to provide this service by the or Services? or 19

MassHealth Covered Services for Standard and CommonHealth Members Department of Mental Health. Specialing Therapeutic services provided to a member in a variety of 24-hour settings, on a one-to-one basis, to maintain the individual s safety or Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services for Members under age 21 Services? or Screening Services Diagnosis and Treatment Services 20

and Referral Requirements for Covered Services for Members with MassHealth CarePlus Coverage This is a list of prior authorization and/or referral requirements for all covered services and benefits for MassHealth CarePlus members enrolled in our health plan. We will coordinate all covered services listed below. It is your responsibility to always carry your health plan and your MassHealth identification cards and show them to your providers at all appointments. You can call our member services team for more information about services and benefits. Please see the telephone number and hours of operation for member services at the bottom of every page of this document. If you have questions about: Medical services Behavioral health services Pharmacy services Dental services Please call: 888.257.1985 (TTY: 711 for people with partial or total hearing loss) See below for hours of operation 888.257.1985 (TTY: 711 for people with partial or total hearing loss) View our drug list at tuftshealthplan.com or call member services at 888.257.1985 (TTY: 711 for people with partial or total hearing loss) DentaQuest customer service at 800.207.5019 (TTY at 800.466.7566) or Translation Line at 800.207.5019. Hours: 8 a.m. to 6 p.m., Monday through Friday. In the chart below, if the column under Prior Authorization Required Services? has a, some or all of these services will need before you receive these Your provider will work with us to request a PA. If the column under Services? has a, then some or all of these services require a referral from your PCP before you receive these Please keep in mind that services and benefits change from time to time. This listing of PA and/or referral requirements for covered services is for your general information only. Please call our member services team for the most up-to-date information. MassHealth regulations control the services and benefits available to you. To access MassHealth regulations: Go to MassHealth s website at mass.gov/masshealth; or Call MassHealth customer service at 800.841.2900 (TTY: 800.497.4648 for people with partial or total hearing loss), Monday through Friday, from 8 a.m. to 5 p.m. 21

MassHealth Covered Services for CarePlus Members Emergency Services Medical and Behavioral Health or Services? or Emergency Transportation Services Ambulance (air and land) transport that generally is not scheduled, but is needed on an Emergency basis, including Specialty Care Transport that is an ambulance transport of a critically injured or ill member from one facility to another, requiring care beyond the scope of a paramedic Emergency Inpatient and Outpatient Services Emergency Services Programs Medically Necessary services that are available seven days per week, 24 hours per day, to provide assessment, treatment or stabilization or any combination of these services to any member who is experiencing a mental health or substance use disorder Youth Mobile Crisis Intervention Youth (under the age of 21) serving component of an Emergency Services Program (ESP) provider Medical Services Abortion Services Acupuncture Treatment For pain relief or anesthesia Acute Inpatient Hospital Services Includes all inpatient services, such as daily physician intervention, surgery, obstetrics, radiology, laboratory and other diagnostic and treatment procedures, and includes Administratively Necessary Days (AND) 22

MassHealth Covered Services for CarePlus Members Adult Dentures Full and partial dentures, and repairs to said dentures, for adults ages 21 and over Ambulatory Surgery Services Outpatient, surgical, related diagnostic and medical and dental services or Services? or Audiologist (Hearing) Services Breast Pumps One per birth or as medically necessary, including double electric pumps, are provided to expectant and new mothers as specifically prescribed by their attending physicians and consistent with state and federal law Chiropractic Manipulative treatment, office visits and radiology We may establish a limit of 20 visits from October 1 through September 30. Chronic or Rehabilitation Hospital Services We cover 100 days of services, for all levels of care, provided at either a chronic or rehabilitation hospital Dental Services Emergency-related dental care Oral surgery performed in an outpatient hospital or ambulatory surgery setting, which is medically necessary to treat an underlying medical condition Dental Services (prevention and maintenance) Preventive and basic services for the prevention and control of dental diseases and the maintenance of oral health for children and adults 23

MassHealth Covered Services for CarePlus Members or Services? or Dialysis Services Durable Medical Equipment Including but not limited to the purchase or rental of medical equipment, replacement parts and repair for such items Enteral Nutritional Supplements (formula) may be covered under your Durable Medical Equipment (DME) benefit Family-Planning Services Hearing Aid Services Home Health Services Hospice Services Infertility Diagnosis of infertility and treatment of underlying medical condition Laboratory Services All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health Orthotic Services Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. For individuals over age 21, certain limitations apply. Outpatient Hospital Services Services provided at an outpatient hospital. For example: Outpatient surgical and related diagnostic, medical and dental services Office visits for primary care and specialists 24

MassHealth Covered Services for CarePlus Members or Services? or OB/GYN and prenatal care Therapy services (physical, occupational and speech) Diabetes self-management training Medical nutritional therapy Tobacco-cessation services Oxygen & Respiratory Therapy Equipment Physician (primary and specialty), Nurse Practitioners acting as s, and Nurse Midwife Services For example: Office visits for primary care and specialists OB/GYN and prenatal care Diabetes self-management training Medical nutritional therapy Tobacco-cessation services Podiatrist Services (Foot Care) Prosthetic Services Radiology and Diagnostic Services For example: X-rays Magnetic resonance imaging (MRI) and other imaging studies Radiation oncology services performed at radiation oncology centers (ROCs) that are independent of an acute outpatient hospital or physician service Therapy Services For example: 25

MassHealth Covered Services for CarePlus Members Occupational therapy Physical therapy Speech/language therapy Transportation Services (n-emergency) n-emergency transportation by land ambulance, chair car, taxi and common carriers that generally are pre-arranged to transport a member to and from covered medical care in Massachusetts or within 50 miles or less of the Massachusetts border n-emergency transportation to an out-of-state location ambulance and other common carriers that generally are pre-arranged to transport a member to a service that is located outside a 50-mile radius of the Massachusetts border Vision Care For example: Comprehensive eye exams once every year for members under 21 and once every 24 months for members 21 and over, and whenever medically necessary Vision training Ocular prosthesis Contacts, when medically necessary, as a medical treatment for a medical condition such as keratoconus Bandage lenses Vision Care (non-medical component) Prescription and dispensing of ophthalmic materials, including eye glasses and other visual aids, excluding contacts Wigs As prescribed by a physician related to a medical condition or Services? or 26

MassHealth Covered Services for CarePlus Members or Services? or Pharmacy Services (See co-payment information in your Member Handbook) Prescription Medicines Over-the-Counter Medicines Behavioral Health (Mental Health and Substance Use Disorder) Services Inpatient Services 24-hour services that provide clinical intervention for mental health or substance use diagnoses Inpatient Mental Health Services Hospital services to evaluate and treat an acute psychiatric condition Inpatient Substance Use Disorder Services (Level IV) Hospital services that provide a detoxification regime of medically directed care and treatment Observation/Holding beds Hospital services for a period of up to 24 hours in order to assess, stabilize and identify appropriate resources for members Administratively Necessary Day (AND) Services Day(s) of inpatient hospitalization for members who are ready for discharge but an appropriate setting is not available Residential Rehabilitation Services (Level 3.1) Adult Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 24-hour residential environment that provides a structured and comprehensive rehabilitation environment Family Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 27

MassHealth Covered Services for CarePlus Members 24-hour residential environment for families in which a member has a substance use disorder and is either pregnant, has custody of a child, or has a physical reunification plan Transitional Age Youth and Young Adult Residential Rehabilitation Services for Substance Use Disorder (Level 3.1) 24-hour developmentally appropriate residential environment with enhanced staffing support designed for either transitional age youth or young adults Youth Residential Rehabilitation Services for Substance Use Disorder (Level 3.1) 24-hour developmentally appropriate residential environment with enhanced staffing support designed specifically for youth, ages or Services? or 13-17 Diversionary Services Those mental health or substance use disorder services that are provided as an alternative to inpatient services or provided to support a member returning to the community after a 24-hour acute placement or to provide intensive support to maintain functioning in the community. These services are provided in a 24-hour facility or a non-24-hour setting. 24-hour Diversionary Services Community Crisis Stabilization Services provided as an alternative to hospitalization, providing 24-hour observation and supervision Acute Treatment Services (ATS) for Substance Use Disorders (Level III.7) 24-hour medically monitored addiction treatment services that provide evaluation and withdrawal management Clinical Support Services for Substance Use Disorders (Level III.5) 24-hour treatment services that can be used independently or 28

MassHealth Covered Services for CarePlus Members following Acute Treatment Services for substance use disorders n-24-hour Diversionary Services Community Support Program (CSP) An array of services delivered by a community-based, mobile multidisciplinary team Partial Hospitalization (PHP) An alternative to inpatient services, PHP offers short-term day mental health programming available five to seven days a week Psychiatric Day Treatment A program of a combination of diagnostic, treatment and rehabilitative services Structured Outpatient Addiction Program (SOAP) Clinically intensive, structured day and/or evening substance use disorder services Intensive Outpatient Program (IOP) A clinically-intensive service designed to improve functional status, provide stabilization in the community and divert an admission to inpatient service Recovery Support Navigators A specialized care coordination service intended to engage members with substance use disorder in accessing and continuing substance use disorder treatment Outpatient Behavioral Health Services Family Consultation Meeting with a member s family to identify and plan for services, coordinate a treatment plan, and review progress or revise the treatment plan or Services? or 29

MassHealth Covered Services for CarePlus Members Case Consultation A meeting with the treating provider, PCP and other BH professionals to identify and plan for services, coordinate a treatment plan, review progress and revise the treatment plan Diagnostic Evaluation An assessment of a member s level of functioning to diagnose and design a treatment plan Dialectical Behavioral Therapy (DBT) An outpatient treatment that combines strategies from behavioral cognitive and supportive psychotherapies Psychiatric Consultation on an Inpatient Medical Unit A meeting between a psychiatrist or Advanced Practice Registered Nurse Clinical Specialist and a member at the request of the medical unit to assess the member s mental status and consult on a behavioral health or psychopharmacological plan Medication Visit An individual visit specifically for psychopharmacological evaluation, prescription, review and/or monitoring by a psychiatrist or R.N. Clinical Specialist Couples/Family Treatment Psychotherapeutic and counseling techniques in the treatment of a member and his/her partner and/or family simultaneously in the same session Group Treatment Psychotherapeutic or counseling techniques in the treatment of a group or Services? or Individual Treatment Psychotherapeutic or counseling techniques in the treatment of an individual 30

MassHealth Covered Services for CarePlus Members Inpatient-Outpatient Bridge Visit Consultation conducted by an outpatient provider while a member remains on an inpatient psychiatric unit Acupuncture Treatment The insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, an electric current, heat to the needles or skin, or both, as an aid to persons who are withdrawing from dependence on substances or in recovery from addiction Opioid Replacement Therapy Medically monitored administration of methadone, buprenorphine or other U.S. Food and Drug Administration (FDA)-approved medications to opiate-addicted individuals, in conformance with FDA and Drug Enforcement Administration (DEA) regulations Ambulatory Detoxification (Level II.d) Outpatient services for members who are experiencing a serious episode of excessive substance use or withdrawal complications Psychological Testing The use of standardized test instruments to assess a covered individual s cognitive, emotional, neuropsychological, verbal and defensive functioning on the central assumption that individuals have identifiable and measurable differences that can be elicited by means of objective testing or Services? or Other Behavioral Health Services Electro-Convulsive Therapy (ECT) A therapeutic service that initiates seizure activity with an electric impulse while the individual is under anesthesia. It is administered in a facility that is licensed to provide this service by the Department of Mental Health. 31

MassHealth Covered Services for CarePlus Members Specialing Therapeutic services provided to a member in a variety of 24-hour settings, on a one-to-one basis, to maintain the individual s safety or Services? or 32

and Referral Requirements for Covered Services for Members with MassHealth Family Assistance Coverage This is a list of prior authorization and/or referral requirements for all covered services and benefits for MassHealth Family Assistance members enrolled in our health plan. We will coordinate all covered services listed below. It is your responsibility to always carry your health plan and your MassHealth identification cards and show them to your providers at all appointments. You can call our member services team for more information about services and benefits. Please see the telephone number and hours of operation for member services at the bottom of every page of this document. If you have questions about: Medical services Behavioral health services Pharmacy services Dental services Please call: 888.257.1985 (TTY: 711 for people with partial or total hearing loss) See below for hours of operation 888.257.1985 (TTY: 711 for people with partial or total hearing loss) View our drug list at tuftshealthplan.com or call member services at 888.257.1985 (TTY: 711 for people with partial or total hearing loss) DentaQuest customer service at 800.207.5019 (TTY at 800.466.7566) or Translation Line at 800.207.5019. Hours: 8 a.m. to 6 p.m., Monday through Friday. In the chart below, if the column under Prior Authorization Required Services? has a, some or all of these services will need before you receive these Your provider will work with us to request a PA. If the column under Services? has a, then some or all of these services require a referral from your PCP before you receive these Please keep in mind that services and benefits change from time to time. This listing of PA and/or referral requirements for covered services is for your general information only. Please call our member services team for the most up-to-date information. MassHealth regulations control the services and benefits available to you. To access MassHealth regulations: Go to MassHealth s website at mass.gov/masshealth; or Call MassHealth customer service at 800.841.2900 (TTY: 800.497.4648 for people with partial or total hearing loss), Monday through Friday, from 8 a.m. to 5 p.m. 33

MassHealth Covered Services for Family Assistance Members Emergency Services Medical and Behavioral Health or Services? or Emergency Transportation Services Ambulance (air and land) transport that generally is not scheduled, but is needed on an Emergency basis, including Specialty Care Transport that is an ambulance transport of a critically injured or ill member from one facility to another, requiring care beyond the scope of a paramedic Emergency Inpatient and Outpatient Services Emergency Services Programs Medically Necessary services that are available seven days per week, 24 hours per day, to provide assessment, treatment or stabilization or any combination of these services to any member who is experiencing a mental health or substance use disorder Youth Mobile Crisis Intervention Youth (under the age of 21) serving component of an Emergency Services Program (ESP) provider Medical Services Abortion Services Acute Inpatient Hospital Services Includes all inpatient services, such as daily physician intervention, surgery, obstetrics, radiology, laboratory and other diagnostic and treatment procedures, and includes Administratively Necessary Days (AND) Adult Dentures Full and partial dentures, and repairs to said dentures, for adults 34

MassHealth Covered Services for Family Assistance Members ages 21 and over Ambulatory Surgery Services Outpatient, surgical, related diagnostic and medical and dental services or Services? or Audiologist (Hearing) Services Breast Pumps One per birth or as medically necessary, including double electric pumps, are provided to expectant and new mothers as specifically prescribed by their attending physicians and consistent with state and federal law Chiropractic Manipulative treatment, office visits and radiology We may establish a limit of 20 visits from October 1 through September 30. Chronic or Rehabilitation Hospital Services We cover 100 days of services, for all levels of care, provided at either a chronic or rehabilitation hospital per benefit year per member Dental Services Emergency-related dental care Oral surgery performed in an outpatient hospital or ambulatory surgery setting that is medically necessary to treat an underlying medical condition Dental Services (prevention and maintenance) Preventive and basic services for the prevention and control of dental diseases and the maintenance of oral health for children and adults 35 Dialysis Services

MassHealth Covered Services for Family Assistance Members or Services? or Durable Medical Equipment Including but not limited to the purchase or rental of medical equipment, replacement parts and repair for such items Enteral Nutritional Supplements (formula) may be covered under your Durable Medical Equipment (DME) benefit Early Intervention Services Family-Planning Services Hearing Aid Services Home Health Services Hospice Services Infertility Diagnosis of infertility and treatment of underlying medical condition Intensive Early Intervention Services Provided to eligible children under 3 years of age who have a diagnosis of autism spectrum disorder Laboratory Services All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health Orthotic Services Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. For individuals over age 21, certain limitations apply. Outpatient Hospital Services Services provided at an outpatient hospital. For example: 36

MassHealth Covered Services for Family Assistance Members or Services? or Outpatient surgical and related diagnostic, medical and dental services Office visits for primary care and specialists OB/GYN and prenatal care Therapy services (physical, occupational and speech) Diabetes self-management training Medical nutritional therapy Tobacco-cessation services Fluoride varnish to prevent tooth decay in children and teens Oxygen and Respiratory Therapy Equipment Physician (primary and specialty), Nurse Practitioners acting as s, and Nurse Midwife Services For example: Office visits for primary care and specialists OB/GYN and prenatal care Diabetes self-management training Medical nutritional therapy Tobacco-cessation services Fluoride varnish to prevent tooth decay in children and teens Podiatrist Services (Foot Care) Preventive Pediatric Health Screening and Diagnostic Services Children, adolescents and young adults who are under 21 years old and are enrolled in the MassHealth Basic, Essential or Family Assistance Plan are entitled to Preventive Pediatric Healthcare Screening and Diagnosis Services Prosthetic Services 37

MassHealth Covered Services for Family Assistance Members Radiology and Diagnostic Services For example: X-rays Magnetic resonance imaging (MRI) and other imaging studies Radiation oncology services performed at radiation oncology centers (ROCs) that are independent of an acute outpatient hospital or physician service Therapy Services For example: Occupational therapy Physical therapy Speech/language therapy Vision Care For example: Comprehensive eye exams once every year for members under 21 and once every 24 months for members 21 and older, and whenever medically necessary Vision training Ocular prosthesis Contacts, when medically necessary, as a medical treatment for a medical condition such as keratoconus Bandage lenses Vision Care (non-medical component) Prescription and dispensing of ophthalmic materials, including eye glasses and other visual aids, excluding contacts Wigs As prescribed by a physician related to a medical condition or Services? or 38

MassHealth Covered Services for Family Assistance Members or Services? or Pharmacy Services (See co-payment information in your Member Handbook) Prescription Medicines Over-the-Counter Medicines Behavioral Health (Mental Health and Substance Use Disorder) Services Inpatient Services 24-hour services that provide clinical intervention for mental health or substance use diagnoses Inpatient Mental Health Services Hospital services to evaluate and treat an acute psychiatric condition Inpatient Substance Use Disorder Services (Level IV) Hospital services that provide a detoxification regime of medically directed care and treatment Observation/Holding beds Hospital services for a period of up to 24 hours in order to assess, stabilize and identify appropriate resources for members Administratively Necessary Day (AND) Services Day(s) of inpatient hospitalization for members who are ready for discharge but an appropriate setting is not available Residential Rehabilitation Services (Level 3.1) Adult Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 24-hour residential environment that provides a structured and comprehensive rehabilitation environment Family Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 39

MassHealth Covered Services for Family Assistance Members 24-hour residential environment for families in which a member has a substance use disorder and is either pregnant, has custody of a child or has a physical reunification plan Transitional Age Youth and Young Adult Residential Rehabilitation Services for Substance Use Disorder (Level 3.1) 24-hour developmentally appropriate residential environment with enhanced staffing support designed for either transitional age youth or young adults Youth Residential Rehabilitation Services for Substance Use Disorder (Level 3.1) 24-hour developmentally appropriate residential environment with enhanced staffing support designed specifically for youth, ages 13-17 or Services? or Diversionary Services Those mental health or substance use disorder services that are provided as an alternative to inpatient services or provided to support a member returning to the community after a 24-hour acute placement or to provide intensive support to maintain functioning in the community. These services are provided in a 24-hour facility or a non-24-hour setting. 24-hour Diversionary Services Community Crisis Stabilization Services provided as an alternative to hospitalization, providing 24-hour observation and supervision Community-Based Acute Treatment for Children and Adolescents (CBAT) Mental health services provided on a 24-hour basis with sufficient clinical staff to ensure safety for children or adolescents Acute Treatment Services (ATS) for Substance Use Disorders (Level III.7) 24-hour medically monitored addiction treatment services that 40

MassHealth Covered Services for Family Assistance Members provide evaluation and withdrawal management Clinical Support Services for Substance Use Disorders (Level III.5) 24-hour treatment services that can be used independently or following Acute Treatment Services for substance use disorder Transitional Care Unit (TCU) Community-based therapeutic programs offering high levels of supervision, support and intensity of service n-24-hour Diversionary Services Community Support Program (CSP) An array of services delivered by a community-based, mobile multidisciplinary team Partial Hospitalization (PHP) An alternative to inpatient services, PHP offers short-term day mental health programming available five to seven days a week Psychiatric Day Treatment A program of a combination of diagnostic, treatment and rehabilitative services Structured Outpatient Addiction Program (SOAP) Clinically intensive, structured day and/or evening substance use disorder services Intensive Outpatient Program (IOP) A clinically-intensive service designed to improve functional status, provide stabilization in the community and divert an admission to inpatient service Recovery Coaching A non-clinical service provided by peers who have substance use disorder experience and are certified recovery coaches or Services? or 41