MEDICAL BENEFIT SUMMARY GRID: TUFTS HEALTH TOGETHER (MASSHEALTH) CAREPLUS ABBREVIATIONS BH = Behavioral health IN = In-network MM = Medical management team at Tufts Health Plan = Out-of-network PA = Prior authorization PCP = Primary care provider Benefit year = March 1 December 31 Annual co-payment maximum per calendar year per member Medical and BH = $0 Pharmacy = $250 Please note: Providers must submit prior authorization requests, if required, five business days prior to the service start date. All services rendered by providers require prior authorization. Some members may require a PCP referral for specialty services. We only need to be notified if the Service requires a Prior Authorization, refer to PA required column below. Service Coverage/Limits/Conditions Related payment policy Co-payment PA required? Abortion Covered Acupuncture Covered for pain relief or anesthesia when medically necessary. Also covered if medically necessary to treat substance use. Acute inpatient stay Covered if medically necessary Acute Inpatient Hospital $0 IN and Admissions Adult day health Not covered Not covered Not covered services Adult dentures Covered by MassHealth as a wraparound service. MM can assist in coordinating services with requesting provider. $0 Contact MassHealth at 800.841.2900 Adult foster care Not covered Not covered Not covered Allergy shots Covered if medically necessary Ambulatory surgery/ Same-day surgery/ Outpatient surgery/ Surgical day care Covered if medically necessary when surgical procedure performed at IN outpatient facility. Includes outpatient, surgical, and related diagnostic and medical/dental services. Anesthesia services Covered if medically necessary. Anesthesia, Obstetric Anesthesia $0 IN for certain services Use the Site Search function on the THP Provider page $0 IN for dental services Audiologist Exams and evaluations covered if medically necessary Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 1
Biofeedback Not covered Not covered Not covered Bone density test Covered if medically necessary. $0 Breast pumps Breast pumps, one per birth or as medically necessary, including double electric pumps, are provided to expectant and new mothers as specifically prescribed by their attending physicians and consistent with state and federal law. $0 IN: Electric hospitalgrade pumps pumps Cardiac catheterization Covered if medically necessary Cardiac rehabilitation Covered if medically necessary Care management Covered when provided by Tufts Health Plan care managers Chapter 766 Not covered Not covered Not covered Chemotherapy/ Covered if medically necessary Radiation therapy Chiropractic services Covered for up to 20 visits per benefit year for manipulative treatment, office visits, radiology services or any combination of these services Chiropractic Cosmetic surgery Not covered Not covered Not covered CPAP/BiPAP May cover continuous positive airway pressure machine DME $0 IN and (CPAP) and bilevel positive airway pressure machine (BiPAP) if medically necessary after sleep study is completed and reviewed. Custodial care Not covered Not covered Not covered Day habilitation Not covered Not covered Not covered Dental, emergency Covered if medically necessary. Includes emergency dental services and oral surgery performed in an outpatient setting to treat a medical or BH condition. Dental, nonemergency Covered if medically necessary to treat a medical condition. MassHealth covers nonemergency dental services as a wraparound service as follows: Members 21 and older extractions and one cleaning per year $0 IN and Contact MassHealth at 800.841.2900 Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 2
Diabetes selfmanagement training Covered if medically necessary. Includes educational and training services by a physician or other accredited provider (registered nurse, physician assistant, nurse practitioner and licensed dietitian) to treat prediabetes or diabetes. Diagnostic procedures Diagnostic testing Dialysis services Drug screening Durable medical equipment (DME) Emergency services Covered if medically necessary. Includes colonoscopy, endoscopy, sigmoidoscopy and gastroscopy. Covered if medically necessary. Includes labs, X-rays, EKGs, EEGs and ultrasounds. Covered if medically necessary. Includes labs, drugs, tubing change, adapter change, training related to hemodialysis and peritoneal dialysis (intermittent, continuous cycling and continuous ambulatory). Covered if medically necessary. Not covered when courtordered, legally required, or when required for residential monitoring. Covered if medically necessary. Includes medical and surgical supplies. Covered for medical and BH emergency services provided within the U.S. $0 Upper GI Endoscopy requires a PA : All services except labs Drug Screening DME $0 IN: See payment policy Nebulizers: None Emergency Room $0 Notification required within 24 hours, if admitted Exams/ Not covered, including services related to or for the Not covered Not covered Other treatment purpose of employment, education, licensing or court order Experimental services Not covered. See our list of experimental and Clinical Trials Payment Not covered Not covered investigational procedures. Policy Family planning Covered for basic services. Includes birth control and intrauterine devices (IUDs). Family planning, medical and counseling services, follow-up health care, outreach and community education may be obtained from any MassHealth family-planning service provider without PA. Fluoride varnish Not covered Not covered Not covered Genetic testing Covered if medically necessary Genetic Testing $0 IN and Group adult foster care Not covered Not covered Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 3
Hearing aids Covered if medically necessary. Includes ear mold, ear impressions and loan of a hearing aid if necessary. No PA required for batteries, accessories, aid, instruction of use/care/maintenance and servicing during the lifetime of the hearing aid. IN: Monaural (one ear) more than $500 or binaural (two ears) more than $1,000 Hepatitis B vaccine Home health care services Covered if medically necessary for adults ages 19 and older. Vaccine and administration covered. Covered if medically necessary when member demonstrates a need for nursing and/or therapy services. Includes part- time or intermittent skilled nursing, physical/ occupational/speech therapies, and part-time or intermittent home health aide services in the home. Vaccine and Immunization Home Health Care $0 IN only if request is for daily visits or for requests greater than 6 months regardless of service (e.g., skilled nursing, PT, OT and speech) Home infusion therapy Covered if medically necessary $0 IN: Some drugs may require PA Hospice care Covered if medically necessary. $0 IN and Human papillomavirus Covered if medically necessary for males and females ages Vaccine and (HPV) vaccine Immunization services Infertility services 19 26 Covered if medically necessary. Vaccine administration covered. Not covered if required for traveling outside U.S. Covered only for the diagnosis of infertility and treatment of an underlying medical condition. Not covered for other infertility services and their diagnosis or treatment, such as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), reversal of voluntary sterilization and sperm banking. Immunization Vaccine and Immunization Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 4
Inpatient hospitalization Covered if medically necessary $0 IN and Elective admissions: Submit PA form 5 business days prior to Institutional care at a skilled nursing facility or a chronic or rehabilitation hospital Laboratory services Maternity care/ Prenatal visits Medical services outside the U.S. or its territories Covered for all skilled levels of care, if provided at either a nursing facility or a chronic or rehabilitation hospital or any combination thereof, up to 100 days per benefit year. Covered if medically necessary to maintain health and diagnose, treat and prevent disease. Includes blood tests, urinalysis, Pap smears, throat cultures and vaccines not covered by the Department of Public Health. Please reference Drug Screening and Genetic Testing above. Covered. IN or providers must submit a Prenatal Registration Form to MM. Facility Maternity admission $0 IN and Not covered Not covered Not covered Covered if medically necessary $0 IN and Mobile Outpatient Cardiac Telemetry (MOCT) Nuclear cardiology Covered if medically necessary. Radiology Imaging Nurse practitioner services Not covered unless credentialed for billing as a PCP. Nurse Practitioner as a Primary Care Provider $0 IN and : Submit PA requests to National Imaging Associates. Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 5
Nutritional counseling Covered if rendered by an accredited provider (physician, licensed dietitian, licensed nutritionist, registered nurse, physician assistant or nurse practitioner). Includes nutritional, diagnostic, therapy and counseling services for a medical condition. Nutritional supplements Covered if medically necessary and formula prescribed for a medical condition. Not covered for nutritional supplements covered by Women, Infants, and Children DME $0 IN and Nutritional therapy (WIC) Nutrition Program. Covered if medically necessary Observation day Covered if medically necessary Observation $0 IN: Stays longer than 48 hours Organ/Bone marrow transplants Orthotics Outpatient hospital services Outpatient therapy physical, occupational, speech and hearing Coverage determined upon review by MM. Experimental and investigational transplants not covered. Covered if medically necessary. Includes braces and other mechanical or molded devices to support or correct any defect of form or function of the human body. Includes repairs. Limit one pair of shoes per 12-month period for diabetics. Shoe inserts covered for diabetics only. $0 IN and Orthotic $0 IN and Covered if medically necessary $0 See specific service for PA requirement Covered if medically necessary. Includes individual Outpatient Therapy $0 IN: After initial treatment, comprehensive evaluation and group therapy. evaluation and 11 visits for PT and OT IN: After 30 visits for ST and hearing Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 6
Over-the-counter (OTC) drugs Oxygen and respiratory therapy equipment Select OTC drugs are covered if requested with a prescription written by an IN or physician. Must be obtained at a participating pharmacy. Examples include: Aspirin/Acetaminophen/Ibuprofen Allergy medication/decongestant Diabetic supplies (e.g., strips, lancets) Multivitamins and iron/calcium supplements Covered if medically necessary. Includes ambulatory oxygen systems and refills, aspirators, compressor-driven nebulizers, intermittent positive pressure breathers, oxygen, oxygen gas, oxygen-generating devices and oxygen therapy equipment rental. Contraceptive agents: $0 Covered OTC drugs: $0 $3.65 for a 30-day supply See Over-the-Counter list on website DME $0 IN: See payment policy Pacemaker implant Covered if medically necessary Pain management Covered if medically necessary Anesthesia $0 IN and : Submit PA requests to National Imaging Associates Personal care attendant Personal emergency response systems (PERS) Pharmacy Physician assistant services Physician services Not covered Not covered Not covered Covered if medically necessary Co-payments for one-month supply via participating pharmacies. Co-payments due at time of service. No co-payment for: Birth control and family-planning supplies Diabetic supplies Spacers or peak flow meters Members while pregnant or up to 60 days after giving birth Prescription diabetes/asthma supplies $0 as indicated $1 for certain covered generic drugs used to treat diabetes, high blood pressure, and high cholesterol $3.65 for certain covered generic, OTC, and brand name drugs Tufts Health Plan pharmacy co-payments Not covered unless credentialed for billing as a PCP Covered, including PCP and specialty services. Some members may require PCP referral for specialty services. However, no Prior Authorization or notification is required for IN. See our Preferred Drug List (PDL) for PA requirements $0 PCP: Specialty: Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 7
Podiatry Covered for medical conditions. Includes medical, radiological, surgical and laboratory care. Includes routine foot care for diabetics. Podiatry Private-duty nursing/ Continuous skilled nursing Prosthetics services and devices Pulmonary function test Pulmonary rehabilitation Radiation therapy, internal selective Radiology/X-rays Not covered Not covered Not covered Covered. Includes evaluation, fabrication, fitting, provision Prosthetic $0 IN and of prosthesis and repairs. Covered if medically necessary Covered if medically necessary Covered if medically necessary Covered if medically necessary. Advanced imaging services (MRI, MRA, CAT, nuclear cardiology and PET) require PA through NIA. Radiology Imaging, Therapeutic Radiology $0 IN and : Contact National Imaging Associates to request PA. Shingles vaccine Covered only for members 50 and older Vaccine and Immunization Skilled nursing facility Covered if medically necessary when received in an $0 IN and inpatient setting for up to 100 days per benefit year Sleep study Covered if medically necessary Specialist Covered if medically necessary. Some members may require PCP referral for specialty services. However, no Prior Authorization or notification is required for IN. Specialty Referral Requirement Stress test Covered if medically necessary Temporomandibular $0 IN and joint (TMJ) treatment Covered for surgery if medically necessary. Not covered for physical therapy, corrective devices and/or other treatments. Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 8
Tobacco cessation Covered for individual and group tobacco-cessation $0-$3.65 for counseling rendered by an IN provider. Includes specific medications obtained from a pharmacy and nicotinereplacement therapy. pharmacy medications Transportation, Covered if medically necessary. Includes land and air. Ambulance Transport $0 emergency Transportation, nonemergency Includes specialty care transport between facilities. Covered for transport to an out-of-state location farther than a 50-mile radius of the Massachusetts border. MassHealth covers in-state nonemergency transportation or transport within a 50-mile radius of the Massachusetts border. Ambulance Transport $0 Contact MassHealth at 800.841.2900 for PA requirements Transsexual surgery Covered if medically necessary $0 IN and Urgent care Covered if medically necessary IN and, if billed with place-of-service code 20 Vaccines Covered if medically necessary. Vaccine administration covered. Not covered if required for traveling outside U.S. Vaccine and Immunization Vasectomy Covered, except for reversal of voluntary sterilization Vision THP covers routine eye exams once every 24 months for Vision Medical non-diabetic members and members age 21+, and once Vision Non- Medical Vocational rehabilitation every 12 months for diabetic members. THP covers medically necessary vision training; ocular prosthesis; contacts, as treatment for a medical condition, such as keratoconus; and bandage lenses. MassHealth covers all non-medical vision care, including eyeglasses and other visual aids. Vision $0 Vision Therapy: IN and All other Vision Medical: $0 Contact MassHealth at 800.841.2900 for wraparound benefits Not covered Not covered Not covered Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 9
Wigs Covered if medically necessary pursuant to 130 CMR 450.204. Must be ordered or prescribed by a provider. Must be reasonably priced pursuant to 130 CMR 450.204(A)(2). Medical Benefit Summary Grid: Tufts Health Together (MassHealth) CarePlus 1 0